Answer Addiction

Tag: evidence-based

  • Addressing the Opioid Epidemic: What the Research Says

    Addressing the Opioid Epidemic: What the Research Says

    Rehab? Safe injection sites? Sue Big Pharma? Find out how each of the Democratic presidential candidates plan to address and treat opioid use disorder, and which of these approaches are supported by evidence.

    In the lead-up to the 2020 elections, the Journalist’s Resource team is combing through the Democratic presidential candidates’ platforms and reporting what the research says about their policy proposals. We want to encourage deep coverage of these proposals — and to do our part to help deter horse race journalism, which research suggests can lead to inaccurate reporting and an uninformed electorate. Our criteria for the proposals we’re covering is simple: We’re focusing on proposals that have a reasonable chance of becoming policy, and for us that means at least 3 of the 5 top-polling candidates say they intend to tackle the issue. Here we look at candidates’ proposals to address the opioid epidemic. Candidates are divided in their approaches; while nearly all favor increasing funding for and access to treatment for opioid use disorder, fewer candidates support harm reduction policy interventions, such as safe injection sites and needle exchanges. A few candidates incorporate broader criminal justice-level changes or physician-level interventions into their policy proposals.

    Candidates favoring increased funding for and access to treatment

    Michael Bennet, Joe Biden, Cory Booker*, Pete Buttigieg, John Delaney, Amy Klobuchar, Bernie Sanders, Tom Steyer, Elizabeth Warren, Marianne Williamson*, Andrew Yang

    Candidates favoring harm reduction interventions

    Michael Bennet, Cory Booker, Pete Buttigieg, Amy Klobuchar, Bernie Sanders, Elizabeth Warren

    Candidates favoring action against pharmaceutical companies

    Michael Bennet, Cory Booker, Pete Buttigieg, John Delaney, Tulsi Gabbard,  Amy Klobuchar, Bernie Sanders, Elizabeth Warren, Andrew Yang

    Candidates favoring interventions that target physician prescribing behavior

    John Delaney, Amy Klobuchar, Andrew Yang

    Candidates favoring decriminalization of possession of opioids

    Pete Buttigieg, Andrew Yang

    What the research says

    Access to treatment: Medication-assisted treatment is an evidence-based treatment for opioid use disorder; it has been shown to reduce the risk of overdose death for people who use opioids. Methadone, buprenorphine and naltrexone are types of medication-assisted therapy for opioid use disorder. These medications reduce symptoms of craving and withdrawal. A systematic review and meta-analysis of medication-assisted treatment find that people receiving such treatment were less likely to die of an overdose or other causes than their peers with opioid use disorder who did not receive medication-assisted treatment.

    Harm reduction: Harm reduction initiatives attempt to reduce the risks associated with using drugs. Such initiatives include needle exchange programs, widespread distribution of the opioid overdose antidote naloxone and supervised injection facilities. Supervised injection facilities, also known as safe injection sites or supervised consumption facilities, are not legal in the U.S. They exist legally in other countries, such as Canada and Australia, however.

    Several studies have demonstrated a positive link between safe injection site use and entry into treatment. Safe injection sites also provide benefits to people who use drugs in the form of sterilized equipment and supervision to mitigate the dangers of overdose.

    Over a dozen studies have linked needle exchanges with lower rates of hepatitis C and HIV infection among people who inject drugs.

    A systematic review of research on take-home naloxone programs, which provide people at risk of opioid overdose with kits including the antidote, concludes that “there is overwhelming support of take-home naloxone programs being effective in preventing fatal opioid overdoses.”

    The pharmaceutical industry: Big Pharma’s role in marketing opioids spurred physicians to prescribe more opioids, research shows. This, in turn, fueled the opioid epidemic the country faces today. Policies targeted toward Big Pharma include proposals to hold industry players liable for their role in the opioid epidemic with criminal penalties and fines.

    Decriminalization: The rationale behind decriminalization of the personal use of narcotics is that criminal penalties essentially criminalize substance use disorder. Proponents of decriminalization argue that such drug use should, instead, be met with evidence-based treatment. There is not much research on the effects of decriminalization because it’s rare. However, in 2001, Portugal decriminalized personal acquisition, possession and use of illicit drugs. Research indicates that drug-related deaths have fallen since the southwestern European country decriminalized illicit drugs.

    Physician-level interventions: These interventions target prescriber behavior. Examples include physician education programs, guidelines or restrictions on the quantity of opioids physicians can prescribe, and prescription monitoring programs that allow physicians to view patients’ prescription history to avoid overprescribing or illegitimate prescribing. While education and prescribing policies have curtailed prescribing habits, prescription monitoring programs have been less successful, studies indicate.

    Key context

    In late 2017, the U.S. Department of Health and Human Services declared the nation’s opioid crisis a “public health emergency.” The problem has been building for over a decade, spurred by sharp increases in prescriptions for opioids, commonly used to treat both short-term and chronic pain.

    About 233.7 million opioid prescriptions were filled each year, on average, from 2006 to 2017, according to a March 2019 study in JAMA Network Open that looks at opioid prescriptions filled in retail pharmacies across the U.S.

