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Recovery-oriented Methadone Maintenance, part 5

Bill cites a methadone advocate making an important distinction--treating dependence vs. treating addiction.

The stigma attached to methadone is also shaped by the expectations of methadone treatment as a system of care. Methadone advocate Walter Ginter comments on such expectations:

Patients, former patients, staff, policy makers, and the public expect the methadone treatment program to treat addiction. While that is a reasonable expectation, it is not what Opioid Treatment Programs (OTPs) do. OTPs treat opiate dependence, and they do it very well. Most patients on an adequate dose of methadone do not continue to use opiates. However, opiate addiction is more than dependence on opiates; it is dependence combined with a series of behaviors. OTPs (with a few exceptions) do not treat the behavioral aspects of addiction. The behavioral aspects are not treated by a medication but rather by counseling, therapy, peer recovery supports, and 12-step groups. As long as well-intentioned people go around saying that “methadone is recovery,” it is going to continue to be misunderstood. Methadone is a medication, a tool, even a pathway, but it is not recovery. Recovery is a way of living one’s life. It doesn’t come in a bottle.547

Recovery-oriented Methadone Maintenance, part 4

Bill summarizes criticism of MM as follows:

Critics of medication-assisted treatment, many of whom were competing for cultural and economic ownership of the problem of heroin addiction, alleged that MM: 1) substitutes one drug/addiction for another; 2) conveys a societal attitude of permissiveness toward drug use; 3) fails to address the characterological or social roots of heroin addiction; 4) cognitively, emotionally, and behaviorally impairs MM patients; 5) is a tool of racial oppression and genocide; 6) is financially exploitive; and 7) as a result of these factors, is morally unacceptable.

He later states:

We concluded in the first two articles that it was time we as a country and a professional field stopped debating the morality of methadone maintenance and focused our energies instead on elevating the quality of methadone maintenance treatment.

I didn't see where another kind of objection is addressed. What about the concern that MM is a manifestation of stigma? That it's based on the premise that drug-free recovery is not possible for opiate addicts (or, certain kinds of opiate addicts)? That it's a form of treatment that doctors never use for their addicted colleagues? That it's born from the failure of drug-free treatment of inadequate intensity, duration and quality and, when we choose to address those inadequacies, outcomes for opiate addicts are very, very good.

Whenever I'm talking with a professional helper about a loved one, one of my first questions is, "What are our options?" followed by, "What would you do if this was your child/parent/spouse?" That's where we determine the ideal course of action and second best options. I'd like to have this conversation with people who have been exposed to the best of both approaches to treatment.

Recovery-oriented=Soviet-style?

Seems the recovery movement in the U.K. has hit a nerve. PeaPod reports:

Writing in SCANbites (not the latest fast food on offer at McDonald’s, but the newsletter of the Specialist Clinical Addiction Network) he [Dr Colin Drummond] rails against what he sees as a politically motivated attempt to force doctors to practise in non-evidence-based ways.

He is ambivalent about the recovery agenda. Praising its potential on one hand, but worried that at its worst “it can be an ideological dogma, imposed by a vociferous minority driven by hegemonic, or, worse, financial motives; a stone’s throw from simple minded translation into daft new Soviet-style targets for treatment delivery”.

Hegemony means the predominant influence, as of a state, region or group over others. A bit like the influence of psychiatrists, say, over the addiction field. 

Recovery-oriented Methadone Maintenance, part 3

Bill White on efforts to broaden the definition of recovery:

Consistent with Newman’s and Dole’s views are definitions of recovery that focus on health and functionality without reference to cessation of medical use of methadone. The examples below illustrate such definitions:

Recovery is the process of pursuing a fulfilling and contributing life regardless of the difficulties one has faced. It involves not only the restoration but continued enhancement of a positive identity and personally meaningful connections and roles in one’s community. Recovery is facilitated by relationships and environments that provide hope, empowerment, choices and opportunities that promote people reaching their full potential as individuals and community members.194

Recovery is a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles.195

The process of recovery from problematic substance use is characterised by voluntary sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.196

Stabilized MM patients would meet these criteria for recovery if they were demonstrating progress toward increased health and functionality. The “sustained control over substance use” in the UK recovery definition is broad enough to include multiple pathways of alcohol and other drug (AOD) problem resolution—traditionally defined abstinence, decelerated patterns of AOD use that no longer meet criteria for a substance use disorder, and medication-assisted recovery—as long as the other criteria of health and positive community participation are met. Similar in spirit to the UK definition were suggestions to the authors from some methadone patients that a broadened definition of recovery is needed.

The only way we will ever be able to move addiction treatment to a chronic disease model is if we take the “abstains from alcohol and other intoxicating drugs” out of the recovery definition, or at least stop making it the deciding factor for the status of being “in recovery”… I think we need to make it one of many goals rather than the focus. This would help us achieve the focus of every other chronic disease treatment: QUALITY OF LIFE and the reduction of symptoms…We have got to stop thinking of recovery as ALL or NOTHING.”

Personally, something about the patient's statement is more compelling than any of the others. I think a lot of people in drug-free recovery would be open to thinking about abstinence as a goal when defining recovery. "One of many" may be a problem because it makes it sounds like it would reduce abstinence to an item on a checklist when, for many of us, without abstinence there is NO recovery--an insufficient, but necessary condition for recovery.

With abstinence being so central to our recovery, it certainly feels like defining recovery as something for which abstinence is not necessary leaves it feeling like an incomplete definition. One of the factors that binds us together is the shared experience of searching for chemical solutions to our addiction problem and having to face the reality there is no chemical solution to our problem. If someone can find one, our hats are off to them, but their experience and our experience are qualitatively different. Not better or worse, but different. The journey may be similar, but it's not the same. Does that make any sense?

This isn't to dismiss recovery-oriented MM, but is it realistic to expect people in drug-free recovery and medication-assisted recovery to identify as one community? We might get there, but we've got a long way to go and a lot of mental barriers to navigate. Many of those barriers were created to protect our recovery and our identity as recovering people. I associate stigma with "otherness". Addicts have long faced being defined as "the other" and recovering people have constructed our own positive sense of otherness. We talk about "normal people" and that we different from people who manage to moderate or find recovery through faith communities. Would embracing MM patients erode this protective differential identity? It also begs the question, why have MM patients been unable to create their own communities of recovery?

The Big Picture on marijuana

The Big Picture (one of my favorite blogs) has a marijuana gallery.

Warning--if you're recovery is a little shaky, you might want to skip it. A few images of people using marijuana.

Recovery-oriented Methadone Maintenance, part 2

Here Bill describes the devolution that troubled early advocates of MM:

The regulation and mass diffusion of MM in the 1970s and 1980s was accompanied by changes in treatment philosophy and clinical protocols. The most significant of these changes in terms of recovery orientation included a shift in emphasis from personal recovery to reduction of social harm; increased preoccupation with regulatory compliance; widening variation in the quality of MM programs; the reduction of average methadone doses to subtherapeutic levels; arbitrary limits on the length of MM treatment; pressure on patients to taper and end MM treatment; the erosion of ancillary medical, psychiatric, and social services; and a decreased emphasis on therapeutic alliance between MM staff and MM patients. The definition of recovery during this period shifted from a focus on global health and functioning to an almost exclusive preoccupation with abstinence—then defined as including cessation of methadone pharmacotherapy. The public face of MM became defined by the worst MM clinics and the least stabilized MM patients.

