How it doesn’t work – the dogma of the 12 steps

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.

Absurd right?

12-Step dogma

Everyone wants to know if they can become addicted

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.

Like advancements in medical care and science? Then support animal research

There was a Pro-Test for Science rally on the UCLA Campus today.  The goal of the rally was to spread awareness about the utility of animal-research and to help combat extremists and prove to the community and world that the ethical use of animals for biomedical research is absolutely vital to the progress and success of advancements in science.

Many of the treatments that we discuss on this site are available because of extensive research with animals. In fact, many scientific discoveries have been possible largely because animal research is an available tool for researchers. Immunizations, medical treatments for Parkinson’s, Alzheimer’s, and diabetes treatments have all been advanced greatly through the use of biomedical research with animals. Of course, great care is always taken to ensure humane treatment of the animals used.  Animals prove a vital part of advancements in medicine, genetics and other research.

Biomedical scientists endure many trials in order to become experts in the type of research techniques we’re talking about here, including extensive schooling, years of training and of course many thousands of hours spent in a lab, all for the benefit of humanity.  They should not have to additionally endure the harassment of extremists and fear for their safety and the safety of their loved ones who often are caught in the middle.

Debate is healthy; discussion is good. But the harassment and terrorizing of researchers must stop if we’re to consider ourselves an open, educated, society. All biomedical researchers want is to better society by finding cures for the many things that plague our world today, so what everyone should really be doing is thanking them.

Co-authored by Jamie Felzer

Better rehab services – Addiction research at work

Fact: Addiction treatment success rates are often lower than 20% ! Addiction research shows that quarterly follow-ups may help us improve success by offering continuous support and recognizing problems earlier.

Addiction is a chronic disease

diabetesWhat do you do when you are sick? Typically, you would go to the doctor, get some treatment and expect a quick fix.  What would you do if you suffered from an addiction?  Most healthcare and insurance companies would expect you to do the same – get a quick treatment and be cured!

The thing is that addiction is much more similar to many chronic diseases like diabetes and hypertension. The compliance rates and follow-through with treatment for these conditions is fairly low. For example, only 27% of patients with high blood pressure have their hypertension under control and only 46% of diabetics have their diabetes effectively managed.  For these kinds of conditions, short term interventions (less than 3 months) have produced positive findings only 38% of the time while long term ones (12 months or more) produced success rates as high as 100%. Still, addiction treatment rarely extends past a few months.

Today’s rehab services

More than half of patients entering addiction treatment are there for their 3rd, 4th,  or 5th treatment episode. Still, most patients who leave treatment return to use within 30-90 days of their release. This use is associated with 6-11 times the risk of dying!!!

Relapsing

Addiction success is most often reached after 3-4 treatment attempts. Recent research may help us reduce the number of treatments needed, or at least the length of time between first drug use and successful recovery (currently estimated at 27 years). These numbers point towards a scary conclusion: Rehabs are abandoning addicts to fend for themselves too early leaving them, and society at large, in danger.

Better rehab services through addiction research

Recent research shows that following the few months of treatment with simple quarterly checkups allowed counselors to catch relapses sooner and get the patient back into some sort of treatment more quickly. The checkups included short phone calls and scheduled face-to-face meetings that allowed counselors to assess a patient’s condition. Although it might sound as if more days in treatment are a negative thing, the number of checkups and increased amount of time in treatment actually improved overall results.  Patients who received RMCs experienced more sobriety and less severe symptoms of abuse than those who received treatment as usual.

So even if more treatment costs more money, addiction is something that can be helped if dealt with appropriately.  It doesn’t have to follow the same non-compliance rates as other chronic medical disorders. If you are seeking addiction treatment, make sure that your provider plans to include follow up services AFTER you leave treatment.

Citation:

Christy K Scott & Michael L. Dennis (2009). Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users. Addiction, 104, 959–971.

Addiction causes – Drug addiction as a chronic disease makes sense

The stigma of addiction is alive and well. Whether you believe in the disease model or not, it seems that people’s judgments regarding what it means to be an addict are well entrenched.

I’d like to work on that a bit.

Why is addiction a disease?

In numerous posts on this site I’ve addressed issues like genetic predisposition and the effects of drugs on the brain that impair addicts’ ability to control their choices. A disease is commonly defined as “A pathological condition of a part, organ, or system of an organism resulting from various causes, such as infection, genetic defect, or environmental stress, and characterized by an identifiable group of signs or symptoms.” (See Answers.com) I don’t think there’s a question regarding whether or not addiction involves a pathology of a body part, namely the brain.

It would definitely be easier if we could all just say that addiction is the product of bad choices. Nevertheless, all the science I’ve seen points to the fact that addicts have impaired decision making to begin with that is only made worse by the drugs they take in.

A comparison with Diabetes

diabetesFor some reason, this still leaves a lot of people seeing addicts as the only ones to blame. I’d like to try a different approach:

We’ve all heard of type 2 diabetes. It’s the kind people aren’t born with, but rather are develop later in life. Most cases are the result of an over exposure of the body to sugars that breaks down its ability to produce insulin, leading to the disease. There are an estimated 15 million people in the U.S. who have type 2 diabetes. They make up 90% of diagnosed diabetes cases.

I think that type 2 diabetes is a disease that can help many reformulate the way they think about addiction.

Patients with adult onset diabetes likely have genetically reduced insulin receptor functionality and possibly other factors that increase their likelihood of developing the condition. They also likely consume more sugars than people who don’t develop type 2 diabetes, though the exact causes are still uncertain. Nevertheless, with early detection, the disease progress can certainly be slowed and perhaps even halted. As the disease progresses, the body’s response to sugar is altered, eventually resulting in what looks like a severe alergy to sugars. However, once developed, type 2 diabetes patients often require similar treatment courses, including medication, exercise, and dietary changes that patients with type 1 diabetes (the type present early on in life). At this point, simply cutting back will no longer do.

This is not all that different from addiction.

Addicts are often born with a set of genetic and environmental factors that predispose them to impulsively engaging in and seeking out, risky, exciting activities. Moreover, the addict’s reaction to drugs is often different than that of non-addiction-prone individuals. For example, many stimulant abusers report a calming, rather than excitatory, effect of drugs like methamphetamine, cocaine, and the likes. That was certainly my experience back in my crystal meth days.

It is true that here the predisposition is more abstract, since it resides in brain activity patterns, but as I’ve said many times before, the brain is certainly a physical part of the body and should be treated as such. Like diabetic patients, once addicts begin using the drugs in large quantities and for extended periods, the drugs cause alterations in physical systems. Like diabetics, once these changes occur, they are certainly long lasting, if not permanent. Dopamine function in the brain of crystal meth abusers has been shown to take as many as 2 years to return to anything resembling non-user levels and we have no way of telling if the newly formed dopamine activity is at all related to what was previsouly there. Once the disease we know as addiction (or dependence) takes hold, there are specific recommended treatments that need to be followed. Simply cutting back will no longer do.

The bottom line?

Addiction fits the model of a disease as well as many other conditions. I have no doubt that people’s moral judgments get in the way sometimes and make it hard for them not to fully blame an addict for their trouble. I don’t doubt that addiction can only develop with the use of drugs, but if there are pre-existing conditions that make that use more likely, I think it need to be taken into consideration as well.