    Prescription painkillers have a high risk of abuse — across the academic literature, rates of misuse among patients taking opioids for chronic non-cancer pain average between 21% and 29%. Research indicates that as of 2013, more than 2 million people in the U.S. had prescription opioid-related opioid use disorder.

    Prescription opioids can also pave the way for illegal drugs like heroin. Eighty percent of people who have used heroin have previously misused prescription opioids, according to an August 2013 analysis of national survey data collected from 2002 to 2011.

    As opioid use and misuse has increased, deaths linked to the drugs have increased. In 2017, opioids were involved in 47,600 drug overdose deaths, accounting for nearly 70% of all overdose deaths nationwide that year.

    Recent research

    Access to treatment:

    A review of randomized controlled trials comparing medication-assisted treatment of opioid use disorder to placebo or no medication finds that medication-assisted treatment “at least doubles rates of opioid-abstinence outcomes.”

    A study of 151,983 adults in England treated for opioid dependence between 2005 and 2009 finds that the risk of fatal drug overdose more than doubled for individuals who received only psychotherapy compared with those who received medication-assisted treatment.

    Harm Reduction:

    Two reviews — one published in Drug and Alcohol Dependence in 2014, and one published in Current HIV/AIDS Reports in 2017 — indicate that supervised consumption facilities promote help people access treatment. The more recent review looks at 47 studies published between 2003 and 2017 on supervised drug consumption facilities. The authors find a handful of studies that demonstrate a positive link between safe injection site use and starting treatment.

    One of these studies compared enrollment in detoxification programs among those who used Vancouver’s supervised injection facility the year before and after it opened in 2003. Researchers find the facility’s opening was linked to a 30% increase in detox program use, which, in turn, was linked to pursuing long-term treatment and injecting at the facility less often. A later study of the injection facility focused on use of detox services located at the facility. It finds that 11.2% (147 people) used these services at least once over the two years studied. The authors conclude that supervised injection facilities might serve as a “point of access to detoxification services.”

    A 2006 study of 871 people who injected drugs finds no substantial increase in rates of relapse among former users before and after the Vancouver site opened. However, the researchers also find no substantial decrease in the rate of stopping drug use among current users before and after the site opened. Another study of 1,065 people at this facility published in 2007 finds that only one individual performed his or her first injection at the site.

    Though supervised injection sites are illegal in the U.S., one opened underground in 2014. Researchers interviewed those who used the underground site during its first two years of operation and their findings were published in 2017 in the American Journal of Preventive Medicine. The site’s users were asked the same set of questions about their use patterns every time they injected drugs at the site. The authors conclude that the site offered several benefits, including safe disposal of equipment, unrushed injections and immediate medical response to overdoses. The authors add that if the site were sanctioned, it might be able to offer additional benefits, including health care and other services.

    Big Pharma:

    Research suggests that physicians targeted with marketing from pharmaceutical companies prescribe opioids at higher rates than doctors not exposed to their marketing.

    Several studies use data from the Centers for Medicare and Medicaid Services’ Open Payments database, which tracks payments made by drug and medical device companies to physicians. That information is used to analyze how relationships between physicians and drug companies are linked to prescriptions written.

    These studies define opioid-related payments as cash payments — for example, speaking fees associated with promoting a drug — and payments-in-kind — free meals pharmaceutical representatives provide to doctors’ offices, for instance. These studies find that physicians who receive opioid-related payments tend to prescribe more opioids.

    A study in PLoS One from December 2018 looks at physicians who received opioid-related payments, some in 2014 and some in 2015, compared with doctors who never received such payments. The authors find that physicians who received opioid-related payments had a larger increase in the number of daily doses of opioids dispensed, as well as in total opioid expenditures, prescribing pricier opioids per dose.

    Another study looking at the same data offers further detail. The study, published in Addiction in June 2019, focuses on 865,347 physicians across the country who filled prescriptions for Medicare patients from 2014 to 2016. “Prescribers who received opioid-specific payments prescribed 8,784 opioid daily doses per year more than their peers who did not receive any such payments,” the authors write.

    Other research geographically links opioid marketing and opioid-related overdose mortality. The paper, published in JAMA Network Open in January 2019, analyzes county-level prescription opioid overdose deaths and county-level opioid marketing payments.

    The authors find that deaths from prescription opioid overdoses increased with each standard deviation increase in opioid marketing as measured by dollars spent per capita, number of payments to physicians per capita and number of physicians receiving payments per capita. Standard deviation indicates the variation of a given value from the average. “Opioid prescribing rates also increased with marketing,” the authors write. They note that the higher prescription rate might be why overdose deaths increased.

    Physician-level interventions:

    An August 2018 study published in Science highlights the role physician education might play in addressing the nation’s opioid crisis. The intervention was simple: When a patient died of an opioid overdose, the county medical examiner sent the prescribing physicians a letter notifying them. The authors conducted a randomized trial of 861 physicians whose patients overdosed. The intervention group received the letter, which included a safe prescribing warning consisting of these recommendations:

    • Avoid co-prescribing an opioid and a benzodiazepine.
    • Minimize opioid prescribing for acute pain.
    • Taper long-term users off opioids.
    • Avoid prescriptions lasting for three consecutive months or longer and prescribe naloxone, an opioid overdose antidote.

    The control group received no communication.