Recovery-oriented Methadone Maintenance

Bill White has a new monograph out on recovery oriented methadone maintenance (MM). There's something in it please everyone and something in it to anger everyone. He takes the position that MM is an essential part of the treatment continuum but is hard on MM in its current form.

I'm very busy with a couple of projects but I plan to try and post some highlights every day for the next several days. Here's the first.

Here Bill descibes the disappointment of methadone pioneers at what they see as a devolution of MM:

Dr. Dole later spoke of the “stagnation of treatment” that occurred throughout the 1970s and 1980s.87 He was particularly incensed at the depersonalization of MM and the loss of partnership with patients in MM: “the contempt with which many regulators and program administrators have treated their patients seems to me scandalous.”

The strength of the early programs as designed by Marie Nyswander was in their sensitivity to individual human problems. The stupidity of thinking that just giving methadone will solve a complicated problem seems to me beyond comprehension.

Dole was not the only early MM pioneer who criticized the evolution of MM in the 1970s. In 1976, Dr. Robert Newman, who led the expansion of MM in New York City, declared:

Methadone maintenance treatment, with its unique, proven record of both effectiveness and safety, no longer exists. One can only hope that it is not too late to reassess that which has been cast aside, and to resurrect a form of treatment which has helped so many, and which could help many more.90

Other critics, including Dr. Stephen Kandall, concurred with Newman and further argued that:

Political forces reduced methadone to an inexpensive, stripped down way to “control” a generation of addicts without having to provide essential rehabilitative services… 91

Tab Dump

• Rangers Use Ginger Ale in Celebration as Way to Include Josh Hamilton
• The Marijuana Number That Was Too Good to Check
• I lost ten years of my life as a middle class, NHS sponsored drug addict...
• Shelter alters its handling of substance abuse

Amazing

From a recent Bill White speech:

Today, I received an email that 200 recovering people and their families marched the streets of Tokyo this week in Japan’s first ever recovery march. Today, we stand, here and abroad, reaching across geographical, political, racial, and cultural barriers, to mobilize our growing numbers and influence. Today, we stand to reach our goal of engaging those who still suffer and creating a world in which recovery is supported and celebrated. Today, we stand to remind ourselves and to send a message to those still wounded: Recovery is contagious.

This anecdote about Japan is really impressive. Here's a little context:

• Japan has a lot of people--127,000,000. About 40% of the U.S. population.
• AA has been around for decades and membership estimates range from 4000 to 5000.
• Danshukai is the largest mutual aid group. It's membership consists of alcoholics and their families and is estimated to be around 10,000.
• AA membership in the U.S. is estimated to be around 1,000,000 people.

The recovering community in Japan is tiny and stigmatized. For them to bring together 200 members to march in public is quite an accomplishment.

Moving back into the shadows

A friend directed me to this comment about the recovering community and prevention workers:

We recently held a United for Prevention - Celebrating Recovery event and it is our 4th year of celebrating recovery in our local community. Youth challenged law enforcement to a back yard game of kick ball... "kicking it for recovery" was on the back of law enforcement t-shirts and "Life At Its Best... Add Nothing... Play Sober" was on the back of the youth t-shirts. The recovery community was there and I know this because some of our greatest volunteers quietly try to slide in unnoticed - out of the shadow of shame as Penny puts it. We gave away the t-shirts as they were provided by our local mental health provider - and the most popular one I might add was "Play Sober".... you could tell that the message resonated for young, old, middle-aged and yes - particularly with the recovery community. One of my friends in recovery commented "it would have been nice if this message had been around many years ago".... 

It is now October and September Recovery Month has come and gone... and as our friends in recovery start to move back into the shadows... I challenge those of you in prevention to reach out and find ways to keep them engaged ... they are your greatest advocates! And remember, the shadows often bring us our most beautiful flowers and offer a calm ending to our day as the sun sets... treasures worth celebrating!

Drug Legalization and Tax Revenue

Ugghh!

I hate this argument for legalization. I also think it's the wrong way to go about it if legalization were to come to pass.

Think for a moment about the power of the alcohol and tobacco lobbies. (In Michigan it's been impossible to raise liquor taxes.) Think about their marketing power. Think about their place in our culture.

Is that what we want for marijuana?

I fear that capitalism, legalization and out political system are likely to be an ugly combination.

If we were to legalize, I like Mark Kleiman's proposal to keep sale illegal and legalize people growing their own on a limited scale.

Salience

I've posted before about the role of salience in addiction. This is a great illustration:

More on recovery without abstinence

Oops. I meant to add more to that last post and didn't.

The commonly held belief about addiction is that addicts won't seek help without a gun held to their heads. Our experience just shatters that.

I meant to introduce the quote with the statement that Dawn Farm would say exactly the same thing. More than ever, I have faith that, given a menu that includes good options, addicts will migrate toward recovery--whatever that looks like for them. Some may be able to quit heroin and continue to drink while achieving the same quality of life as another who chooses to abstain completely. I believe that the former person is the exception to the rule and that it's a risky experiment--if this path doesn't work, they may not survive or their illness may progress in a manner that makes it more difficult to stabilize and achieve recovery the next time around. However, if a person chooses to pursue this path after reviewing the risks, it's their choice to make. What I fear is programs or systems that don't offer hope for recovery, don't offer accurate information, don't offer treatment/support of adequate duration and intensity and celebrate any positive change without encouraging addicts to keep moving in the direction of full recovery--whatever that means to them.

Recovery without abstinence

I'm not about to start recommending this as a path to recovery, but I really like the tone of this guy. Fascinating story.

The commonly held belief about addiction is that addicts won't seek help without a gun held to their heads. Our experience just shatters that.

The book that started it all

"more than 5 pounds"

only $13 a pound! 

That's cheaper than Starbucks Anniversary Blend!

Let's hope they offer a cheaper version in the near future. (They offer a more expensive version.)

Social network mapping and recovery facilitation

This begs some fascinating questions.

Could targeting specific roles in the culture of addiction bring others into recovery with them--a kind of domino effect?

How many of your friends drink alcohol? How many might say they used alcohol problematically? What about illicit drugs? Probably a smaller proportion of the people you know take drugs, but perhaps a few have experienced problems with drug use at some point in the life.

For the 160 current and former drug users who took part in the RSA’s User-Centred Drug Services Project survey, answers to these questions are, I presume, rather different to yours. ...30 per cent said that all of the people they know use drugs, with most of them using problematically. Similarly, around a third reported that all of the people they know used alcohol, and around half of them had problems because of it.

...The average probability of smoking, for example, is found to be 61 per cent higher if a friend smokes (one degree of separation), 29 per cent higher at two degrees of separation, and 11 per cent higher at three degrees of separation.

A recent RSA paper on problem drug use suggests that recovery may be ‘contagious’ in the same way. This is an important insight, but problematic: if all of the people you know take drugs, how do you get out of this networked influence that entrenches drug use? A study (external PDF) of drug user networks in Connecticut found that, on average, 85 per cent of the people in a drug user’s personal social network (or ego-network) used drugs. Piecing together the community-wide drug using network, the researchers found clustering of drug users into African American, Puerto Rican and White communities. Interestingly, the mapping also revealed who the key influencers were in the drug using network;  those ‘nodes’ at the centre of the network most strongly connected to large numbers of other users.

