drug-free treatment model
A voice from the wilderness
The drug-free treatment model is worth defending, now more than ever
by Andrew D. Bennett, CADC II
The chemical dependency treatment field is experiencing significant changes in the service of “new technologies.” We seem to have been swept away by these changes within a professional atmosphere characterized by compliance, lacking sufficient critical review.
We are currently moving to a medical model emphasizing a psychiatric orientation embracing dual diagnosis and bio-pharmacological interventions. The primary disease concept and the drug-free model are clearly challenged. They need to be defended.
With a single major exception, an archival review of the trade magazines reveals that time and time again articles characteristically have supported medication-assisted treatment (MAT), including but not limited to Suboxone for opioid addiction and anti-craving medications.
1 A recent example of this dominant point of view appears in an article not surprisingly scheduled as the first of a continuing series of columns. In the article,
Marshall Rosier refers to an “anti-medication bias” and “ingrained ideologies” on the part of recovering people and addiction professionals regarding MAT.2 Could MAT proponents likewise suffer from “ingrained ideologies” regarding an “anti-drug free” bias?
Articles of this kind recommend that counselors who prefer a drug-free approach “need to be educated” concerning the “research-based evidence” regarding “breakthroughs in neuroscience.” I assume they’re talking about people like me; folksy old-school Middle Cretaceous 12-Steppers who are apparently ignorant of the scientific method and who are not academically equipped or otherwise inclined to review the literature. Despite our alleged educational deficiencies, we see fundamental problems with the quality of their teaching materials.
In 1961 it was thought that alcoholics drank over underlying emotional problems and a “Valium deficiency.” In 2010, alcoholics and drug addicts drink and use over underlying emotional problems and a serotonin deficiency. Legions of psychopharmacologists are pumping out new and improved anti-craving synaptic rejuvenator pills.
Professionals are telling patients that on the one hand they are powerless over alcohol and other drugs, but at the same time they are prescribed pills designed somehow to make them feel less powerless.
It’s time to take a good look at how we’ve been doing business and what it is we’re selling.
It’s time that chemical dependency treatment providers joined the ranks of all the other social sciences in the application of critical peer review to our work.
I take no issue with MAT or competing clinical approaches that do not claim to fit into a 12-Step context.
However, if there is such a thing as an abstinence-based 12-Step treatment model that is worth preserving, boundaries need to be put around it.
Research shortcomings
Antidepressant medication, nutritional supplements and opiate antagonists are promoted to allay craving and other dysphoric feelings following classical detoxification.
They are used, in theory, to help restore depleted neurotransmitters following chronic substance abuse. Agents of this kind are supposed to help restore neurological integrity at the synapse.
The short-term efficacy of this class of medications has been mixed.1 More importantly, problems of experimental research design are noted across the literature.1,3,4,5,6,7
No amount of placebo-controlled, double-blind methodological safeguards can make up for short-term studies lacking meaningful control groups and limited to a statistically compromised number of subjects willing to be experimented on within treatment facilities willing to conduct drug therapy experiments.
One cannot make any scientifically coherent statements about long-term efficacy in arresting chemical dependency based on the methodological compromises characteristic of current anti-craving or opioid agonist/antagonist medication studies.
My bachelor of science degree tells me that these kinds of trials cannot clarify whether offering drug addicts and alcoholics mood-altering substances is generally a good thing.
In the March/April 2007 issue of Addiction Professional, Stuart Gitlow, MD, and Mark S. Gold, MD, offered an enlightening review of the methodological shortcomings characteristic of current CD drug trials.1 There are few, if any, long-term patient outcome studies demonstrating the efficacy of anti-craving agents.
The research fails to differentiate functional or reactive dysphoria from organic or endogenous dysphoria.
Patients who all of a sudden find themselves squeaky clean following a protracted chemically induced post-traumatic stress disorder will naturally be a little fuzzy around the edges, especially after looking at the mess they have made.
This kind of dysphoria is very different from the protracted organic dysphoria thought to occur as a symptom of chronic chemical thrashing and assault at the synaptic level.
Psychogenic dysphoria is always expressed neurologically as well, altering neurotransmitter levels. The research fails to tease one out from the other.
Is “craving,” following detoxification, essentially psychogenic, driven by euphoric recall (functional), or organic? My unscientific opinion, drawn from routine clinical observation, tells me it is psychogenic. CD patients should not be medicated for functional reasons.
Effects of medications
A wide variety of antidepressant and mood-stabilizing drugs billed as non-addictive are frequently prescribed for chemically dependent patients. It would seem, even to a layman, that using mood-altering drugs to help addicts recover flies in the face of common sense.
Strung-out cocaine addicts have been known to snort “non-addictive” white battery acid residue found on car batteries.
What may be non-addictive for a non-user might act very differently when processed through the well-entrenched substance-dependent mind of a recovering person.
Instances of chemically dependent patients abusing these kinds of substances before returning to their drugs of choice are not uncommon. Chemically dependent people have problems with mood-altering substances.
Certainly the conservative, judicious use of psychotropic medication in patients presenting with a genuine dual diagnosis has played a critical role in continued recovery.
Prescriptions of this kind, however, always carry with them a dangerous message that somehow patients are neurologically, or organically, or pharmacologically, or constitutionally compromised in tolerating their feelings and for this reason they will benefit from continuing to use “different” drugs.
Before prescribing psychotropic medication, the clinician needs to decide if this is really true before advising the patient to go out on that kind of limb.