    Physicians in the intervention group cut their opioid prescribing by 9.7% — as measured by milligram morphine equivalents in prescriptions filled — in the three months after the letter was sent. These physicians also started fewer patients on opioids and wrote fewer high-dose prescriptions than the control group.

    Prescribing policies and guidelines also have successfully curbed physicians’ distribution of opioids.

    In October 2017, the Michigan Opioid Prescribing Engagement Network released opioid prescribing guidelines for nine surgical procedures to clinicians participating in the Michigan Surgical Quality Collaborative, a statewide initiative to improve surgical care.

    Researchers compared opioid prescribing before and after these guidelines were released, analyzing data from 11,716 patients across 43 hospitals collected from February 2017 to May 2018. They find that prescriptions declined, on average, from 26 pills to 18 pills per month after the guidelines were released.

    Patients also took fewer of the pills they were prescribed. As measured by patient-reported survey data, opioid consumption following surgery dropped from 12 pills to nine, “possibly as a result of patients anchoring and adjusting their expectations for opioid use to smaller prescriptions,” explain the authors of the August 2019 New England Journal of Medicine study. Although patients received smaller prescriptions and used fewer pills after the guidelines were published, there were no substantial changes in the patients’ satisfaction and pain scores.

    Similar to the study of Michigan’s opioid prescribing guidelines is a February 2018 study in the American Journal of Emergency Medicine that tracks the effects of an emergency department opioid prescribing policy. The policy resulted in declines in opioid prescriptions. Compared with the control emergency department, the two intervention hospitals had a more pronounced decline in opioid prescribing. The authors conclude that emergency department-based policies might help reduce opioid prescribing.

    Prescription drug monitoring programs, which allow physicians to view patients’ prescription history to avoid overprescribing or prescribing opioids to people who don’t actually need them, have been shown to be less effective. A January 2018 study of national data published in Addictive Behaviors finds that there were not statistically significant differences in the likelihood that physicians would prescribe opioids for chronic pain when comparing states with prescription drug monitoring programs with those without.

    Further reading

    General overview

    Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic

    Allison L. Pitt, Keith Humphreys and Margaret L. Brandeau. American Journal of Public Health, October 2019.

    The gist: “Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation.”

    Safe injection sites

    Attendance at Supervised Injecting Facilities and Use of Detoxification Services

    Evan Wood, Mark W. Tyndall, Ruth Zhang, Jo-Anne Stoltz, Calvin Lai, Julio S.G. Montaner and Thomas Kerr. New England Journal of Medicine, June 2006.

    The gist: A study of Vancouver’s supervised injection facility finds “an average of at least weekly use of the supervised injecting facility and any contact with the facility’s addictions counselor were both independently associated with more rapid entry into a detoxification program.”

    Injection Drug Use Cessation and Use of North America’s First Medically Supervised Safer Injecting Facility

    Kora DeBeck, Thomas Kerr, Lorna Bird, Ruth Zhang, David Marsh, Mark Tyndall, Julio Montaner and Evan Wood. Drug and Alcohol Dependence, January 2011.

    The gist: “These data indicate a potential role of SIF [supervised injecting facilities] in promoting increased uptake of addiction treatment and subsequent injection cessation.”

    “A Little Heaven in Hell”: The Role of a Supervised Injection Facility in Transforming Place

    Ehsan Jozaghi. Urban Geography, May 2013.

    The gist: “Participants’ narratives indicate that attending InSite [Vancouver’s supervised injection facility] has had numerous positive effects in their lives, including changes in sharing behavior, improving health, establishing social support and saving their lives.”

    Process and Predictors of Drug Treatment Referral and Referral Uptake at the Sydney Medically Supervised Injecting Centre

    Jo Kimber, Richard P. Mattick, John Kaldor, Ingrid Van Beek, Stuart Gilmour and Jake A. Rance. Drug and Alcohol Review, May 2009.

    The gist: Researchers conducted 1.5-year study at a supervised injection site in Sydney. They find that 16% of clients at the site referred to treatment by health and social welfare professionals went on to receive it, leading the authors to conclude that the center “engaged injecting drug users successfully in drug treatment referral and this was associated with presentation for drug treatment assessment and other health and psychosocial services.”

    Inability to Access Addiction Treatment and Risk of HIV Infection Among Injection Drug Users Recruited from a Supervised Injection Facility

    M.-J.S. Milloy, Thomas Kerr, Ruth Zhang, Mark Tyndall, Julio Montaner and Evan Wood. Journal of Public Health, September 2012.

    The gist: Many who use supervised injection facilities have the desire to access treatment. This study surveyed 889 people who were randomly selected to be surveyed at Vancouver’s supervised injection facility. “At each interview, ∼20 percent of respondents reported trying but being unable to access any type of drug or alcohol treatment in the previous 6 months,” the authors write. The main barrier to access, respondents said, was waiting lists for treatment.

    Big Pharma

    The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy

    Art Van Zee. American Journal of Public Health, February 2009.

    The gist: In the first six years it was on the market, Purdue Pharma spent about six to 12 times more to promote OxyContin than it had to promote another long-lasting opioid. The paper describes various marketing strategies including promotional giveaways and Pharma-funded medical education programs.

    Industry Payments to Physicians for Opioid Products, 2013-2015

    Scott E. Hadland, Maxwell S. Krieger and Brandon D. L. Marshall. American Journal of Public Health, September 2017.