The RSA is extending its work on drugs to look at how we might similarly map drug using networks in Peterborough, with a view to identifying and working with these potential ‘recovery champions’ to transmit recovery through the network. There is good reason to try this: intervention programmes to tackle smoking and alcohol use that deliberately employ peer effects and social network ‘modification’ are found to be more effective than those that do not.

Stigma Unaffected by Acceptance of Disease Model, Study Finds

This doesn't surprise me. So much of what fuels stigma is fear. Calling addiction an illness or disease doesn't really get at the question, "Am I and my loved ones safe with you around us?"

Psychiatric fads

Allen Frances, Chair of the DSM-IV Task Force, deconstructs the  phenomena of psychiatric fads:

To become a fad, a psychiatric diagnosis requires 3 preconditions: a pressing need, an engaging story, and influential prophets. The pressing need arises from the fact that disturbed and disturbing kids are very often encountered in clinical, school, and correctional settings. They suffer and cause suffering to those around them--making themselves noticeable to families, doctors, and teachers. Everyone feels enormous pressure to do something. Previous diagnoses (especially conduct or oppositional disorder) provided little hope and no call to action. In contrast, a diagnosis of childhood Bipolar Disorder creates a justification for medication and for expanded school services. The medications have broad and nonspecific effects that are often helpful in reducing anger, even if the diagnosis is inaccurate. 

The "epidemic" of childhood Bipolar Disorder fed off the engaging storyline that it: 

1. Is extremely common
2. Was previously greatly under-diagnosed
3. Presents differently in children because of developmental factors
4. Can explain the variety of childhood emotional dysregulation
5. Has diverse presenting symptoms (eg, irritability, anger, agitation, aggression, distractibility, hyperactivity, and conduct problems)

The prophets were "thought leading" researchers who encouraged child psychiatrists to ignore the standard bipolar criteria and instead to make the diagnosis in a free-form, over-inclusive way. Then enter the pharmaceutical industry-- not very good at discovering new drugs, but extremely adept at finding new markets for existing ones. The expanded reach of childhood Bipolar Disorder created an inviting target. The bandwagon was further advanced by advocacy groups, the media, the internet, and numerous books aimed at suffering parents. 

[hat tip: David Mee-Lee]

Hope

This comment on a previous post caught my attention:

Drugoholism is a field, a combination of various processes, internal and external. "As the twig is bent the branch doth grow." is an old adage. I have realised that IN PRACTICE this is true for many. At times the only PRACTICAL solution, apart from the exceptional few is amelioration.

I'm reminded of this post from a few years ago:

Ideas like this are rooted in despair, rather than hope. (see here, here, here) We get overwhelmed by the problem. (here) We're too cheap to offer adequate help. (here) We don't believe that these people can recover. We think they have no chance. We're scared that they'll hurt us and get us sick. (here)  So, we offer them these kinds of interventions. Often, these programs represented in the name of choice, (here) when, the addicts themselves, want better from us. (here, here) They actually want to get well, but often lose hope that it's possible for them. The system starts patting them on the head an encouraging them to be more realistic. (here, here, here) What they need from professional helpers is for us to lend them our hope to cultivate some of their own. (here, here) They need a system that stops talking about if they recovery and starts talking about when they recover. (here)

"If you want to treat an illness that has no easy cure, first of all, treat them with hope." --George Vaillant

Smoking and recovery

PeaPod just posted on one of my pet causes--smoking among recovering people.

The situation is very similar in the U.S. and we are trying hard to address this within Dawn Farm for a few key reasons:

• In Michigan, 23% of the population smokes while 85% of our clients smoke.
• Addicts and alcoholics have a harder time quitting than other smokers.
• Addicts and alcoholics experience greater physical harm from smoking than other smokers.
• Quitting smoking at the initiation of recovery is associated with improved treatment outcomes. Quitting smoking is good for recovery.
• 15% of nonsmokers who enter programs that allow smoking become smokers by the time they leave treatment.   

One of our handouts is available here.

A slidecast is available here.

Ecstasy, meth and marijuana

New drug use survey findings.

Stuck on ... dopamine

In attempting to explain attention and ADHD, Jonah Lehrer explains dopamine's salience function:

But the caricature of dopamine as simply the chemical of hedonism is woefully incomplete. For instance, studies have shown that the dopamine reward pathway is also extremely active when people are forced to eat something disgusting, or when a subject is gasping for air after holding their breath. These are intensely unpleasant experiences, and yet our dopamine neurons are pumping out neurotransmitter. This leaves two possibilities: 1) We are all secret masochists, and take pleasure in pain or 2) Dopamine is really about attention and motivation, and is not just the chemical of pleasure and rewards.

I don’t know about you, but I’m betting on hypothesis number two. I think there’s a growing body of evidence suggesting that the real purpose of the dopamine is to help us efficiently assess the outside world. Many dopamine researchers, for instance, refer to the chemical as our “neural currency,” since it allows us to quickly assign a value to the multitudes of things and ideas we perceive. (In other words, dopamine is the price tag of sensory information, and it attaches hefty prices to things that are delicious, beautiful, or reflect some urgent homeostatic need.) When we see something we want  - and it doesn’t matter if it’s a chocolate cupcake or a glass of water – the mere sight of the object triggers a wave of emotional desire, which motivates us to act. (Emotion and motivation share the same Latin root, movere, which means “to move.”) The world is full of possibilities, and it is our dopaminergic urges that help us choose between them.

Put simply, dopamine's salience function makes certain stimuli nearly impossible to ignore.

Previous posts here.

Is abstinence best? redux

The link I posted to Peapod's post about abstinence prompted a few comments on this blog and several on Wired In.

Many of the comments could be summarized as, "abstinence is best for some, for other's it's not."

I think this misses the forest for some of the trees.

The real questions is, in general, what goal should the treatment system treat as the ideal, achievable outcome--abstinence or maintenance?

To me, if the choice is between elimination of symptoms or management of symptoms, the choice is clear.

To be fair, a maintenance advocate might reframe the question this way, "which treatment is likely to lead to the most improved quality of life for the most people?"

I think, as Peapod pointed out, Laudet's research responds to this question:

“We conducted a study among former substance users, the Pathways Project, to examine the question. 289 participants had had a severe history ofDSM-IV dependence to crack or heroin lasting on average 18.7 years, and had not used any illicit drugs for an average (mean) of 31 months when they entered the study. They were asked to select the statement best corresponding to their personal definition of recovery – 86.5% endorsed total abstinence (Laudet, 2007).

Because the treatment system in the US is strongly influenced by 12-step ideology (McElrath, 1997), we repeated the study in Melbourne, Australia, where the approach to substance user services focuses on a harm-minimisation ideology. Australian participants were also people who had experienced a long and severe history of dependence, mostly to heroin, but who had not used any drugs recently. 73.5% of Australian participants endorsed total abstinence from both drugs and alcohol as their personal definition of recovery (Laudet & Storey, 2006).”

Further, whenever I'm confronted with a health question (for myself or a loved one), my first question is this, "what treatment do doctors with this problem receive?"

