…that is the question.”

I came across an Internet debate on the relative merits of opioid maintenance versus opioid-free treatment. Not the first such debate I’ve encountered, and certain not to be the last.

One side argues that if addiction is indeed a chronic disorder along the lines of diabetes, then the use of ongoing medication should count as a legitimate form of recovery, the way it would with insulin used by a Type 1 diabetic. That seems reasonable enough.

The other side, however, counters that because the addict is still completely dependent on high doses of opioids — the drug that brought him to treatment in the first place — that can’t be considered equivalent to recovery without opioids, even if other drug use has been curtailed.

That also seem pretty reasonable.

Both sides tend to focus on the flaws in one another’s approach as a way of demonstrating the superiority of their own. Advocates of maintenance point to low abstinence rates for drug-free programs. Their opponents argue that all maintenance does is make their addiction legal.

It would be nice if we had a third option. One where a patient could reasonably expect to be on methadone or buprenorphine for a period, until stable, and then taper off without an expected return to heroin. But the evidence so far suggests that doesn’t often happen. Opioid maintenance, for most at least, seems to be an endpoint, not a beginning.

I heard from one psychiatrist who claimed considerable success tapering people slowly off buprenorphine and onto monthly naltrexone injections. The patient’s still dependent on the naltrexone, of course, but since it’s not an opioid, objections are few. The doc admits to focusing only on the highly motivated patient, and there are never all that many of those around.

You know what would help put an end to the debate? A protocol for a successful transition off maintenance for those patients who would prefer not to remain dependent. Something that would reassure the public that we hadn’t just “settled for” permanent maintenance, sometimes called ‘parking’.

I’ve been looking for signs of an effort by scientists to find one. So far, I haven’t seen much.