Why individualized addiction care means holding every legitimate pathway open — including the one that does not involve daily medication.

The addiction medicine field has largely settled the debate: medication-assisted treatment works, the data are clear, and abstinence-only programs are relics of a moralistic era that cost lives. That consensus is not wrong. But it has produced a quieter problem — the near-total dismissal of abstinence-based recovery as a legitimate pathway, and the professional condescension directed at patients who choose it.

This piece is not an argument against MAT. I prescribe buprenorphine, naltrexone, and Sublocade. I have seen these medications restore people's lives in ways that nothing else could. The evidence base for MAT is not ambiguous, and clinicians who withhold these tools based on ideology are causing harm.

This is an argument for something more specific: that a field which rightly dismantled one form of paternalism should not replace it with another.

What the Evidence Actually Says About Abstinence-Based Recovery

The research literature on MAT outcomes is robust and well-publicized. Less discussed — though equally present — is the evidence supporting abstinence-based recovery for a meaningful subset of patients.

Long-term follow-up studies of twelve-step participants, including Project MATCH and subsequent NIAAA-funded research, have consistently shown that active engagement in twelve-step programs is associated with higher rates of sustained abstinence and improved quality of life measures. A 2020 Cochrane review concluded that Alcoholics Anonymous and twelve-step facilitation programs produce higher rates of continuous abstinence compared to other interventions, including some evidence-based alternatives.

Faith-based residential recovery programs, while less studied, show comparable long-term outcomes in populations with high baseline motivation and strong social support networks. Therapeutic communities — long-term residential programs emphasizing peer accountability and behavioral restructuring — have decades of outcome data supporting their effectiveness for patients with severe, treatment-resistant substance use disorders.

None of this contradicts the MAT evidence base. Both can be true: medications dramatically reduce overdose mortality and improve outcomes for the majority of opioid-dependent patients, and a distinct subset of patients achieve durable recovery through abstinence-based frameworks and report that medication was not the right path for them.

The mistake is assuming that the best-average treatment is the best treatment for every patient.

Where the New Paternalism Shows Up Clinically

I want to be specific about what I mean, because the problem is subtle enough that it often goes unrecognized.

It shows up when a patient comes in and says they want to try naltrexone with the goal of eventually stopping all medication, and the clinical response is a lengthy explanation of why indefinite buprenorphine maintenance is the evidence-based standard — delivered in a way that is more persuasion than education.

It shows up in the language clinicians use: referring to patients who have chosen abstinence-based recovery as "undertreated," or describing twelve-step participation as a placeholder until the patient is ready for real treatment.

It shows up in clinical training, where the pendulum has swung so far from the old abstinence-only gatekeeping that residents and NPs sometimes graduate without meaningful instruction in how to support a patient who wants to pursue abstinence — not because they cannot access medication, but because they have considered it and declined.

It shows up in intake processes that screen heavily for MAT readiness without equivalent attention to identifying patients whose goals and values align better with abstinence-based frameworks.

None of these are malicious. Most are well-intentioned overcorrections from a field that spent decades watching people die because they could not access medication. But overcorrection is still error.

Patient Autonomy Does Not Have a Preferred Conclusion

The addiction medicine field has done important work rehabilitating the concept of patient autonomy in the context of MAT — arguing, correctly, that a patient who wants medication should not be forced to demonstrate motivation or meet abstinence requirements first. That framing protected a lot of people.

But patient autonomy is not a value that applies selectively to patients who choose medication. It applies equally to the patient who says: I have looked at the options, I understand what buprenorphine is, and I want to pursue recovery without daily pharmacotherapy.

That patient is not making an uninformed choice. That patient is not engaging in magical thinking about willpower. That patient may have strong family, spiritual, or personal reasons for their preference — reasons that deserve to be engaged seriously, not managed out of existence in a single appointment.

The goal of individualized care is not to guide every patient toward the same destination. It is to meet each patient where they are and support the path most likely to result in their recovery.

A clinician who spends most of the appointment trying to convince an abstinence-oriented patient to reconsider has not provided patient-centered care. They have provided their-preferred-outcome-centered care with a patient-centered vocabulary.

What Holding Both Options Open Actually Looks Like

In practice, this means a few concrete things.

It means the initial assessment includes genuine, non-leading exploration of what the patient wants recovery to look like — not just whether they are willing to take medication.

It means being able to describe abstinence-based frameworks accurately and without condescension: what twelve-step programs offer, what therapeutic communities are, what faith-based recovery programs exist in the patient's community, what the outcome data look like.

It means offering MAT without pressure to every patient who might benefit — because many abstinence-oriented patients have not had an honest conversation about what these medications actually do, and accurate information is not coercion. But it also means accepting a clear, informed refusal without treating it as a clinical problem to be solved.

It means following the patient's lead on timeline. Some patients start in abstinence-based programs and later request medication. Some patients stabilize on MAT and later want to taper off. Both are legitimate trajectories, and the clinician's job is to support the current goal while keeping future options available — not to use each visit as an opportunity to relitigate the patient's choices.

It means being honest when a patient's abstinence-based plan is not working — presenting that information clearly, without an "I told you so" subtext, and re-offering medication access without making it conditional on the patient admitting failure.

The Strongest Version of This Field

The strongest version of addiction medicine does not have a preferred pathway. It has a preferred outcome — stable, sustained recovery — and it holds every legitimate tool open in service of that outcome.

MAT saves lives. Abstinence-based recovery, for the patients for whom it works, also saves lives. These facts are not in competition.

What diminishes the field is treating clinical preferences as ethical obligations, or allowing the justifiable frustration with ideology-based MAT refusal to curdle into ideology-based abstinence refusal. One form of paternalism does not justify another.

Recovery is not one road. Pretending otherwise is its own kind of dogma — and our patients deserve better than that from us.

About the Author

Dawn Gadon, APN, CARN-AP, is a board-certified addiction registered nurse practitioner and the owner of Dawn Gadon Wellness in Somers Point, New Jersey. She provides addiction medicine, MAT, hormone optimization, and direct primary care through a direct-pay model with both in-person and telehealth availability throughout New Jersey.

dawngadon.com  |  609-365-0028