In the case of addiction, the answer to that question is abstinence oriented treatment, recovery support and monitoring that lasts years. And, the outcomes are outstanding.

Why would we focus on a different goal for other populations?

Is abstinence best?

I'm in a time crunch, so no time to write anything about it, but this post from Peapod is a must-read.

Parental drug use and adolescent treatment outcomes

A study of juvenile drug court participants finds one powerful predictor of poor outcomes:

Results indicated that youth whose caregivers reported illegal drug use pretreatment were almost 10 times as likely to be classified into the nonresponder trajectory group. No other variable significantly distinguished drug use trajectory groups.

Meta-analysis of acamprosate

Money quote:

Compared to placebo, acamprosate increased the number of days drinkers stayed abstinent by about 11%, and reduced the odds of their return to drinking by 9% during a 3- to 12-month follow-up period. Combining naltrexone and acamprosate increased the odds of sobriety by 30% — but this drug cocktail had so many side effects that many patients simply dropped out.

A well defended smoker

As a former smoker, I can relate to irritation when my smoking was brought up, but I think it's only going to get worse for smokers in the public eye.

Alcohol first aid

The British Red Cross is recommending that alcohol first aid be taught to school age kids.

Makes sense to include in any first aid course, and looks like it's part of comprehensive first aid education. I like that aspect.

Drug problems and domestic violence screening

This study found that patients with diagnoses related to alcohol and other drug problems were MUCH less likely to be screened for interpersonal violence. Why is that?

Crash course on dopamine and addiction

Crash course on dopamine and addiction:

First, Nora Volkow:


Next, Adam Kepecs:

E-cigarettes and a random thought

The FDA has weighed in on some of the marketing strategies being used for e-cigarettes.

It's amazing how this industry has exploded. Locally, it seems that one of the things driving sales is this year's smoking ban in Michigan. Bars are selling them so that people can "smoke" in the bar.

Tangential thought: I was driving this morning and was stopped at a light. In front of me were a police car and next to the police car was another car. The driver of the other car was smoking and tossed their butt out the window while waiting for the light to turn green. This struck me as an incredibly stupid thing to do right next to a police officer.

What is that all about? I suspect the smoker doesn't even think of tossing a cigarette but as littering. (I didn't until someone confronted me.) Why is that? Further, I suspect the smoker thought nothing of tossing his butt next to a cop.

I'd guess that it's some combination of semi-conscious autopilot behavior and cognitive defenses around smoking.

Whatever it is seems as though it would be a significant barrier to quitting.

Funding Recovery Support Services

One of the big challenges in treating chronic illnesses is that they don't fit well into tradition funding models. With any chronic illness, one of the most important goals is to facilitate behavior change and then provide long term support to maintain those behavior changes. There are no billing codes for these activities and they are not "procedures" as we are used to thinking about them. Practitioners who choose to engage in these activities often have to do so on their own dime.

So...it's good to see that the federal government is thinking about how to fund these activities.

Heavy drinkers outlive abstainers?

Interesting post about the relationship between drinking and longevity.

A recent study found that heavy drinkers outlive nondrinkers. Other bloggers suggested that drinking is a proxy for social connectivity and this explains the difference in longevity.

Maia follows up on these posts and wonders whether membership in AA for alcoholics might serve a similar function as drinking for non-alcoholics.

So, that got me to thinking: could the life-extending benefit of drinking be extended to nondrinkers, minus the alcohol? For instance, couldn't AA's social network offer similar health advantages to teetotalers?

The reasoning here is that abstainers are on the whole a lonelier and more depressed bunch, compared with their tippling peers (though, again, there are exceptions to every rule: many abstainers don't drink for religious reasons and still have strong social networks through church). Lehrer notes a spate of recent research connecting loneliness and lack of friends and family to higher risk of illness and death. One major study even found that loneliness may just as bad for your health as smoking. That helps explain why the harm done by staying home alone may be greater than that from binging in bars.

It would be very interesting to see follow-up on this study. Do these findings hold in geographic regions with more abstainers? Do these findings hold for people affiliated with religious communities that discourage drinking?

She also points to one big hole in attempts to generalize the findings from this study:

Incidentally, another possibility that hasn't been much considered in the debate over whether heavy drinking really is a boon to health is that the recent study [pdf], published in Alcoholism: Clinical and Experimental Research, included only people who were 55 or older. As a result, heavy drinkers who died early — in car accidents, bar fights, falls, alcohol poisonings, from liver disease or other alcohol-related incidents — would not have been captured by the research.

So, the real conclusion might be not that heavy drinking increases longevity — only that if you're a heavy drinker and you make it to 55 without being killed by it, you're probably a hardy survivor for other reasons, possibly social ones. Nonetheless, even this may not explain the results because other research finds that the leading killer of alcoholics is cigarette smoking, to which people typically succumb in their 50s or later.

Stigma lit review

A lengthy review of research on stigma and addiction:

A key conclusion from this review is that stigmatisation matters. We feel rejection exquisitely because we are deeply social in our makeup and are unavoidably responsive to the behaviours, expressions and words of others. Stigmatisation therefore has a serious impact on the lives of those it afflicts. . . . To be a problem drug user, addict, junkie or drug abuser is to have a master status that greatly affects one’s interactions with others: with members of the public, nurses, doctors, pharmacists and police officers alike. It is a status that obscures all others, and it is a status that frequently incites disgust, anger, judgment and censure in others. No wonder then that stigmatisation has a profound effect on drug users: certainly on their sense of self-worth and probably on their ability to escape addiction.

New resource

Bill White has added a Friends and Favorites page to his website. I'm looking forward to watching him highlight the efforts and writing of lesser known advocates, researchers, practitioners and thinkers.

How many families have tried this?

What is there to say? What feeds the interest in creating these programs?

IT IS only 11am, but already Cora, a friendly, attractive woman in a colourful top and tight trousers, has downed two half-litres of beer and is thinking about her third glass. A chronic alcoholic who lost her home and contact with her family, and was roaming the streets, she proudly tells how her intake of alcohol has been reduced, and her dependency on spirits to get through the day has also gone down.

The Maliebaan centre, in the large town of Amersfoort, east of Amsterdam, opened last October. The first centre of its kind in Europe, it is based on a unique concept regarding the care and rehabilitation of alcoholics.

Far from aiming to dry out its residents – those with no work, no home and no desire to stop drinking – the clinic takes the view that they will never stop consuming alcohol. Instead it aims to help them to end dangerous binge-drinking and to control their intake of alcohol, with noticeable improvements to their health and wellbeing as a result.

Cora and the 19 other clients – 15 men and four women in their mid-20s to late 50s – are allowed to order up to five litres of beer daily, with an hour between each half litre, which costs 40 cent per serving (this is the wholesale price to the centre, which gets through 4,500 half-litre cans per month).

The bar opens at 7.30am and closes at 9.30pm, and the only criterion for being served is that the drinker must be able to get up themselves from their chair, walk to the counter and be able to hold their half-litre glass steady.