    The gist: This study examines payments pharmaceutical companies make to physicians to market opioid products. The authors find that 375,266 opioid-related payments that weren’t related to research work were made to 68,177 physicians over the study period. The authors estimate that about 1 in 12 physicians in the U.S. received a payment from a pharmaceutical company to promote their opioid medications during the 29-month study period. The bulk of the money went toward speaking fees or honoraria, but the most common expense was food and beverages – 352,298 payments totaling $7,872,581.

    Association of Pharmaceutical Industry Marketing of Opioid Products to Physicians with Subsequent Opioid Prescribing

    Scott E. Hadland, Magdalena Cerdá, Yu Li, Maxwell S. Krieger and Brandon D. L. Marshall. JAMA Internal Medicine, June 2018.

    The gist: “Whereas physicians receiving no opioid-related payments had fewer opioid claims in 2015 than in 2014, physicians receiving such payments had more opioid claims,” the authors write.

    Physician-level interventions

    Differences in Opioid Prescribing Practices among Plastic Surgery Trainees in the United States and Canada

    David W. Grant, Hollie A. Power, Linh N. Vuong, Colin W. McInnes, Katherine B. Santosa, Jennifer F. Waljee and Susan E. Mackinnon. Plastic and Reconstructive Surgery, July 2019.

    The gist: Plastic surgery trainees were asked about their opioid prescribing education, factors contributing to their prescribing practices and what they would prescribe for eight different procedures. The authors find that, of the 162 respondents, 25% of U.S. plastic surgery trainees received opioid-prescriber education, compared with 53% of Canadian trainees. For all but one of the eight procedures, U.S. physicians prescribed significantly more morphine milligram equivalents than their Canadian counterparts.

    Source list

    Caleb Alexander, professor and co-director of the Center for Drug Safety and Effectiveness. Johns Hopkins University.

    Michael L. Barnett, assistant professor. Harvard T.H. Chan School of Public Health.

    Chinazo Cunningham, professor. Albert Einstein College of Medicine.

    Scott Hadland, assistant professor. Boston University School of Medicine.

    David N. Juurlink, scientist. Sunnybrook Research Institute.

    Thomas Kerr, associate professor. The University of British Columbia.

     

    For more, check out JR’s long read on the opioid prescribing problem, our summary of research on where opioids are prescribed the most and our tip sheet for reporting on fentanyl and synthetic opioids.

    This piece adheres to suggestions offered by the National Institute on Drug Abuse’s media guide, which recommends language that avoids the potentially stigmatizing term “addict” in the context of substance use. It states: “In the past, people who used drugs were called ‘addicts.’ Current appropriate terms are people who use drugs and drug users.”

    *Dropped out of race since publication date.

    This article first appeared on Journalist’s Resource on December 9, 2019 and is republished here under a Creative Commons license.

  • Can 12-Step Programs Treat Dual Diagnoses?

    Can 12-Step Programs Treat Dual Diagnoses?

    Effective treatment needs to include both the substance use disorder and the co-occurring disorder in an integrated approach because the two conditions build on each other.

    Thirty-three percent of people with mental illness also have a substance use disorder (SUD); that number rises to 50 percent for severe mental illness. Fifty-one percent of people with SUD have a co-occurring mental health disorder. Effective treatment needs to include both the SUD and the co-occurring disorder in an integrated approach because the two conditions build on each other. People with mental illness may turn to substances to alleviate symptoms and severe substance misuse can cause lasting psychological and physiological damage.

    12-step programs are free, prolific, and available throughout the world. These mutual-help organizations are designed to facilitate recovery from addiction, but are they suitable for treating the large segment of people with addiction who also have other mental health conditions or psychiatric diagnoses?

    A 2018 meta-analysis  undertook a literature review on 14 years of studies related to dual diagnosis and Alcoholics Anonymous (AA). This extensive quantitative look into the effiicacy of AA for people with dual diagnosis found that participation in AA and abstinence “were associated significantly and positively.” The research supports the clinically-backed notion that an integrated mental health approach that encourages participation in mutual help programs is the best approach for treating patients with comorbid SUD and mental illness.

    Does it Depend on the Dual Diagnosis?

    There is enormous variation in mental illnesses, so does the potential effectiveness of 12-step programs change based on the type of disorder or diagnosis? The co-founder of AA, William Wilson (known as Bill W.), was afflicted with a co-occurring disorder. Wilson struggled with “very severe depression symptoms” and today his mental health issue may have been diagnosed as major depressive disorder.

    A study published in the Journal of Substance Abuse Treatment followed 300 alcohol-dependent people with and without social anxiety disorder who went through hospital-assisted detox followed by participation in AA. Social anxiety disorder is characterized by an intense fear of being rejected or disliked by other people. This study found that there was no significant difference in relapse or abstinence rates between the two groups and concluded that social anxiety disorder was “not a significant risk factor for alcohol use relapse or for nonadherence to AA or psychotherapy.”

    Do Sponsors Matter?

    People with dual diagnoses tend to participate in 12-step programs like AA as much as people with just SUD and receive the same benefits in recovery. Those people with co-occurring conditions may actually benefit more from “high levels of active involvement, particularly having a 12-step sponsor.”

