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.

Drug use cravings, obsessions, and trying to get clean…

When I first got sober, everything I thought about had something to do with drugs. It wasn’t just that I always thought of getting high, but everything in my life was tied to drugs, especially crystal meth.

Adi Jaffe playing music now sober

My drug use centered life

I used to make music in my studio, but I was always smoking crystal meth while doing it; I had a few girls I was “seeing,” but I got high with almost all of them (if they weren’t into it, I’d sneak a smoke in the bathroom alone). Every one of my friends was on drugs. I paid my rent with cocaine, made my money from selling anything you could think of, and overall, was simply surrounded by the stuff.

The drug use to craving connection

If you haven’t heard about this yet, memories are reconstructions of the past. When you remember something, your brain doesn’t just pull it out of some secret drawer like you were told when you were a kid. Instead, the different areas of your brain involved in making the memory (like your visual cortex, your olfactory bulb, and your language areas) light up all over again, re-exposing you to those same old thoughts, feelings, and senses.

Knowing that, it’s not surprising that cravings are so difficult to handle. Who wants to re-experience getting high with their best friend, their girlfriend, or in their favorite place over and over while trying to get sober? It’s literally maddening, sometime to the point where you just say “screw it” and run out to do it all over again (as in relapse).

I told my sister the other day that when I think about smoking glass (another name for crystal meth), the thing I miss the most is the white puff of smoke that fills the room. We used to call it “Dragon’s Breath” and I was pretty talented at producing the biggest clouds. It freaked her out a little to know that I could possibly still miss something about meth after everything that happened.

Even though I felt that it was necessary to calm her, I know that the addicts reading these pages know what I’m talking about. Of course I still miss smoking  crystal meth sometimes; Given everything I now know about drugs, which is a lot given the fact that I’ve spent 8 years studying nothing but drugs, I’m surprised I don’t miss the stuff more.

Drug use, reward, and what’s next

Almost every drug I know of eventually gets down to activating your reward center. Meth does so in a way that’s so extreme (like I said in an old post, it literally floods your brain with DA), that I’m surprised I ever managed to come out of it. I definitely know why it felt like such hard work.

So when a craving comes, don’t think of it as a sign that your failing. If that were true, there would be no survivors of addiction. Instead, recognize what your brain is doing, allow it, then think about the changes you’re trying to make. As the memory gets reconstructed, those new aspects you’re thinking about, those that have to do with your recovery and the positive changes you are making, will incorporate themselves into those old memories.

This, along with everything else you’re doing, will make the cravings less and less threatening, allowing you to stay sober even when they come through.

ADD and ADHD medications: Lessons from a crystal meth experiment

I’ve recently completed a study that I presented at the Society For Neuroscience (SFN) meeting in DC. The study was actually aimed at looking at the usefulness of two medications in interfering with the rewarding qualities of methamphetamine. The thinking was the if we could figure out a way to interfere with crystal meth being perceived as rewarding by the brain, we may be able to help addicts from continued use after a relapse.

Two prescription stones but only one hits crystal meth

The two medications are atomoxetine and bupropion, though you may know them as Strattera and Wellbutrin or Zyban. Their mechanisms of action are similar, but distinct enough that we wanted to test them both. The results of the study, in one sentence, were that atomoxetine (or Strattera), but not bupropion (or Zyban) succeeded in eliminating animals’ preference for meth if given along with it. The implication is that in the future, these, or other, similar, medications, may be given to newly recovering addicts. The hope would be that by taking the drug, they may be somewhat protected in the case of a relapse. If they don’t enjoy the drug during the relapse, they may have a better chance of staying in treatment.

More to these medications than meets the eye

I learned some other interesting things while preparing, and then carrying out, the study. While Zyban could, by itself, be liked by the animals, Strattera did not seem to produce any sort of preference. Given the common use of these drugs in the treatment of ADHD, the difference may be very important. As you may recall, I’ve talked before about the connection between impulse control problems and being predisposed to developing addiction. Given this relationship, it would seem that we’d want to be especially careful about using drugs that can cause abuse with this population. Many of the stimulants used to treat ADD and ADHD can indeed lead to abuse, as their effects are very similar to speed, or crystal meth (Adderall and Ritalin come to mind). Zyban’s abuse liability is definitely lower, given the greatly reduced preference animals develop for it. Still, it seems that Strattera’s abuse potential is almost zero. In trial after trial, animals given atomoxetine fail to show a preference for the drug.