My not drinking bothers friends

Though there are aspects of the writer's social circle that I have some difficult relating to, this article does a really good job of describing the social mines one must navigate as a non-drinker:

I couldn't figure out why the roommate kept bringing up my dryness that evening, but I suspect the threat of having a non-drinker in the midst is that, when folks are drinking together, everyone -- except the abstainer -- is going somewhere. Together. On a journey. Booze softens the edges. It massages the ache of unspoken words. It dissolves the perceived boundaries among people. When you're sober, especially if you want to stay that way, you have to be at peace with where you are. You have to believe you're already where you need to be.

There are a lot of young recovering drunks out there who could be benefit from their drinking peers' acceptance and support -- or at from their least social tact. I chalked up the roommate's behavior to callousness or insecurity. Her nightlong needling didn't send me shuttling to the bottle, but someone with less time sober might not have the same tools, the same carefully constructed self-respect, or the same support network as I.

For many, drinking versus not drinking is the difference between life and death. Harping on a vegetarian for not enjoying meat at a barbecue is galling and insensitive, but if the vegetarian breaks down and heads out for a hamburger after the party, she won't die.

An addict who picks up a drink after being nit-picked by her peers might despair and throw herself off a building or just sink back into the groove of self-destruction and self-hatred that could come to define her life.

Stigma and the other

Dirk Hansen included this quote in a post on stigma:

“Psychological theories of illness are a powerful means of placing the blame on the ill. Patients who are instructed that they have, unwittingly, caused their disease are also being made to feel that they have deserved it.”--Susan Sontag, Illness as Metaphor

It brought to mind this quote from Bill White:

How alcohol and other drug problems are constructed are not merely a theoretical issue debated by academics. Whether we define alcoholism as a sin, a crime, a disease, a social problem, or a product of economic deprivation determines whether this society assigns that problem to the care of the priest, police officer, doctor, addiction counselor, social worker, urban planner, or community activist. The model chosen will determine the fate of untold numbers of alcoholics and addicts and untold numbers of social institutions and professional careers.

It's been on my mind because of this post in the Guardian:

The most miserable aspect of Labour's methadone policies is that they encouraged people to believe that in switching from illegal drugs to methadone, they have become "clean". This is a delusion. The most defeatist aspect is that the policies foster the idea that drug addiction is virtually impossible to overcome. Another delusion. . . . I'm not in favour of removing medical crutches that make addicts less of a threat (and I'd advise Cameron to think twice before doing it). But I'm not in favour of leading addicts to believe that they are not capable of doing any better by themselves.

Her use of the word "clean" really bothers me and it's stuck with me all week. I'm not one to get too hung up on language and I often fear that recovery advocacy movements will hurt themselves by focusing on things like language and adopt a victim position that does little to advance the cause. However, the insinuations lurking in her quotation marks and calling it a delusion stirred very protective feelings toward these methadone clients. In the final sentence, her choice of the words, "by themselves" raises suspicions. Is she implying that they just need to pull themselves up by their bootstraps?

I suspect that the writer and I share a lot of common ground on policy positions (as they relate to methadone) and I agree with her concerns about the pessimistic message sent by methadone programs and policies, but I'm not sure I want her as an ally. I hate to sound cynical and tribal, but I often struggle with the influence of non-addicts in policy and the development of services for addicts.

That sentiment brings to mind this Malcolm X story:

Several times in his autobiography, Malcolm X brings up the encounter he had with "one little blonde co-ed" who stepped in, then out, of his life not long after hearing him speak at her New England college. "I'd never seen anyone I ever spoke before more affected than this little white girl," he wrote. So greatly did this speech affect the young woman that she actually flew to New York and tracked Malcolm down inside a Muslim restaurant he frequented in Harlem. "Her clothes, her carriage, her accent," he wrote, "all showed Deep South breeding and money." After introducing herself, she confronted Malcolm and his associates with this question: "Don't you believe there are any good white people?" He said to her: "People's deeds I believe in, Miss, not their words."

She then exclaimed: "What can I do?" Malcolm said: "Nothing." A moment later she burst into tears, ran out and along Lenox Avenue, and disappeared by taxi into the world.

I can relate to his sentiment that the most helpful thing others can do is leave us alone. ("Other" can be a pretty ugly word, no?) Then, when I'm a little less emotional, I'm left to consider my own cognitive biases and 

creeping certitude. I have to think about the contributions of people like Dr. Silkworth, Sister Ignatia, George Vaillant, A. Thomas McLellan, etc. 

Malcolm X had a similar experience to this too:

In a later chapter, he wrote: "I regret that I told her she could do 'nothing.' I wish now that I knew her name, or where I could telephone her, and tell her what I tell white people now when they present themselves as being sincere, and ask me, one way or another, the same thing that she asked."

Alex Haley, in the autobiography's epilogue (Malcolm X had since been assassinated), recounted a statement Malcolm made to Gordon Parks that revealed how affected he was by his encounter with the blonde coed: "Well, I've lived to regret that incident. In many parts of the African continent I saw white students helping black people. Something like this kills a lot of argument. . . . I guess a man's entitled to make a fool of himself if he's ready to pay the cost. It cost me twelve years."

Malcolm X realized, too late, that there was plenty this "little blonde coed" could have done, that his response to her was inconsistent with what he, his associates, and his followers wanted to accomplish.

Bill White wrote about the things that have allowed practitioners to avoid the cultural traps in working with addicts:

Four things have allowed addiction treatment practitioners to shun the cultural contempt with which alcoholics and addicts have long been held: 1) personal experiences of recovery and/or relationships with people in sustained recovery, 2) addiction-specific professional education, 3) the capacity to enter into relationships with alcoholics and addicts from a position of moral equality and emotional authenticity (willingness to experience a “kinship of common suffering” regardless of recovery status), and 4) clinical supervision by those possessing specialized knowledge about addiction, treatment and recovery processes. We must make sure that these qualities and conditions are not lost in the rush to integrate addiction treatment and other service systems.

Recovering Jewish Addicts/Alcoholics, 12 Steps And Rosh Hashanah

A nice reminder of all the tribes within the recovering community. (hat tip: Rabbi Pinson)

A breathe of fresh air on policy

A great sense of perspective from a treatment provider. I'm a fan!

As an advocate for abstinence, Oliver might be expected to defend this option to the detriment of others. On the contrary, she refuses to be drawn into a dispute that, she says, is not only divisive, but misses the point. Abstinence is not about telling all addicts that the only way to "move forward" is to stop suddenly, she says – "it's about providing choices".

Any limits on the prescribing of methadone would, she says, be the "antithesis of individualised care" and "may actually put lives at risk". There is no need for a fissure in drugs policy, she argues. The first treatment an addict receives is about "stabilising the chaos", and if that means something other than abstinence, so be it.

...

As she puts it: "[Drug policy] has been very good at getting people into treatment. We've been very, very good at stabilising them [with methods] such as methadone. What we haven't done and must do is look at what can be done next."

Referring once more to her own struggle to give up drinking, she adds: "The reality is, you can't just put the drink or the drug down. Something has to go with it – people need support as well."

Marijuana for pain

Findings from a study of medical marijuana for treatment of pain:

The study had screened 113 participants but only 23 were eligible. Out of these, 21 completed all four cycles.

The researchers found that the average pain intensity was significantly lower on 9.4% THC cannabis (score 5.4 out of 10) than on 0% THC cannabis (6.1 out of 10) (p=0.023). However, no other comparisons between the different doses were found to be statistically significant.