    In many 12-step mutual help organizations, people enter into an informal agreement with another recovering person who will support their recovery efforts and hold them accountable for continued sobriety. This one-on-one relationship of sponsor and sponsee has been compared to the “therapeutic alliance” that is formed between patients and their clinicians. The therapeutic alliance is positively correlated with treatment outcomes and abstinence.

    The therapeutic alliance is one of the most important aspects of effective psychotherapy, as it helps the therapist and the patient to work together. The relationship is based on a strong level of trust. Patients need to feel fully supported, and know that that their therapist is always working towards the best possible outcome for the patient. In the sponsor-sponsee relationship, a similar level of trust and belief is essential if sponsorship is going to be beneficial. 

    As with therapy, it may take many tries with many different people to find the right fit. Not all people are suitable to be sponsors and not all sponsorships go well. A sponsor is generally expected to be very accessible to their sponsee, and available at any time, day or night. They are supposed to help with completing the 12-steps, and they often provide advice and suggestions from their own experiences. It’s a lot of responsibility.

    A strong therapeutic alliance has been found to be an excellent predictor for treatment outcomes. Does that mean a failed therapeutic alliance could derail treatment? In short, the answer is yes. Trust is critical to healing from any mental illness.

    Trauma and the Therapeutic Alliance

    Traumatic events have a serious impact on mental health. People with mental illness are at a higher risk of being further traumatized and people who are traumatized are at a higher risk of developing mental illness than the general population. Childhood trauma “doubles risk of mental health conditions.”

    Recovery from trauma is based on empowering the survivor and developing new connections to life, including re-establishing trust. Judith Herman, a leading psychiatrist specializing in trauma is adamant that recovery is not a solitary process. This may be why 12-step programs have been successful in helping some people recovery from trauma. 

    Being a sponsor to someone who has been traumatized requires a fine balance between listening and giving space. Herman explains that survivors need to know they’re being heard when telling their story. At the same time, “trauma impels people both to withdraw from close relationships and to seek them desperately.” Meaning that when the sponsor does not go away, their motives may seem suspect in the eyes of the survivor. Yet, if the sponsor doesn’t stay, it can reinforce negative self-appraisal and stoke a fear of abandonment.

    Individuals with psychological trauma can struggle to modulate intense emotions, such as anger. A sponsor or therapist has to have healthy boundaries with a sponsee/patient if the relationship is going to work. Providing good sponsorship is a huge undertaking that requires a firm commitment.

    The good thing about the 12 steps is that they are considered a long-term program which encourages revisiting the steps many times to sustain successful recovery. This is useful in terms of trauma recovery because most trauma is never fully resolved. A traumatized person will likely experience reappearance of symptoms; traumatic memories can surface in different stages of life. Stress is a major cause of these recurrences and having a place to process these events as they come up is important.

    Do 12-Step Programs Have a Role in Treating Dual Diagnoses?

    Integrated holistic treatment that addresses how the two conditions interact and affect each other will provide the best outcomes. Ultimately, what we want is to improve quality of life and to return to ordinary life with an open door to future support when necessary. The research shows that when the principles of 12-step programs are integrated with other treatments, we see improvements in self-esteem, positive affect, reduced anxiety, and improved health.

    Further research is necessary to compare 12-step programs with other emerging mutual and self-help organizations, as they have been around for less time and there are fewer published studies on their efficacy. 

    View the original article at thefix.com

  • AA 2.0: Why the Evolution of Alcoholics Anonymous Needs to Happen Now

    AA 2.0: Why the Evolution of Alcoholics Anonymous Needs to Happen Now

    The founders purposely left the door open for science to come into the realm of recovery, and unlike modern AA, they did not discount its potential importance when it came to helping people.

    I am an alcoholic, or, as conventional wisdom goes, an alcoholic in recovery. I’ve had my share of rehabs, detoxes, and IOPs. I’ve dealt with numerous counselors, doctors, psychiatrists, and even a hypnotist. I have mastered “white-knuckling.” And I’d “given myself fully to the simple program” that is AA. Nothing worked. This is not to say I did not have my dry spells, as well as full-on productive years of zero consumption of anything that contained ethanol. Still, I relapsed, and went down a black spiraling abyss pretty confidently when my consumption quickly became prodigious in both amount and frequency of use.

    Sheer yet fully predictable insanity ensued. Binges went on for weeks and ER visits became routine. Doctors gave me a bleak prognosis, as coming out of the drinking spells had become nearly impossible. Maintenance drinkers had nothing on me — I drank to breathe, to sleep, to go to the bathroom. Beer and wine became juice, annoyingly un-intoxicating. Blended whisky — aka brown vodka — was the only thing that worked, before it didn’t. A rehab intake clocked me at .43 blood alcohol content, with the fatal spectrum usually starting around .35. I am not a large guy by any means; turns out it was the tolerance I’d developed that saved me from kicking the bucket from alcohol poisoning. I stayed drunk for two days just on what was in my bloodstream, and then the withdrawal hit like a train. Librium, Zofran, Librium. An in-house doctor woke me up; my pulse was barely there. But, as always, thankfully, in a week I started feeling better. 

