I get asked which addiction treatment option is the best all the time. The short answer? Whichever one ends up working for the client.
I don’t like being stuck in the corner, having to pick a “best of” option just because I’m asked. For some clients Moderation Management will work, others need intense day-treatment or an in-hospital residential treatment program before moving into a more traditional residential place for a year or more. Some clients feel suffocated by such a structured environment and can’t manage it – outpatient treatment options can be a better fit there.
Sometimes we ask ourselves questions in a way that forces us to make bad choices: Which is better, chocolate or vanilla ice-cream? I reject the premise.
It’s about time we all faced the fact that only rare occasions allow for two-word answers that are absolutely true. The world is full of nuance and if we don’t start allowing some gray into our conceptualization of questions and answers we are going to keep repeating the past mistakes of polarized opposition to a small number of camps that are all equally wrong.
Brain research supports the notion that they way in which questions are posed can affect the sort of answers we look for – our brain pays attention to the stimuli it expects to find. So if you think that all you have to pick from are two or three options, your brain will calculate costs and benefits and spit out an answer – 42. It’s what happens when you ask the wrong question – you get a nonsensical answer.
So I don’t answer question like “which treatment is best?” or “which is more important, biology, the environment, or personality?” The way I see it the pieces are all so interconnected that the separation is false. The question is moot. And that’s true whether you’re picking addiction treatment or a your favorite cone.
About three years ago, I was attending a national conference on public health (American Public Health Association) and presenting my posters on the relationship between drug use and violence, and sexually transmitted infections and injecting drugs. As I walked the aisles I ran into a woman who runs a Florida addiction “treatment” facility. We talked for a bit about my work, her facility, and then we shared some of our personal stories. Mine included meth addiction, jail, recovery, and now graduate school studying addictions. Everything was great until I mentioned that I now drink alcohol socially… “We’ll save a seat for you” she told me as she handed me her business card. Idiot.
Recovery bullies and addiction treatment
As soon as my version of recovery from addiction didn’t match her expectations, it was an immediate failure. Forget the 6 years I’d spent free from crystal meth use, the excellent graduate school career that was producing real results I was there to present. Forget the fact that my family, my bosses, and my girlfriend at the time thought I was doing amazingly well – As far as this woman was concerned it was her way, or her way. Well I call bullshit on that thinking once and for all.
Unfortunately for her, the research evidence, as well as the actual human evidence that I’ve seen, shows that recovery from addiction comes in many colors and flavors, like pretty much everything else in life. We’ve covered research on all about addiction before showing that the best evidence to date actually calls into question the idea that relapse is the necessary disaster so many paint it as. The fact that the majority of those who meet criteria for drug dependence at some point in their life actually recover on their won is also there, and although this does nothing to reduce the impact of addiction on all those who have an incredibly difficult time quitting, it’s there and can’t be ignored. Drug dependence is almost certainly not a one size problem and the solution is probably far from a one-size-fits-all, no matter how much you like your own solution.
So there’s cognitive behavioral therapy, peer support solutions (like SMART Recovery, Rational Recovery, Life Ring, 12 Step groups like Alcoholics Anonymous, and more), medication-supported recovery (like Suboxone, Methadone, Vivitrol and more), Motivational interviewing and other Motivational Enhancement techniques, as well as a whole host of psychotheraputic approaches that are more eclectic. No research we have to date indicates that any of these approaches is necessarily more effective than others, which means that they are all essentially equally effective. We’ve already talked about some combinations that work very well together, like PHP programs for physicians, but there is absolutely nothing to indicate that the 12-steps (for examples) are somehow superior to CBT, or Rational Recovery, when it comes to treating addiction.