Participants using 9.4% THC cannabis reported finding it easier to fall asleep and had better quality of sleep than those taking 0% THC. No differences in mood or quality of life were seen with the different THC potencies.

Of the reported side effects, none were serious or unexpected. The most frequent side effects reported by participants when taking 9.4% THC cannabis were headache, dry eyes, burning sensation, dizziness, numbness and cough. Feeling “high” and euphoric was reported once in the 2.5%, 6% and 9.4% THC cannabis treatment periods.

Medicare to cover smoking cessation

Good news. Hopefully Medicaid is not too far behind.

Oxford House in Michigan

Glad to see Oxford Houses making their way into Michigan.

Science and moral truth

This post by Sam Harris gets at something that I suspect is at the crux of much of the disagreement over harm reduction. He argues that there are objectively true answers to moral questions.

There is undoubtedly a great deal of truth in what he says, but the potential for excessive certitude is troubling. It feels like it creates more ground for people to indulge moral vanity rather than less. He introduces a contrast between there being no answers in practice vs, no answers in principle, but it point is to emphasize that there is a correct answer.

He seems to define the correct answer to moral problems as the answer that contributes most to human happiness and thriving--so, he appears to be arguing for a form of utilitarianism, probably a form of rule utilitarianism. It seems, to me, that you can't avoid subjective judgement when we get into defining happiness and thriving and what conditions or acts create happiness and thriving, however we choose to define them.


Related posts:

• Heroin anyone?
• Science can answer moral questions
• Limitations of Utilitarianism
• Politics, Science and Harm Reduction

The Harper government and the Insite flim-flam

I decided not to comment on this today, but here I am. Why do I find this so grating? I think it's the certitude.

I understand the anger of the writer. Government officials trying to construct evidence to support biases or politically convenient positions is frustrating. It sounds like the RCMP dealt with their concerns in a pretty indirect and dishonest manner.

What I find grating is the assumption that one position is bias-free and has objective truth on its side. Science can only answer the questions it's asked. I'm willing to cede that Insite's existence results in fewer ODs, more treatment referrals and fewer discarded syringes when compared to DOING NOTHING.

Doesn't that beg some important questions? If we're spending $3,000,000, aren't there a lot of things we could do to achieve the same outcomes? Who's to say that those outcomes are the most important, or that they address the most important problems?

Further, the writer never really addresses the questions raised in the opposing papers. He seems to just dismiss them as worthless because they were not published in peer-reviewed journals. Why?

It seems like more political theater--both sides seem to assume the matter is a no-brainer and that anyone who disagrees is brain-dead.

Smart readers

Loran Archer left the following comment on the previous post:

Lifetime DSM-IV alcohol dependence in the NIAAA NESARC survey is not a chronic condition. It a broad spectrum of disorders ranging from mild dependence (3 to 9 lifetime symptoms), moderate dependence (10 to 14 lifetime symptoms)and severe dependence (15+ lifetime symptoms).

The 63% with mild and moderate lifetime symptoms do not self-identify as alcoholics and would not be identified by others as alcoholics. If they attend AA 53% will drop out.

The mild/moderate and the severe dependent populations are categorically different types of drinkers. 

In an earlier study of AA access and continuance, A model of access to and continuance in Alcoholics Anonymous http://knol.google.com/k/a-model-of-access-to-and-continuance-in-alcoholics-anonymous# , I describe the differences.

His link is an AMAZING resource. He has two Knol articles:

• A model of access to and continuance in Alcoholics Anonymous
• Pathways to abstinence: Impact of Alcoholics Anonymous

I've never seen such a clear summary of research on AA attendance and abstinence among AA attendees (and dropouts).

The first paper reports on the people who try AA, who continues, who does not and possible reasons.

The second looks at abstinence rates among people who have attended AA.

It looks at data from only one study and some of the numbers are not huge due to low numbers of subjects with any prior AA attendance, and it won't satisfy critics who will only accept randomized controlled trial, but it seems to me like a pretty strong response to a lot of the twelve-step facilitation criticism.

From the conclusions of the paper on abstinence:

The abstinence recovery rate for Americans with high severity alcohol disorders who continue to attend AA ranges from a low of 45%, age 18-29, to a high of 84%, age 50+ years.

The findings of this study support the findings of Kaskutas et al that "disengagement from AA does not necessarly translate to a return to drinking". The rates of abstinence, over 60%, in the 40+ years high severity AA drop outs are similar to the rate of abstinence, 63%, in the 30-39 year age high severity group who continued in AA.. The findings suggest that a substantial portion of the "AA drop outs" attain sobriety or abstinence after a period of AA membership and maintain their abstinence without AA attendance.

The problem with DSM dependence

This NIAAA feature points out a big problem with the DSM diagnosis alcohol dependence. The diagnosis is intended to capture people with chronic problems and the NIAAA article suggests that as many as 70% have one episode that lasts less than 4 years and that 75%  of those who "recover" do so without any treatment. This leaves 30% having more than two or more epsiodes. The former group appears to be people who go through a period of heaving drinking (most often as young adults) and then moderate or stop drinking on their own.

This begs all sorts of questions, such as:

• Should these two groups be in one diagnostic category? 
• I what ways are these categorically different types of drinkers? Do they respond to different treatments? Do they require different treatment goals? (abstinence vs. moderation) 
• Do these people who "recover" think of themselves of recovering? Should they?
• Are there ways for clinicians to distinguish between these two types? Are the people with more severe forms more likely have the chronic form? Are there patterns in terms of the diagnostic criteria that are met for the 2 groups? (I suspect that the loss of control criteria are more frequently met for the people with the chronic type.)
• When we read stories about the number of people who need treatment and don't receive it, are those 70% included? (yes) What does this mean for those kinds of statistics?

[via Adi Jaffe]

Washington Post redux

Another take down of the Washington Post op-ed has been posted here.

Bye Bye Bereavement Exclusion?

A NYT op-ed reports that the APA is close to either dropping the bereavement exclusion from the Major Depression diagnostic criteria or adding something like Bereavement Related Depression.

I too find this troubling and see no way to characterize this other than an attempt to pathologize a normal human process.

One of the advocates left a comment on a post a couple of years ago. One of the links he left was a counter argument against the concerns identical to those expressed in this NYT op-ed. Among his counter arguments was this:

There are no convincing data showing that the bereavement exclusion for the diagnosis of major depression protects against “pathologizing” normal grief,

Really? The title of his response is "DSM5 Criteria Won’t “Medicalize” Grief, if Clinicians Understand Grief". Isn't the DSM a manual of DISORDERS?

Does someone who is grieving have a disorder? Even if they have the same symptoms as someone with a disorder? Is context unimportant? Does someone who experiences intense anxiety in the days following a traumatic event have an anxiety disorder until proven otherwise? How about a patient detoxing from alcohol or benzodiazapines?

No.

Symptoms do not equal diagnosis.

UPDATE: What does this mean? It does not mean we ignore those symptoms. We can respond to the person's suffering without treating them as though they are ill in some way. We can also recognize that the vast majority of grieving people will get their needs met from their family and community and that these natural supports should be the first line response. We can recognize them as at risk for depression and intervene if they are not experiencing gradual relief of their depressive symptoms.