    A Revolutionary Program… for 1939

    The role of AA in my recovery has been significant. The fellowship of men and women — a genius brainchild of Dr. Bob and Bill Wilson, and wholeheartedly endorsed by Dr. Carl Jung himself, has helped countless families. It is incredible in its selflessness and honesty and yet, today’s AA is rigid, too antiquated, and legacy-driven. It’s normal, though, for an organization of this stature and with this much history. After all, back in 1939 this was an absolutely revolutionary, even visionary, break-through. But we’re not in 1939 or even 2009, and so AA must adapt or it will lose its edge. 

    Both Dr. Bob and Bill Wilson were complex, highly educated, empathetic, and caring individuals. Their realization of a prominent role of Higher Power in recovery did not come easy. Skeptics, cynics as they were, they had to overcome an internal struggle before making peace with the fact that human nature was helpless in the face of the monstrous foe of addiction. The resulting text, which we all now know as the Big Book, was the product of a multi-year intellectual effort, which was by no means easy or straightforward. For example, one little-known fact about the book is that initially it used the 2nd person throughout its chapters, as in “you recover, you need to, you have a problem.” The authors decided to change it to the 1st person (we), which brought a completely new tone to the script. From preachy and authoritative it became welcoming and tolerant.

    In addition, when it comes to finding ways to recover from alcoholism (specifically becoming a “normal drinker” as opposed to an alcoholic), the Book mentions that “science may one day accomplish this, but it hasn’t done so yet.” In fact, multiple recovery groups and schools of thought have stepped in to fulfill this prediction. For instance, the Sinclair Method introduced its harm reduction model, based on the pre-emptive use of Naltrexone to reduce cravings and use. Like with everything else, if it works for you, great. It did not for me or any other alcoholic I know. 

    AA’s Founders Expected AA to Change

    The founders purposely left the door open for science to come into the realm of recovery, and unlike modern AA, they did not discount its potential importance when it came to helping people. Today’s AA, on the other hand, has forgotten that approach, adopting more of a “my way or the highway” when it comes to alternative recovery techniques.

    My respect and love for AA is beyond mere deference. I firmly believe that its overall purpose is remarkable. However, I also know that it could be more effective in reaching more people if it actively adopted — or at least discussed — modern-day scientific findings when it comes to addiction. Yes, rigorous honesty and humility are key, however, an inquisitive and questioning mind is not something that should be shunned; on the contrary, it should be celebrated. Ask Bill Wilson. 

    The Book should be akin to the concept of a “living, breathing” Constitution, which celebrates evidence-based evolvement of the original understanding of the Supreme Law of the Land (for example, ever-present discussions of the Fourth Amendment as applied to modern-age surveillance technology. Back when it was written, there was no phone or Internet surveillance, yet the maxim against unreasonable search and seizure is alive and well). Evolution of approaches, when it comes to addiction treatment, is a natural occurrence and fighting it is like trying to cross-breed humans and monkeys hoping we can get better, more advanced Homo sapiens, or even a new humanoid altogether.

    Let’s also take a look at the concept of singularity, as defined by famous futurist and (coincidence?) Google’s Director of Engineering, Ray Kurzweil. Essentially, he summarized it as an ever-developing concept of a progressively consequential role of technology in everyday life. One of the most striking illustrations of that concept is Kurzweil’s conclusion that today, an average child in Africa (or Russia, U.S., Cuba, China, etc.) with an off-the-shelf smartphone has more information at her fingertips than the president of the United States had 30 years ago. As any brilliant idea, singularity was successfully explained and encapsulated in simple terms by the above example.

    Science and Spirituality

    The same type of evolution awaits AA in particular, and the fight against addiction in general. Get with the program or get run over, as progress does not stop, and that is exactly what Bill Wilson understood so well in his pragmatic ingenuity. 

    From the reptilian middle brain and limbic system responsible for survival hijacking the thinking territory of the prefrontal cortex (in the AA lingo, home of the white-knuckling demon), to the brain’s neuroplasticity and ability to heal itself and learn new reward pathways after alcohol (or meth, heroin, porn, etc.) has done its scorched-earth number on its dopamine receptors, today’s science has explained it all. That is not to say that it has effectively pre-empted the field and left no room for miraculous recovery (doctors sometimes call it spontaneous remission) or any other spiritual component. To the contrary, following Dr. Carl Jung and his glorious pronouncement Spiritus Contra Spiritum, with which he famously concluded his 1961 letter to Bill Wilson discussing the viability of AA, science leaves ample room for spirituality when it comes to addiction. Now it’s time for AA to return the favor and welcome science in its rooms. 

    AA (or any other single-tier approach) cannot win this war on its own. And I am not even talking about the alleged (yet well-researched) 5-7 percent long-term success rate of AA (see Lance Dodes, MD, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry).

    What I am referring to instead is inclusiveness and intentional wariness of rigidity. Like Tolkien’s Balrog, addiction is a shape-shifter, a cunning, conniving, vindictive foe with an overpowering ability to maim and kill. Gandalf the Gray — arguably the strongest protagonist of Tolkien’s Middle Earth, simply could not dispatch the demon of all demons through his conventional, albeit awe-inspiring powers, and had to adjust and in a way shape-shift himself into Gandalf the White.