To my mind, this means that as long as it’s successful in treating the attention problems, atomoxetine is the better candidate. All in all, I’d think the first choice should be the one that helps the symptoms of ADHD while having a reduced likelihood of dependence. Obviously, if the drug is not able to treat the problem, other options should be selected, but it seems to me that given the known relationship between attention deficit problems and addiction, the question of abuse liability should play a significant role in the selection of medication.

Once again, this doesn’t mean that all users of Adderall, Ritalin, or the other stimulant ADHD medications will develop an addiction to their prescription. In fact, we know that rates of addiction to prescriptions are generally relatively low. Nevertheless, I’d consider ADHD patients a vulnerable population when it comes to substance abuse so I say better safe than sorry.

When you fall… Failing at rehab and trying again

When my life started seriously veering off track, a few of my friends sat me down and told me that they want to help me. At the time, drugs were paying my rent, and they literally offered me their couch to help me lower my cost of living. They were good friends and they really meant it. I didn’t take them up on it; I thought I was fine.

My first try at rehab

Fast forward 4 years, and my first attempt at rehab. I still didn’t really think I needed help, but my lawyer insisted that unless I wanted to spend the rest of my life behind state-sponsored bars, I should give this thing a try. I went in as a way out. I’d been living on drugs, mostly crystal meth, for the previous 5 years or so. I was a daily user, everyone I knew used, I was paying my rent with ounces of coke, but somehow, I thought everything was going well.

Two months or so after entering rehab, sitting at my recording studio pretending to work, I ran across a baggie that had apparently been left behind. It took me less than 15 minutes to find something to smoke it with.

I only used a little bit that day. I’d been off the stuff for almost 3 months, and I didn’t need a lot to get high. I also wanted to save enough for my next “workday.” I was back to using daily within 5 minutes. By New Year’s Eve that year, I was smoking with an ex-customer in the corner of her bedroom before her guests showed up for the yearly party. I ended the night bored at an ecstasy party with half-naked friends giving each other backrubs. This time, I knew something was wrong.

Another attempt at rehab

Needless to say, I got kicked out of that rehab facility. I spent the following two weeks sleeping on a friend’s couch looking for another treatment option. It was on my way to a meeting at noon on a sunny day in Santa Monica that I saw where I really was. Passing a homeless vagabond on the promenade, I did a double take. I knew the guy; we used to party together. I’m one misstep away from being homeless. I need help.

As I write this today, I am five years into a well-respected graduate program in psychology. I’m writing a book about my experiences, and by the time it comes out, I’ll have a Dr. posted in front of my name. But that wasn’t always my story, and as recently as 5 years ago, it was the unlikely ending to my tale.

Addiction demoriliizationThe reason I’m sharing it with you here is because I want you to know that there is no magic number. There’s no right way to find your escape from the life, and there’s no necessary mindset when you try to save yourself. No one knows what is going to work for you yet. We’re working hard on figuring out a way to tailor treatment to specific people based on their drug use, their family history, their genes, and anything else we can think of. As of right now, we have no better answer than this:

Keep trying. No matter how many times you fall down, pick yourself up again. If AA doesn’t work for you, try something else. There are options, a lot of them. If you don’t know about any others, ask me, ask anyone. If you keep trying, keep believing in yourself, keep giving yourself a chance, you’ll find the way out eventually.

Until then, keep your head above water and come back here to learn more. As always, feel free to email me with any questions. I’ll keep answering.

One is too many, a thousand not enough: Does a slip or relapse mean the end?

Breaking news: When alcoholics who have gone through treatment have a drink after a certain length of sobriety, most don’t go off the deep end.

Slip scares and abstinence relapse

RelapsingThe old AA adage: “One drink is too many, and a thousand not enough,” refers to the fact that alcoholics who are sober are assumed to return to their evil ways after even a small slip (known as a relapse). This notion is meant to warn AA members to resist temptation lest they find themselves right back where they started. Or worse.

Most research into sobriety considers a person a success only if they remain sober throughout the study period. The followup periods last anywhere between 6 months to a year (or sometimes more). Have a drink, and you’ve lost. Game over. No one’s ever really looked at what people who have relapsed actually do after the relapse. Which is why the recent findings reported in the journal Psychology of Addictive Behaviors are so intriguing.