Insite's dollars and cents

This article seeks to answer an important question about Insite. (Vancouver's injection center.) How much does the program save in health care costs?

The argue that the $3 million annual investment in Insite saves nearly $18 million due to and estimated 84 avoided HIV infections.

This begs the question, what else could be done with $3 million that would also prevent 84 HIV infections?

Dawn Farm's annual budget is just over $3 million. We'll serve more than 2000 people this year in 140 transitional housing beds, 49 long term residential treatment beds, 18 detox beds, outpatient services and corrections outreaches. This is pure speculation, but I suspect that in a high-HIV environment like Vancouver, I suspect we'd prevent at least as many infections and save much more by moving people into recovery.

Which is a better investment of scarce resources?

If low-threshold drug-free treatment and recovery support services were proven to provide a similar or better return on investment (as measured by reductions in disease transmission), would Insite supporters resist shifting resources toward those programs? I suspect they would. If so, then it's not just about HIV, is it? What then? Values?

Reflections on the state of the field

Highlights from an interview between 2 of the most important figures in the field.

On the relationship between psychiatric symptoms and AOD use:

Bill White: One of your early interests there was the relationship between patients’ drug choices and particular types of psychiatric disorders. How did that interest develop?

Dr. McLellan: Well, once again, there was no planning involved. I was a junior faculty member at the Coatesville Veteran’s Administration Medical Center. At that time, they had about 3,000 residential beds that were constantly filled with people who had psychiatric illness, really quite severe psychiatric illness. This was the era of the first patients’ rights movement, and it fell to me to evaluate a random sample of patients and ask them confidentially about their satisfaction with all manner of things, like their treatment, the food, the doctors and all of that. Well, in the course of this, I was able to insert some additional questions about whether there had been any drug use in their history. And indeed, there was. More importantly, many of them were actively involved in using alcohol and other drugs right on the campus. I was amazed by that—showing my naïveté—so that was the first report; but the second report was a little more interesting.

Because I had interviewed these individuals without any kind of background, I later went and looked up their diagnoses. It turned out that their diagnoses were quite related to the kinds of drugs that they had been using. People who were diagnosed as depressed were often using a variety of depressant or tranquilizing drugs. People who were diagnosed with schizophrenia had histories of using amphetamine—there was very little cocaine use at that time. The people with alcohol and opiate use backgrounds had a variety of diagnoses. I wrote an early paper on this possible relationship.

This led me to ask such questions of current patients, many of whom had been coming to the Veteran’s Administration for a number of years. By tracing back their early psychiatric test results, I found over a six year period, in a sample of people who had returned to treatment every year for six years, that there was a progressive development of psychiatric problems that mirrored the actions of the drugs they were using. Particularly interesting were the changes in psychiatric diagnoses among people who used amphetamine/methamphetamine over a six year period. They moved from being treated primarily in the drug unit, to being treated in the psychiatric unit, and finally, into locked wards. It looked as though, after some period of time, the symptoms that were purely drug-related and temporary ultimately ended up being permanent or semi-permanent. The same thing happened with people who used combinations of alcohol and depressants. Depression—significant, serious depression—was sustained. Also interesting, we saw no major changes in the psychiatric problems of people who used opiates or alcohol.

As a point of potential interest to young researchers, I wrote these findings and tried to present them to the American Psychological Association, and they turned it down flat.

On thinking about multiple problem clients:

Some problems cause substance use; some problems result from substance use; and some simply emerge along with substance use as the result of genetic, personality or environmental conditions. This was one of the most important things I ever learned about addiction. Like many of the people I meet in my current job, I too thought that if you just reduce the drug use, all the other “drug related” problems would disappear. This was, and still is, a very naïve view. Worse, it has been a very big force in the way the original—and some of the existing—treatment programs were conceptualized, designed, funded and evaluated.

On service integration and the future of the field:

In this policy environment that I’m in now, one of the emerging themes is integrating addiction treatment into mainstream healthcare. I know a lot of readers are going to get very worried about that. They know the bad old days when addiction was treated under the mental health umbrella and was viewed as merely a symptom of an underlying depression or personality disorder and never given the emphasis it properly required. I hope that doesn’t come back, but here’s the other truth: addiction treatment as a field is currently reaching only a tiny fraction of the people it should reach.

Addiction is causing and is complicating a lot of medical disorders. Mainstream healthcare has never really paid the attention it should have to addiction related problems in the mainstream healthcare system. Meanwhile, as addiction treatment has become more segregated, budgets have been reduced virtually every year since I’ve been working in this field. I know of no kind of treatment, education or public enterprise that is best when it is segregated. So we’re trying very hard to bring addiction treatment—particularly screening and early intervention with mild to moderate substance use disorders—into lots more healthcare settings, particularly primary care and family medicine centers. Importantly, I am talking less about “addiction,” than about the less severe and less chronic forms of substance use—unhealthy use, problematic use, etc. We’re trying to develop more and more varied kinds of treatments: treatments that will involve medications, treatments that will involve families; treatments that will involve whole communities. We are hoping that different types of treatments for mild to moderate substance use problems, delivered within the same context as the rest of medical care, are more attractive and engaging to those who will not even consider treatment now.

Prayer and drinking

Not a study of alcoholics, but may offer some insight into a mechanism of change:

... they randomized students (all of them religious believers) to two groups. One group was asked to pray every day for their friends and family (they had to pick 5). The other group was asked simply to think positive thoughts daily about their friends and family.

By the end of the study, four weeks later, the 'good thoughts' group were drinking nearly twice as much alcohol as the 'prayer' group.

So it seems that making nominally religious people actively engage in their beliefs can discourage them from drinking. But why?

Lambert has two theories. First is that prayer may help to improve your relationships with others (that's something Lambert has shown in an earlier study). And if relationships are stronger, then you'll have less need to turn to drink to overcome social barriers.

His second theory is that spirituality and alcohol consumption are alternative routes to relieve the 'burden of self'. This is the idea that, particularly in Western cultures, people are under high pressure to succeed as individuals. By turning to prayer, people may have less need to turn to the bottle.

Personally, I think something else is going on here. By making people pray every day, what you are doing is reminding people constantly of their religion. It's called priming. And by doing that, you remind them of their cultural expectations - and also remind them that god is watching them.

Rehab doesn't work

The Washington Post published an opinion piece on addiction treatment and AA. I can't help but think of Emerson:

Well, most men have bound their eyes with one or another handkerchief, and attached themselves to some one of these communities of opinion. This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars. Their every truth is not quite true. Their two is not the real two, their four not the real four: so that every word they say chagrins us and we know not where to begin to set them right.

Where to begin? How about the beginning?

the 12-step model pioneered by Alcoholics Anonymous that almost all facilities rely upon

Really? "almost all . . . rely"? How many is "almost all"? What constitutes "relying"? Surely, most treatment programs make referrals to 12 step programs, but I'd say relatively few "rely" on 12 step programs and owe much more to CBT based relapse prevention and motivational interviewing. Most seem to view 12 step involvement as a potentially helpful adjunct rather than something core or central to treatment. Of course, there are programs that rely on 12 step programs (Dawn Farm could be characterized this way, though we do integrate other approaches.), but to say that "almost all" "rely" on them is difficult to swallow.