    So, who’s to say that what’s good for the U.S. Constitution, Kurzweil, and Gandalf is not good for Alcoholics Anonymous? More importantly, will AA even survive if it doesn’t embrace its own evolution?

    View the original article at thefix.com

  • How Does AA Work? A Review of the Evidence

    How Does AA Work? A Review of the Evidence

    AA is cloaked in misconceptions and mysticism: a society of “former drunks” who tout spirituality as a means to cure the chronic, genetic, and life-threatening disease of alcoholism.

    Alcoholics Anonymous (AA), as an organization, “neither endorses nor opposes any causes.” But AA, as a societal symbol, is very controversial. People have strong opinions about its benefits and its dangers. It’s an organization cloaked in misconceptions and mysticism: an anonymous society of “former drunks” who tout spirituality as a means to cure the chronic, genetic, and life-threatening disease of alcohol use disorder (AUD). There is no denying that many have found support and achieved recovery through involvement in 12-step programs. That has left researchers with the question: what mechanisms are at work behind the scenes?

    Peer Support Groups like AA Increase Oxytocin

    Participation in mutual help programs may increase levels of oxytocin, the feel-good hormone. Nicknamed the “love hormone,” it is released when people bond socially or physically. A neurobiological view of addiction recovery might look at how oxytocin plays on the brains of people in a treatment program. Oxytocin increases when bonding socially with others in AA and there are other neuroplasticity rewards that come from 12-step program participation. Interactions with other members improve the connectivity between the part of the brain that makes decisions and the “craving behavior” part of the brain.

    The oxytocin system is created before age four and its development can be affected by variables such as genetic differences within the receptor itself, or environmental causes like stress or trauma. An underdeveloped oxytocin system is a risk factor for drug addiction. Healthy levels of “oxytocin can reduce the pleasure of drugs and feeling of stress.” Creating opportunities for healthy oxytocin production could benefit people in recovery from addiction.

    Oxytocin also boosts feelings of spirituality, according to Duke University research. The study defined spirituality as “the belief in a meaningful life imbued with a sense of connection to a Higher Power, the world, or both.” Study participants who received a dose of oxytocin prior to meditation reported higher levels of positive emotions and feelings of spirituality. The effects lasted until at least one week after the initial experience.

    Do AA Prayers Reduce Cravings?

    Researchers at the NYU Langone Medical Center used brain imaging to see what, if any, effect praying has on the brains of AA members. They were able to see increased activity in the areas of the brain associated with attention and emotion during prayer which correlated with a reduced craving for alcohol. When exposed to triggers such as passing a bar or experiencing an emotional upset, people who were abstinent from alcohol but not members of AA were significantly less likely to experience the benefits of “abstinence-promoting prayers.” This brain activity seems to also be associated with a “spiritual awakening.”

    A spiritual awakening is not necessarily about the divine; rather, it’s an awareness of needing resources that are beyond the reach of a person’s individual ego. This awareness causes a shift that alters one’s perspective about drinking. There are also physiologic changes that seem to occur with increased spiritual awakening/awareness. In previous research, those who were directed to pray daily for four weeks drank half as much as the study participants who were directed to not pray.

    Research published in the last five years has tried to find ways to measure effectiveness in 12-step programs, in a way that is unbiased and scientific. One such study published in 2014 discovered that spiritual (rather than behavioral) 12-step work was important for later abstinence.

    Spirituality Is Not for Everyone

    Not everyone who enters AA experiences a spiritual awakening. According to a review of 25 years of research, it seems that only a minority of people with severe addiction experience this spiritual Aha! moment. While a sense of spirituality creates changes in the brain that can be measured on an MRI machine, there are other aspects of AA — social, mental, and emotional — that aid recovery for the majority of participants.

    Twelve-step programs can help addiction recovery because of their ability to propagate therapeutic mechanisms similar to the coping tools and behavioral strategies that are utilized in formal treatments. AA has a lot of parallels with cognitive behavioral therapy (CBT). CBT is an evidence-based form of psychotherapy that is effective over just a short period of time. In CBT, patients learn new habits through increasing self-awareness, overcoming fears, taking personal responsibility, and developing shifts in perspective. These are the same underpinnings as the 12 steps.

    Clinical interventions that encourage 12-step participation are more successful than clinical interventions that do not encourage attendance. Meeting attendance, sponsorship, and active involvement have come up in multiple studies as being positively correlated with continued abstinence, highlighting the critical nature of connection to others as part of an effective plan for managing addiction long term.

    12-Step Programs as a Useful Management Tool

    Addiction is a chronic illness with no cure, according to AA literature as well as the medical community, and chronic illnesses require lifelong management. AA can be a good ally in the quest to maintain a healthy lifestyle free of active addiction.

    The International Journal of Nursing Education published a study that sought to learn about the quality of life for those attending AA as opposed to those who are not attending AA. They found a significant difference, with those who attend AA reporting a better quality of life than non-attendees.

    When looking at meeting attendance over long periods of time, abstinence patterns can be predicted. For people who went through inpatient treatment, the pattern shows that meeting attendance is highest during treatment and reduces at a steady pace afterwards. With reduction in attendance there is also a reduction in abstinence from using drugs or alcohol. Findings from many long-term studies suggest that meeting attendance is important in early recovery and for successful long-term recovery. The reasons for this echo other research findings: community matters.