If you get better, you’re a success in my book
When it comes down to it, whether this Florida 12-stepper likes it or not, I am still a social drinker and I still don’t believe that this nullifies any of my other achievements or my successful recovery. More importantly, it doesn’t nullify the success of millions of others, no matter how poorly it fits with some people’s notions. When a life gets overrun by drug use or another addiction, a successful outcome to me means recapturing a functional life that is no longer dictated by the pursuit of that addictive behavior. Anything more or less is a personal preference sort of thing. The problem with these idiots who will absolutely ignore success because it doesn’t conform to their expectations is that they drive people out of treatment and away from success and that is not okay. I’ll continue to call them out for their narrow mindedness and hopefully eventually, their voice will be far from the dominant one.
In cognitive behavioral therapy they’re a big part of the “Five W’s” = When, Where, Why,With, and What. In the various 12-step programs they’re simply referred to as “People, places, and things.” But no matter how you refer to them, drug-associated cues, or “triggers” as they are more commonly known, obviously play a big role in reminding addicted individuals about their drug-seeking behavior, and they are often enough to restart old behavior, even among those who have been abstinent for a while and especially when unprepared for their effect.
Different triggers to reactivate old behavior
Research on relapse (what researchers call reinstatement) has long shown that there are a number of things that can return a person, or an animal, to drug seeking after they have been abstinent for a while. Stress, small drug doses, and the presentation of triggers are all very capable of doing this, even after months of abstinence and likely even years. It’s probably not surprising that giving drugs to an abstinent person can make them want the drug again. In fact, I would venture to guess that most readers believe that this is the most powerful way to induce a relapse (assuming the initial exposure was out of a person’s control and doesn’t count).
Well, recent research suggests that in actuality, triggers, or those people, places, and things, might be more powerful or at least longer lasting relapse risks than even taking drugs!
Triggers, not drugs, are shown to be longest lasting relapse risk
Researchers in Japan trained mice to press a lever for meth, getting them to poke their nose into a hole 60 times for a total of 30 meth administration per three hour session. Every time they poked their nose in the right hole they got a shot of meth and a little light above their nose-poke hole went on (this will become the trigger in the end). Once they were doing this reliably the researchers took away the meth and the animals learned, within 10-20 days, that pressing the lever no longer got them a drug and reduced their number of presses to less than 15 presses per session.
After all this the researchers gave the mice an injection of meth 30 minutes before putting them back in the box – leading the mice to start pressing again for the drug even though in the previous session they has pretty much stopped pressing knowing that no drug was coming. Obviously, the drug injection caused the mice to relapse back into their drug seeking. But, as you can see from the figure below (on the left side, the right side shows that the mice didn’t poke their nose into a hole that did nothing as a control), this little trick only worked once, and the next time the mice were given a shot of meth before being put in the box (after once again being taken through extinction training teaching them that pressing the lever did nothing), they didn’t press the lever any more and just around not doing much.
For the following part of the study the researchers once again took the animals through extinction training (and once again the mice stopped pressing the lever for meth) and then in a following session reintroduced the little light that used to go on every time the mice originally got meth. Just like they did with the meth the animals immediately went back to pressing the lever like crazy, hoping that now that the light was back, so was their meth. Just like with the drug relapse experiment above, the researchers repeated this whole process over two months later, only this time, the little light managed to re-trigger the lever pressing again, unlike the one-trick-pony meth. Seeing this, the researchers went for broke and tried another run of this with the same animals, now following up five months after the last time the animals received meth when they pressed the lever. Again the little light got the animals to increase their pressing, only this time it was a little less impressive than the first two tries (but still significantly higher). All in all, the little light managed to restart the lever pressing by the mice three times and a full five month after the meth-relapse experiment had failed!!!