We have little indication that this treatment is effective.

Just not true. (The link offers reams of evidence.)

When an alcoholic goes to rehab but does not recover, it is he who is said to have failed. But it is rehab that is failing alcoholics.

Blaming the patient for relapse is definitely a historical failing of addiction treatment providers. However, these attitudes have dramatically improved, and this problem is not unique to addiction treatment. Doctors are only beginning to look at ways to improve compliance with treatment for chronic disease and use of prescription medications? Haven't they too historically blamed patients for failing to take their meds, exercise, follow diets, etc.? This doesn't excuse this failure of addiction treatment providers, but it provides some important context.

And the way we attempt to treat alcoholism isn't just ineffective, it's ruinously expensive: Promises Treatment Centers' Malibu facility, where Lohan reportedly went for her second round of rehab, in 2007, has stunning vistas, gourmet food, poolside lounging and acupuncture. It costs a reported $48,000 a month.

We think this is just as bad as he does. There are too many people who are cashing in on treatment. But what about nonprofits like Dawn Farm?

Even nonprofit facilities that don't cater to Hollywood types are too costly for most people. At the 61-year-old Hazelden center in Minnesota, which bills itself as "one of the world's largest and most respected private not-for-profit alcohol and drug addiction treatment centers," a typical 28-day stay costs $26,000.

So these are the only 2 tiers of treatment providers? Come on. We charge around $2700 per month. Does he not know that most treatment programs programs/episodes cost nowhere near $26,000? Why would he leave uninformed readers with the impression that these programs are the norm?

And when they do report a success rate, be it 30 percent or 100, a closer look almost always reveals problems. That 100 percent rate turns out to apply only to those who "successfully completed" the program.

Fair criticism. Many programs engage in this practice. It's, at least in part, an artifact of the acute care model where the expectation is that one time-limited treatment episode with produce full and permanent remission. I suspect that Dr. Johnson rejects the acute care model and you'd think that he'd address this fallacy in these kinds of "success rates"--that, not only are they often deceptive, but their premise is faulty.

A recent review by the Cochrane Library, a health-care research group, of studies on alcohol treatment conducted between 1966 and 2005 states its results plainly: "No experimental studies unequivocally demonstrated the effectiveness of AA or TSF [12-step facilitation] approaches for reducing alcohol dependence or problems."

I've posted about Cochrane before, the most germane is a summary of a Sara Zemore presentation last year:

She very effectively rebutted the Cochrane Review from a few years ago by making the following points. (These are based on notes I took and are incomplete. Hopefully they post video so that you can see her complete rebuttal for yourself.)

• It was limited only to randomized trials and ignored the overwhelming observational evidence. 
• It included one of Zemore's studies which was NOT a randomized study of AA. 
• She acknowledged that the randomized evidence is ambiguous. 
• Randomized trials of AA are hard to do because some subjects in other groups end up participating in AA. This happened in Project MATCH. 
• The Cochrane Review did not find Twelve-step Facilitation ineffective. It found it no more effective that CBT and MET. (The summary from the abstract says, "The available experimental studies did not demonstrate the effectiveness of AA or other 12-step approaches in reducing alcohol use and achieving abstinence compared with other treatments, but there were some limitations with these studies.")
• Finally, she cited 4 randomized studies of Twelve-step Facilitation: The outpatient arm of Project MATCH, a study by her colleague Kaskutas, and two others that I missed. 

Onward...

AA itself has released success rates at times, but these numbers are based only on voluntary self-reports by alcoholics who maintain their ties to AA -- not exactly a representative sample.

Even taken at face value, the numbers are not impressive. In a 1990 summary of five membership surveys from 1977 through 1989, AA reported that 81 percent of alcoholics who began attending meetings stopped within one month. At any one time, only 5 percent of those still attending had been doing so for a year.

A few things. First, he acknowledges that this is not scientific survey. It's fair to say that many AA members and allied professionals have little faith in the accuracy of these surveys. Second, did it really report that 81% of alcoholics stopped attending? How were they identified as alcoholics? A common concern among AA members is that courts send non-alcoholics to AA because of an alcohol related offense. Third, here's the report on the most recent survey. It doesn't include dropout info, but does that paint the same picture he paints?

As for his comparison to spontaneous recovery, I've got a few questions. The rate he cites seems very high and begs a couple of questions. First, how stable is this recovery? Second, how rigorous was the screening for DSM dependence? Did they let people slip in who were not chronic or experiencing loss of control? Finally, we've already cast doubt on his portrayal of AAs effectiveness.

Many proponents of AA cite Project MATCH ... After eight years and $27 million, the study concluded that the techniques were equally effective. 

Actually, Project MATCH found few differences in overall effectiveness, but 12 step facilitation was superior for the most severe alcoholics and people with heavy drinking social networks.

Although AA doubtless helps some people, it is not magic.

AA is not magic. It does not work for everyone. It should not be the only option available to people with alcohol problems. However, this is damning with faint praise. AA has been part of the path to recovery for millions of American alcoholics. Not to mention the drug addicts that have been helped by 12 step programs. Why is he so dismissive of this? Are there approaches that have played an important role in more recoveries?

I have seen, in my work with alcoholics, how its philosophy can be harmful to patients who chronically relapse: AA holds that, once a person starts to slip, he or she is powerless to stop.

This is known as the "Abstinence Violation Effect" theory. It's commonly cited in criticism of the disease model, and it makes intuitive sense, but there's little evidence to support it. Studies looking for this effect have often failed to find it.

Equally troubling, AA maintains that when an alcoholic fails, it is his fault, not the program's. As outlined in the organization's namesake bible, "Alcoholics Anonymous" (also known as "The Big Book"): "Those who do not recover are those who cannot or will not give themselves completely to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates . . . they seem to have been born that way." This message can be devastating.

This is a fair criticism. It's also fair to point out that treatment is not AA (and AA is not treatment). Treatment providers who are dropping the acute care mindset don't hold these attitudes or allow them into the treatment milieu. It's also worth pointing out that AA has a pretty loving and accepting toward active alcoholics and its literature humbly acknowledges the limitations of their knowledge. I also can't help but notice Dr. Johnson's choice of words in introducing the quote--bible. Most people refer to it as AA's text. Why did he choose such a culturally loaded term? Does it intimate a bias?

Finally, it's worth noting that in the AA participation fits exceptionally well with a chronic disease management approach. Medical professionals who try to help patients with diabetes and heart disease make behavioral changes would live would love a free, easily accessible, thriving community organized around supporting patients in making behavioral changes to support recovery and reduce the risk of relapse. Why doesn't Dr. Johnson?

I asked a lot of questions in this post and one might interpret them as passive-aggressive. Let me be more clear. I believe that Dr. Johnson doesn't like AA and I believe his piece paints treatment and AA in the worst possible light, primarily by using half-truths. Most troubling (and maybe most telling) is that he offers no alternative. AA is not magic, it does not work for everyone, there should be a menu of options, and research into other treatments should continue, but AA and treatment do work. We don't say bypass surgery doesn't work because some people have more blockages and heart attacks. We don't say diet and exercise aren't good treatment for type 2 diabetes and heart disease because too many people don't follow through. Why hold AA and addiction treatment to another standard?