    Dangers Inherent to 12-Step Groups

    The nature of AA and other 12-step programs leaves them to be individually organized and without a central governance. There is no oversight and no quality controls. Abuse, inappropriate behavior, bad advice, and social ostracizing can happen.

    Perhaps most dangerous is when a single solution is pushed on someone for whom a different angle would work better. Individual satisfaction with treatment plays a major role in “subsequent psychiatric severity,” which means that recovery rates are lower for people who are unsatisfied with the addiction treatment they receive. The World Health Organization suggests that to improve treatment outcomes and engagement with treatment, patient satisfaction ought to be a focus when caring for people with substance use disorders.

    AA provides a range of pathways to recovery, but it is not the one-size-fits-all approach it claims to be. It’s particularly challenging for people who also have a diagnosis of (or just struggle with) social anxiety. It’s common for AUD to exist alongside social anxiety. The fear of being negatively appraised can impede progress in recovery. Long-term participation in mutual aid groups such as AA may reduce social anxiety but overcoming that hump in early recovery may require clinical interventions or alternative treatments.

    Did you find recovery in 12-step programs or did you have a negative experience? Let us know in the comments.

    View the original article at thefix.com

  • Cohort Based Recovery at The Clearing—What It Is and Why It Matters For People Seeking Residential Treatment

    Cohort Based Recovery at The Clearing—What It Is and Why It Matters For People Seeking Residential Treatment

    “We’re looking for more and better and different ways that are more effective in healing addiction.”

    The decision to seek residential treatment for addiction is not one that any family takes lightly. Addiction is a notoriously complex issue. When someone finally does decide to get the care they need, they’re often faced with an entirely new, complex set of questions. How much is reasonable to pay for treatment? What are the major differences between the programs? Is 12-step or non-12-step the best option?

    Though there’s obviously not one right choice when it comes to recovery, the recovery industry has become something of a monster in recent years. According to an article in the Daily Beast, the rehab industry now represents a $35 billion dollar pie—and many of the practices therein seem ultimately concerned with the bottom line rather than the long-term health of their patients. By way of example, most facilities use rolling admissions as a way to keep as many clients coming in and going out as possible. After all, the more clients who come in, the more insurance money can be collected and the more the industry can grow.

    Although this paints a somewhat sinister picture of an industry that does undoubtedly help many people, the question remains: is this the best way to do recovery? For Joe Koelzer, CEO and co-founder of the non-12-step rehab The Clearing in Friday Harbor, Washington, the answer is a resounding no.

    For their part, The Clearing emphasizes a cohort-based recovery model where all clients enter the same day and graduate the same day, completing their therapy programs together. “As it turns out, it’s a really great healing model,” Koelzer says. “It’s a much harder business model, which is why nobody else does it.”

    All jokes aside, Koelzer believes in the cohort-based approach as a response to the revolving doors of rolling admissions found at the majority of other residential programs. “When we decided to create The Clearing, we made a conscious decision to start with a blank piece of paper,” he said. “We said, ‘We’re not going to look at what everybody else is doing, we’re not going to look at what insurance wants to pay for. Let’s just focus on creating a program with the best chance of healing, what would it look like?’”

    The answer is a program that breaks most of the familiar recovery molds—including a defiance of 12-step dogma. The philosophy expressed is similar to one presented in an article in the Atlantic, which took the recovery industry to task for relying almost exclusively on the 12 steps as an outdated treatment protocol. In reality, according to the article, the success rate of such programs alone is between 5 and 10%.

    While this shouldn’t necessarily disqualify 12-step entirely, what’s clear is that this recovery philosophy was developed as far back as the 1930s—and there’s likely more to the story of addiction that needs addressing. “Our program does have a spiritual component to it,” Koelzer says, “but we mean true spirituality. We’re not preaching a dogma but rather we are working with each Participant to assist them through their self-discovery process.’”

    From the perspective of Koelzer and The Clearing, the approach that practitioners take to recovery ought to be a lot more fluid. “I don’t think we’re the answer for everybody. I don’t think anybody is the answer for everybody,” Koelzer says. “Almost nothing is the same as it was in the 1930s. We need to let our evolution, our new understanding of science, psychology and spirituality change the way that we heal. We’re looking for more and better and different ways that are more effective in healing addiction.”

    To put things in perspective, there are many things that The Clearing has in common with other programs—namely, evidence-based psychotherapy, holistic care methods, dual diagnosis support and a qualified staff. The primary difference, however, is in allowing clients to chart their own emotional journeys in a calm environment without the disruptions of people coming and going. “How do you create any kind of true consistency and safety within [a program that’s] always changing?” he says.

    Above all, according to Koelzer, the shift in addiction medicine that may need to happen is to slow the pace of treatment more generally. “The whole industry is built around the urgency of, you’ve got to go to treatment today.’” he says. “Well, you don’t have to go today. You’ve been doing this for 15 or 20 years. If you take the made-up urgency out of it, you can say: ‘Let me go to the place that I need to go rather than just the place that has a bed open.’”

    Reach The Clearing at (425) 678-3566. Find The Clearing on Facebook, Twitter, LinkedIn, Google+, YouTube and Instagram

    View the original article at thefix.com