Conclusion, thoughts, and implications about triggers, relapse, and addiction
In a completely different article I’d written that researchers found a number of different patterns of relapse among alcoholics who went to rehab and that in fact, the vast majority of those who did relapse never went back to the kind of heavy drinking that characterized their earlier problem (see here for One is too many, a thousand not enough). While this research touches on a different aspect of relapse, it once again challenges our thinking about the crucial factors in relapse prevention among addicts. Everyone knows that triggers are important, but the fact that they are at least as powerful and apparently longer lasting dangers than even being re-exposed to the addictive drug is a novel one. Still, this isn’t very surprising given the very long-lasting impact of drugs of abuse (especially stimulants like crystal meth) on learning mechanisms. In my opinion, and based on my own experience, those changes are essentially permanent and the only thing that makes an ex-user less likely to run back to pressing that drug lever when being re-triggered 10 years later is the life they’ve built, the experience they have, and the training they’ve undergone in reacting to those triggers. As you can see from the graph above, if a person runs back to the drugs and actually starts using again on that first, second, or third exposure to a trigger they are likely to start the whole cycle again, possibly making it ever more difficult to escape the next time.
Obviously preventing trigger-induced relapse should be a major strategy of addiction treatment and indeed, from CBT relapse prevention strategies to groundbreaking medications that have been shown to be effective for relapse rate reduction (like Vivitrol, Buprenorphine, Bupropion, and more), there is quite a bit of effort going exactly that way.
The brain damage left behind after long-term cocaine use can apparently tell us quite a bit about how well a cocaine addict will do in addiction treatment – as long as we assess the right kind of damage.
Different kinds of brain matter
I’ve talked before about the fact that use of cocaine, and other drugs, can bring about long-term changes in the brain that sometimes include the actual destruction of neural pathways. What you may not know is that brain matter consists of several different components including the cell bodies of neurons (known as gray matter) and the tracts of axons that transmit messages across the brain (known as white matter). There are other parts as well, but those are the two important ones to know for this article.
Gray matter is important because brain transmission isn’t possible without a cell body, which is its operations center. But white matter is equally important because without it, the messages don’t get anywhere. It’s like having a telephone without a communication network – The phone can work perfectly and no one will ever hear you speak.
Until recently, it’s been pretty hard to measure the structure of white matter because it consists of very thin bands that twist and turn throughout the brain. But recent advancements in fMRI imaging and analysis have allowed us to look at it by measuring the direction in which water molecules flow through white matter. It’s called DTI (Diffusion Tensor Imaging) and it’s pretty complicated, but all you need to know is that it lets us know a lot about the integrity of axons in the brain.
White matter and cocaine
Use of cocaine has already been shown to cause damage to brain white matter. A recent study conducted at Yale examined whether the degree of damage can tell us anything about how well people will do in addiction treatment. Researchers took 16 participants and gave them a host of tests as well as some brain scans before sending them off to an 8 week treatment program. The addiction treatment utilized was outpatient and provided different individuals with different combinations of CBT, medication (antabuse), individual, and group therapy. At the end of treatment, the number of clean urine tests (out of 56 total tests) was used as a measure of treatment success. The more clean urines, the better, something I think we need to adopt overall instead of the all-or-nothing view that abstinence is the only form of improvement.
The bottom line: Using three different measures, the researchers found that individuals with more damaged white matter provided less clean urines throughout the addiction-treatment period. Another important fact – the damages areas that were found to be associated with treatment success were found all over the brain. Interestingly, brain damage wasn’t associated with the length of drug use, but it may have been associated with the extent of use (in terms of years and amount used), something the researchers didn’t report on.
Brain matter and addiction treatment outcomes
One day, we’ll have a battery of tests that will let us tailor treatment more effectively towards specific addicts. Genetics, brains scans, and more, will be able to tell us where an addict is especially weak so that we can focus on those areas first. Some may need specific help with impulsivity and weakened learning systems whereas others may be better off with treatment that addresses past trauma and an oversensitive stress response system.
As this research shows, brain scans can offer us a glimpse into the aspects of an addict’s brain that have been compromised. But we’re not there yet – right now, all we know is that certain genes, brain function patters, and experiences, are associated with a greater risk for addictive behavior or a lower chance of recovery. Getting better at more specifically tailoring treatment is still a little farther than we’d like.
