Calling bullshit on addiction treatment bullies

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

Dr. Adi Jaffe Lecturing in Los AngelesAs 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.

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.