Overview
A “gold standard” refers to the best possible practice, method, or benchmark available within a field or discipline.
There are a handful of practices that are often considered a gold standard in treatment for substance use disorders, though it should be noted that gold standards are highly subject to change as more research is conducted and more evidence is aggregated:
-
Medication-Assisted Treatment (MAT): also referred to as Medication for Opioid Use Disorder (MOUD), treatment schedules involving Buprenorphine (Suboxone) and Methadone have been shown in studies to cut overdose mortality rates in half
-
Naltrexone or Acamprosate: these medications block the pleasant psychoactive effects from and cravings for alcohol
-
Contingency Management (CM): there are no FDA-approved medications for stimulant use disorders, so CM steps in as a behavioral intervention that delivers tangible rewards for passing drug tests and participating in other treatments like therapy or counseling sessions
-
Motivational Interviewing (MI): every type of substance use disorder, or any health condition for that matter, can leave individuals ambivalent about their perspective and desires to attempt behavioral changes. MI is a style of delivering therapeutic interventions that works alongside a patient’s goals and values rather than attempting to persuade or impose changes.
Cognitive-Behavioral Therapy has often been treated as a gold standard. In my own experience, there’s an almost perverse delight some practitioners and clinicians have taken in their stacks of worksheets and manuals. There’s substantial mounting evidence indicating that CBT does not consistently outperform other evidence-based therapeutic interventions like psychodynamic therapy, which researchers have called the Dodo bird verdict. In fact, the cognitive elements of CBT that involve challenging cognitive distortions may not be a significant factor in the outcomes of CBT, as Behavioral Activation alone provides comparable benefits. Much of the prevalence of CBT comes from its manualization that enables its operationalization, which means that it’s easier to provide mass training for CBT to practitioners and easier to calculate the costs of delivering CBT for insurance companies and healthcare services. Jonathan Shedler is one of the most vocal critics of CBT:
“Even ardent CBT advocates have acknowledged that manualized CBT offers lasting help to few. Writing in Psychological Science in the Public Interest, eminent CBT researcher Steven Hollon noted ‘Only about half of all patients respond to any given intervention,and only about a third eventually meet the criteria for remission…Moreover most patients will not stay well once they get better unless they receive ongoing treatment.’ Ironically, this was written by the same researcher who declared other forms of psychotherapy ‘inadequate.’ Sadly such information reaches few clinicians and fewer patients. I wonder what the public and policy makes would think if they knew these are the same treatments described publicly as ‘evidence-based,’ ‘scientifically proven,’ and ‘the gold standard.‘”