Recent relapse research findings

When looking at the behavior of 563 participants, the researchers found that 30% stayed sober for the entire 12 month follow-up period. This leaves a whopping 70% who had at least a drink in the year following treatment. However, the vast majority of those who drank in the first year after treatment (82%) developed moderate, infrequent, drinking habits. In fact, only about 6% started drinking heavily and frequently after their relapse. Even of those who drank, as many as 25% were completely dry for at least an entire month after their relapse.

The bottom line on relapse?

These findings suggest that at least for a year after becoming sober, a relapse is not necessarily the detrimental, destructive, event it has always been feared to be. It is surely possible that these drinking habits change, but according to these findings, if drinking frequency goes anywhere after the initial relapse, it’s down, not up.

I’m not trying to make light of relapse here, and I’m certainly not saying that relapsing is a positive thing. Nevertheless, given the fact that relapse is almost always a part of the recovery process, I’m suggesting that having a relapse shouldn’t scare everyone involved. It doesn’t seem to in any way suggest a necessary demise.

Citation:

Witkiewitz, K. & Masyn, K. E. (2008). Drinking trajectories following an initial lapse. Psychology of Addictive Behaviors, 22, 157-167.

Drug use memories and relapse: Can medication provide addiction help?

About a year ago, while sitting in a lecture on learning and memory, the idea that certain drugs can affect the emotional responses to memory long after the memory itself has been formed came up. As someone interested in addiction research, the implication for treatment immediately came up in my head:

Could we reduce the effect of triggers by giving people a pill?

In one word – Yes! But, the answer is not, in fact, that simple. Even in the studies already done in PTSD patients, the memories have to be re-triggered and the drug given at exactly the right time to be effective. In fact, in humans, some of the best work has been done in PTSD patients immediately after the traumatic event.

Addiction help through relapse prevention

Still, a recent study in animals suggests that the theory is sound. By interfering with the activity of a neurotransmitter important in the formation of memories, researchers were able to stop animals trained to self-administer cocaine from doing so. The animals, which had been trained to push a lever for cocaine when a light went on, reduced, or even stopped responding after a single dose of a substance that blocked memory formation. Essentially, the researchers prevented the animals from relapse. Again, this only worked if the drug was given while the light (as in the drug-trigger) was presented at the same time.

More recent studies, using repeated doses of the drug propranolol, have been shown to have an even more promising effect. Check out my coverage of that research here.

Given the powerful role of triggers in relapse, this avenue of research has some promising possibilities for future treatment of drug addiction.

Proteins and cocaine: Addiction is a disease, not a question of morality.

While there are some people who still argue about whether drug addiction is a disease or a condition that results from the moral failing of an individual, most of the scientific community has long agreed that there are at least some influences on it that are far beyond a person’s control.

I’ve mentioned the genetic influences that have been shown to be associated with a risk for addiction before (look here). However, most of the research I’ve been involved in myself recently has more to do with the way that trying drugs changes your brain in ways that make it more likely that you’ll try them again.

Along these lines, a recently published study has shown that very specific molecular targets can have a huge impact on the probability that addicts will keep going after drugs. The molecules studied were common targets of cocaine that are altered after long-term use of coke.

The interesting thing is that the research found that deactivating each of these targets produced completely different effects:

Animals that had the GluR1 receptor subunit turned off were unable to stop themselves from searching for cocaine in a spot where it used to be long after normal mice gave up. I don’t know about you, but that sounds more than a little relevant for addiction given what I know, and have experienced. We’ve been studying this sort of stuff for a while, but the fact that a single molecule can make an animal pursue drugs in a way that is completely irrational is amazing!

Animals that had the NR1 receptor subunit turned off experienced a different effect. While normal mice relapse to drug use when they experience a drug after a long break, the NR1 deficient mice just wouldn’t go back to their addictive behavior when they got a little sample. Again, the implications for relapse preventions are promising to say the least.

In short, while some people may think there’s still a reason to argue whether people with addiction should simply be left to god’s mercy, ongoing work is showing us that we can uncover specific molecular mechanisms that may one day allow us to combat addiction with much more success. I for one welcome that.