Editorial Comment:  Efficacy claims

When we began the present format for the ASAM Weekly, it was to improve access to recently-arriving news in the addiction medicine field.  Judging by the subscription rate and similar factors (e.g., click-rate, email comments), we have enjoyed some success. But there are obstacles to assigning the correct treatment to the illness that become apparent in publications advancing either pharmacotherapies or nonpharmacologic therapies.  One of these is in the area of trustworthiness.

In the Sunday New York Times (25 August 2019, Ending the War on Drugs, Nicholas Kristof (https://www.nytimes.com/2019/08/23/opinion/sunday/opioid-crisis-drug-seattle.html ) showcases Seattle's LEAD (Law Enforcement Assisted Diversion) program, which purports to use a public health model associated with decriminalization of drug usage. He gives a pretty enthusiastic endorsement, and there has admittedly been considerable buy-in from other cities. Much of this was anticipated in Judge Steven Alm’s HOPE program, a court-based diversion program highly reliant upon contingency management principles, over 15 years ago (https://www.courts.state.hi.us/special_projects/hope/about_hope_probation ).  One concern is that court-based programs are often predicated on deferral of a legal penalty, adding motive to participation as the author suggests but also providing access to an invaluable resource:  probation officers, who have the authority to compel testing, an essential component of contingency management.  Whether these programs can engage the target population without legal sanctions is by no means resolved. Validating such large-scale programs between municipalities requires a commitment to the long view, and a high order of cooperation.  Not surprisingly, management of addictions as a social or community issue mirrors the experience of the individual person with addiction: persistent pursuit of the long-term objective is required, as is trust in the effectiveness of the intervention.  But because it is not reasonable for all patients to objectively research the treatment options, they have historically relied upon the integrity and knowledge of the providers.

Unfortunately, years after the Prometa implosion, physicians and clinics continue to promote  unproven interventions that are principally effective in relieving families of their assets and adding to their burden of misery  ( https://khn.org/news/addiction-clinics-expensive-unproven-infusion-treatments-desperate-patients/  ). They do damage beyond simply failing to deliver on the promise of a good treatment outcome; they set reliance on medicine and the scientific process back centuries, all the while claiming to be "research-proven" and "scientifically-based" interventions. This returns me to the issue of validation of studies, and the responsibility of publications. Where possible, we identify risks of conflict of interest on the parts of the authors.  And while some journals are very clear on the affiliations of their contributing authors, others are less so, so that it takes serious detective work to determine what may be a profitable alliance for the author.  Such alliances do not necessarily negate the value of the research, but concealment only adds to dubiety.  It will help us meet our objectives if you will pass on any identified possible conflicts of interest  to the ASAMW staff, below, and they will be forwarded to the editors.

- Bill Haning, MD, DFASAM