In his disturbing new book Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, Robert Whitaker points out that the number of Americans diagnosed with mental illness has tripled over the past 20 years.
5 This statistic is also reflected in the burgeoning dual diagnosis trend, where ever-increasing numbers of chemically dependent patients are diagnosed with concomitant mental disorders and are consequently prescribed psychotropic medication.
In his thoroughly researched publication, Whitaker finds no scientific evidence that psychiatric medications stabilize “chemical imbalances in the brain” and that they are more likely to cause them.
Whitaker, a recipient of the George Polk Award for medical writing and a finalist for the Pulitzer Prize, goes on to state that with some exceptions, long-term studies consistently show that patients have worse outcomes on psychiatric medication than off psychiatric medication.
Some researchers point to longer treatment retention for patients who are prescribed antidepressant and/or anti-craving medication.
It is not surprising that a drug-addicted patient, having a great investment in pharmacology, might hold out longer when offered anti-craving substances within facilities that invite patients to use them.
Researchers point to a reduced AMA rate for patients who are prescribed antidepressant/anti-craving medication. If some patients were given methamphetamine, they would stay in treatment even longer.
Impeding long-term success
It has been said that in some ways, 12-Step programs are against human nature. Willingness to work a 12-Step program requires an enormous motivational force.
The patient must accept “being whipped.” For this reason, the Big Book makes reference to “incomprehensible demoralization.”
The use of anti-craving agents is most likely to fortify patients’ normal resistance to 12-Step programs. In this way, higher short-term abstinence rates may contribute, paradoxically, to lower long-term rates of recovery.
Physician colleagues point out that chemical dependency counselors are not qualified to understand fully the therapeutic effects of psychotropic drugs.
This is true. CD counselors are, however, experts on how they can hurt people. Powerlessness and craving are precisely what drive people into 12-Step programs. In this way, the most dangerous thing about anti-craving agents is if they work as intended.
Willingness to work a 12-Step program requires an enormous motivational force. The patient must accept “being whipped.”
Methadone and other maintenance protocols have earned their place in the sun. Although I am not qualified to comment on the efficacy of these regimes, I believe they cut down on drug-related crime. The goal of controlled drug use, while certainly preferable to uncontrolled drug use, is nevertheless antithetical to recovery.8
Treatment used to be about helping patients recover from chemical dependency. Since the advent of Suboxone, its manufacturer wants recovery service providers to adopt the Orwellian position of helping chemically dependent patients successfully remain chemically dependent longer.
Treatment plans suggest that Suboxone patients during maintenance or extended ambulatory detox can somehow conform to NA 12-Step principles where they are advised that they are powerless over their addiction, including but not limited to some variation of their opioid drug of choice.
Step 1 makes no qualifications concerning the contrary opinions of the pharmaceutical companies and the physicians who have frequently provided the substances required to cause the problem in the first place.
The inclusion of Suboxone-maintained patients within a 12-Step abstinence-based treatment model will fundamentally compromise the integrity of the peer group by undercutting the common task of adjusting to becoming clean. The alcohol, cocaine, benzodiazepine and methamphetamine peer group members are left to wonder why their opioid-dependent peers are encouraged to remain on a replacement for their drug of choice, antagonist properties notwithstanding.
The medical model appropriately charges the technologist with providing treatment for the patient. Recovery services, however, are often more spiritual and less technological in nature.
12-Step CD counseling also involves a greater emphasis on peer support, patient compliance and responsibility. A medical model philosophy used for a cancer patient can have an enabling effect when applied to an alcoholic or a drug addict.
Alcoholism and drug dependence have been described as baffling, cunning and powerful. While undoubtedly driven by psychosocial forces, chemical dependency is essentially biogenic in nature.
The debate concerning the etiology and treatment of this complex disease rages on. Recovery, however, carries with it a spiritual component that has proven itself to respond favorably to a “moral psychology,” as proposed in the Big Book by William D. Silkworth, MD.
Discussions about clinical theory and treatment protocol are crucial. They define what we do as professionals. They help us to describe and improve upon our skills. Discussions of this kind, however, continually remind me to recognize the limitations of technological solutions for spiritual problems.
Andrew D. Bennett, CADC II, based in Oceanside, California, has 30 years of experience in the chemical dependency treatment field, including conducting patient lectures and professional trainings. He is a published author and a frequent contributor to state and national conferences. His e-mail address is cloudedb@aol.com.
References
Gitlow S, Gold MS. The inadequacies of the evidence. Addiction Professional 2007 Mar/Apr; 5:17-25.
Rosier M.. Medication-assisted recovery: emerging trends in the treatment of substance use disorders.Counselor 2010 Apr; 32-8.
Als-Nielsen B, Chen W, Gluud C, et al. Association of finding and conclusions in randomized drug trials. JAMA 2003; 290:921-8.
Bodenheimer T.. Uneasy alliance: clinical investigators and the pharmaceutical industry. N Engl J Med 2000; 342:1539-44.
Whitaker R.. Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. New York City:Crown Publishing Group; 2010.
Jackson G.. Rethinking Psychiatric Drugs: A Guide for Informed Consent. AuthorHouse; 2005.
Shah AA, Finucane TE.. Commercial influence on psychiatric drug studies. Psychiatric Times 2006; 13:71-3.
Hazelden Publishing. Buprenorphine adds value to opiate maintenance therapy, but is not recovery.The Hazelden Voice,Winter 2003.
Addiction Professional 2011 March-April;9(2):30-33