Authors’ reply to commentators

TL;DR: Van den Brink, Davoli and Perucci, Verthein et al. as discussed by the authors, and Monteiro and Newman made the conceptual distinction between cure and care and pointed out that in real life, even if cure is the eventual goal, care may be used for different reasons on the difficult pathway leading to abstinence.

Abstract: We are grateful to the editors of SPM for having invited comments on our report and to the distinguished commentators for their thoughtful remarks. We appreciate the opportunity that is given us here to respond. The remarks of van den Brink, Davoli and Perucci, Verthein et al. and Monteiro are mostly complimentary of, and largely complementary to, our report and, in that sense, do not require extensive replies. The criticisms of Newman will be dealt with in more detail. Van den Brink’s comments are generally supportive of our approach and conclusions, though he does regret certain absences in the paper. It is correct that stage of illness (as opposed to stage of treatment) and treatment objectives are not explicitly included, as such. This is because we felt that the modular approach in our scenarios allows the therapists to implicitly consider illness severity and the therapeutic response to targeted problems. Van den Brink has correctly made the conceptual distinction between cure and care. However, it is important to emphasise that in real life, even if cure is the eventual goal, care (i.e., MMT) may be used for different reasons on the difficult pathway leading to abstinence. Physical examination and blood tests are not listed in our list of initial assessments, though they could very well have been. The reason, as van den Brink understands, is because in our system the first level of treatment is with the primary care physician and it is assumed that this assessment has been done if the patient’s condition and physician’s need for information requires. Physical examination and blood tests were thus considered to be part of usual care and left out of the framework of the specific criteria examined. As can be seen from the actual ratings, all the elements we identified for initial assessment were considered appropriate by the expert panel. A further element that van den Brink misses is substitution with other opioids. There are at least two reasons for this 1. more than 90% of maintenance/substitution is based on methadone, and 2. the other substances are more generally used in case of failure of methadone.