Imagine being diagnosed with cancer, going through a regimen of chemotherapy only to have the cancer return within months, and being told by your doctor that there must be something wrong with you and that he can’t treat you unless you let the chemo do its work.
Unfortunately, if you replace the cancer above with addiction, the chemotherapy with the 12-steps, and the doctor with 12-step dogma, you have what we know as the ________ Anonymous model (fill in your favorite blank). It’s even written in what 12-steppers call The Big Book (officially called “Alcoholics Anonymous”) and often read as part of the “How it Works” section.
“Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves… They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty.”
Well, as far as I’m concerned, this is where the 12 steps lose credibility with me. In any other field, if one treatment doesn’t work, another one is tried, and another. Different people with different conditions may need slightly different approaches. If no known treatment works, experimental ones are attempted. This is how medical science advances. Still, the notion of a physician blaming the patient for a treatment not working is ridiculous. There’s an entire field built around intervention research and I’m pretty sure that simply dismissing the patient as constitutionally dishonest isn’t a common technique.
Treating chronic conditions
In diabetes, like in addiction, there is a rate of compliance with prescribed treatment. And just like among addicts, that rate is relatively low, averaging around 30% or less. Relapse is also pretty common in other chronic conditions like diabetes, asthma, and hypertension, and rests around 50%-60%, not far from estimates for addiction.
Some patients are better at following one regimen while others do better with a different schedule, different doses, or different treatment methods altogether. Similarly, while some addicts respond beautifully to CBT, it seems to help some very little. The same is true for the 12-steps, religion, and a host of other practices. As far as I’m concerned, this means that when an addict seeks treatment, their provider should take a good assessment of the issues, prescribe the treatment that seems to fit best, but if that one doesn’t work, try another method, not throw them out because the favorite approach didn’t cut it.
12-step Dogma Vs. Progress
And therein lies the problem with the 12-steps, whether supporters acknowledge the religious nature of the program or not is tangential, the important thing is that they cling to a book written decades ago much like believers hold onto a bible. Both are collections of stories and messages passed on that no one is willing to re-examine and, if needed, change. Medical texts, and indeed any textbook seeking to stay relevant, stay current by issuing new editions that incorporate new knowledge, but the 12-steps haven’t been touched since 1939, or since the beginning of world war II!!!
Advancement requires flexibility
1939 was an important year, with the 3rd Reich beginning its exploits, Steinbecks’s “Grapes of Wrath” seeing its first publication (another book without major edits since), the first stocking ever sold, and the emerging use of penicillin. I think many of us would agree that there have been some serious advances since that time.
When it comes to addiction, those advances include our vastly improved understanding of the neuroscience, genetics, and general brain function involved. Additionally, the development of very effective treatment modalities, like Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT), and Contingency Management (CM), has given providers a much more complete toolbox with which to deal with addiction problems. Unfortunately, many within the 12-step community have never heard of any of these methods, or of the use of medications (like Bupropion) to help with cravings. Personally, I think that’s just sad.
How it works. Really.
It’s time to dust off the covers, and incorporate the 12-steps into the bigger picture of addiction treatment. When 12-steppers wonder why people can’t just see the value of the program, I automatically think of the preacher who sat in on of my addiction class and kept yelling that if only addicts accepted Jesus into their lives, they would be saved. Laugh all you want, but not only did the 12-steppers dismiss him, they missed an opportunity. He had a point- those who accept Jesus into their lives fully may succeed in recovering from addiction on that basis alone – but those who fail to do so should be given every other treatment tool available so that they may also.
This is supposed to be the age of inclusion, a time for Change with a capital “C.” Let’s make ourselves proud and help those suffering by making sure that we’re offering every treatment option possible.
When I was still attending my addiction counseling classes at UCLA, we often discussed the many different tools now available when treating drug abuse (CBT, 12 step, medications, rapid detox, etc.). Still, most of the class members focused on how many of these don’t work with everyone and how some have actually resulted in problems for certain patients. I think this is a mistake.
Like a physician treating any other chronic disease, I think that practitioners in the field of addiction need to come to terms with reality: Chronic conditions (and I don’t mean smoking good weed) are difficult to treat. Still, cancer treatment works by trying the best possible method, then the next, and then the next, until all options have been exhausted. In the addiction world, most therapists and counselors still stick to their guns with the method they believe work best.
Unlike with roses, an addict is not an addict, is not an addict… Different methods will work for different people. It isn’t hard to believe this when you consider the fact that while many addicts recover within outpatient substance abuse treatment settings, others need an intensive residential program, and some recover spontaneously with no real intervention.
It’s time to start focusing on results in this field and leave the moral dogma behind. If there’s a tool that can help, we need to put it into action. It’s that simple.
I can’t hide it any longer, I just have to confess: I hate the way addiction treatment is managed nowadays. With over 25 million people meeting criteria for addictions in the U.S., only 10% are seeking treatment on a yearly basis. Sure, part of the problem is that others just don’t want it, at least yet, but there’s something else going on and it’s terrible.
The horrible pain of finding addiction treatment
If you, or someone you know, needs help for an addiction, your options aren’t just limited, they’re hard to find and are simply too stressful to deal with. Where do you even start? Most people wouldn’t dare go to their neighbors or family members with something like “Bobby is really struggling with his cocaine problem, do you have an idea of what we should do?” Instead, everyone is left fending for themselves, scared of going to doctors for fear of later insurance trouble, ashamed to admit their difficulties for fear of being stigmatized, and inundated with conflicting information about their chances for recovery if they do seek help.
So people go online, they seek out information, and they call provider after provider, often getting only partial semi-truths. At the end, most are left confused and the rest simply check in to the first place that will take them given their financial reality. Could you imagine if the same were true when someone broke their leg?
But isn’t addiction treatment really useless?
No, it’s not. Treatment works. It’s just that most people don’t get the treatment they need and end up paying the price (literally and figuratively). Well guess what, help is possible, it’s available, and it shouldn’t be this damn hard to find!
I think it’s about time we create a system that makes it easy for those suffering from addiction to find the right treatment for them. Not everyone needs treatment that costs $50,000 a month, and to be perfectly honest, that treatment is rarely better than much cheaper options. Still, no one would know that given bogus advertisements by rich addiction-industry-players that promise cures and fixes. The truth is that recovery is a difficult road and that different individuals may need different treatment.
Still, we know things that work: CBT works, motivational interviewing works, social-support, contingency-management, exercise, meditation, and specific medications work! So why is it that the addiction treatment industry still looks like something put together by a couple of addicts who suffer from too much self-focus and not enough organizational-capacity? Well, probably because that’s exactly our reality at the moment.
How can we make things better? Matching rehabs to patients
I say it’s time for a new age, especially given the passage of mental-health and addiction parity laws and the slow, but eventual inclusion of our most vulnerable citizens in the American health care system. As addiction-treatment becomes (finally) incorporated with medical care, the increased resources are going to mean an increased need for some standardization. It’s time for us to put people in treatment that works, that everyone can afford, and that is easy to find.
We’re currently testing a system that will use some basic, and some a bit more advanced, criteria to help direct addicts towards the right provider for them. Don’t have much money and working full-time? Then residential treatment should probably not be your first choice? Medicated for schizophrenia? You better stay away from providers that don’t offer serious mental health services (though they’ll sure take you if you walk through their doors)
We’re still figuring out the kinks, trying to improve the system even further than its current state, which I think is nothing short of magical. Eventually, I hope that it will be available for everyone, giving people real, reliable, objective access to addiction-treatment providers that do good work across the united States. It’s that easy to find a condo to buy, why shouldn’t it be that easy to find help?
Yes, I have almost 10 years of research experience into what works, but in truth, most of the issues here probably don’t require that at all. What’s needed is a little big-picture thinking and a little less fine-tooth combing. Hospitals can triage people based on a pretty quick, efficient, assessment. We can too.