Almost All Outcomes “Studies” of Addiction Treatment and Recovery are Wrong

My credentials are sobriety date 1/20/00, MA in Addiction Studies, Certified Alcohol and Drug Counselor II in Oregon, 13 years in treatment field.

There is an entire universe of academics who apply “science” to addiction treatment and recovery, and few if any such studies are in fact scientific or look at the outcomes of treatment combined with 12-Step recovery (and in some cases) combined with medication-assisted therapy. So you hear everywhere “treatment doesn’t work” and “AA doesn’t work.”

In order to be “scientific,” studies need to be replicable. A huge percentage of studies in the addiction field are not replicable because they are based on ever-shifting sets of assumptions — some measure abstinence, others measure “reduced use”; most measure little pieces of the process (Here is one from Hazelden Betty Ford Foundation’s Butler Center for Research on motivational interviewing, which studies the efficacy of a tool that is dependent on the application of other tools: MI is most effective when used as a prelude to other treatments or in addition to other treatments.

In fact, the reproducibility of most studies in the entire field of psychology is at least questionable.

A large portion of replications produced weaker evidence for the original findings despite using materials provided by the original authors, review in advance for methodological fidelity, and high statistical power to detect the original effect sizes. Moreover, correlational evidence is consistent with the conclusion that variation in the strength of initial evidence (such as original P value) was more predictive of replication success than variation in the characteristics of the teams conducting the research (such as experience and expertise). Science10.1126/science.aac4716

The other problem with most of these studies is they see treatment as an event, not a process. If you have a loved one addicted to something other than opiates or methamphetamine (more on that later), and you send them to a reputable treatment center for 30 days (but insurance companies will probably fight you on funding for the whole 30 days, and you’ll end up with more like 14-20 days), and your loved one takes no further action post-treatment, then you can expect a high rate of relapse, despite all the “evidence-based” treatments applied there. It’s not that hard to stop using in a controlled environment, but it is very difficult to stay stopped using in an uncontrolled one. But some will stay clean and sober in any event. * The same thing applies if your loved one just shows up at a 12-Step meeting one day after detoxing on their own. The percentage of people who just show up like that and never relapse is small for the same reason. They are in an uncontrolled environment. But some do it.

But what happens when your loved one goes through a treatment continuum that ranges from  medically monitored detox though outpatient treatment, lives in a sober environment for at least several months after treatment and becomes active in a 12-Step program right away? Academics measure the pieces of the process, not the process itself. Many treatment centers, as noted above, have their own measuring systems and research arms but the biggest failing they have when it comes to measuring whether people are clean/sober is that the people who are motivated to respond to their surveys are the ones who are doing well. The person drinking every day after a month in residential treatment and three months of the same facility’s outpatient treatment is not going to answer the phone or respond to an email from them. But even with this built-on bias, the number of people who follow a long-term process and are clean and sober at one year post-residential-treatment is far higher than those who just went to treatment or just got involved in a 12-Step program or just took a pharmaceutical to reduce cravings.

The bias among academics about 12-Step programs is huge because those programs do not yield to study by social science. The people in them are anonymous and hard to find. They are also conditioned to lie (or maybe “exaggerate) to anyone outside their recovery group, even it’s just because they can. Not one person in a 12-Step program with more than five years clean and sober can tell you exactly “why” the program worked for them. People at this stage of recovery have learned that “why” questions are irrelevant. It doesn’t matter why I got to where I was, what matters is what am I going to do about it and how am I going to go about it? But if you have to ask why, much of it probably has to do with the honesty and connection they began to experience rather than the lying and isolation they experienced as active addicts. 

I think most members of Alcoholics Anonymous would agree with the general observation that in general it takes about 30 days for your body to clear up, 90 days for your mind to clear up and a year for your emotions to clear up. Hence the old AA adage: “Go to 90 meetings in 90 days.” Hence the adage: “No new relationships in the first year.” Hence the group acknowledgement of numerous recovery milestones (30 days, 60 days, three months, nine months) in the first year.

If you spend the first 30 days of your recovery in a reputable treatment center, get better nutrition, get a little exercise, start to build a sense of community and learn about 12-Step recovery, then the next 60 days toward clearing of the mind will be easier and thus produce better outcomes. Maybe you come out of treatment with a pharmaceutical to reduce cravings. You probably go to some kind of step-down outpatient treatment that keeps you focused on the idea that you have a disease, not a shortage of moral character. And if you combine this with active involvement in a 12-Step program and the sense of community it can provide, then you will have outcomes that far exceed what most of the academics measure. (Those who don’t find community in 12-Step programs obviously don’t “keep coming back.” They need something else.)

So why don’t they measure the entire process? 1.) They don’t understand that it is a process. 2.) It’s too hard to follow people for a year in any kind of objective way.  3.) They don’t understand that the change a recovering addict goes through is first behavioral and then perceptual. The active addict’s behavior drives his/her perceptions (“it’s not fair”, “it’s not so bad”, “I deserve it,” “I can quit whenever I want,” “It’s the only way I can have fun,” etc.) The recovering addict’s perceptions drive his/her behavior (“If I pick up that drink/drug I’ll lose my community,” “Being of service to other addicts always makes me feel better,” “I don’t feel like I have to go to 12-Step meetings anymore; I feel like I get to.” etc.)  Sufficient funds provided to people who understand both addiction and true science would solve this problem. I expect this to happen around the same time those aliens in the movie Arrival actually do show up here and show us how to defeat the constraints of time.

The problems with opiates and methamphetamine are different. Meth first. This drug blows up the dopamine system in the brain and produces profound anhedonia (inability to feel pleasure) in the chronic user. Recovery from meth addiction requires a long time in a controlled environment. When I was new in the treatment field, the more experienced residential-treatment professionals first noticed this when they saw that their meth-addicted clients who came from jail did far better than those who came off the street. That is, the clients from jail had done basically nothing but sleep and eat for at least a few months, and that is how one treats meth withdrawal. Withdrawal always involves processes and factors opposite of the effect of the drug. Alcohol and benzodiazepine withdrawal involves agitation, insomnia, elevated blood pressure and “the shakes.”  Active meth users rarely eat or sleep unless/until they crash. Thus, withdrawal involves intense sleepiness and hunger. Measuring the effect of 21 days of treatment on a chronic meth addict is like measuring the effect of sandbags on a tsunami.

“Opiates” today means heroin or heroin laced with fentanyl or carfentanil or in some cases fentanyl or carfentanil alone. It’s clear that at least 75 percent of current heroin addicts started out using prescription painkillers such as Vicodin, Percocet and OxyContin. (The nation is awash in these medications, and maybe public policy people will get around to viewing the “opiate epidemic” the same way they viewed the “cigarette epidemic” and treat Big Pharma the same way they treated Big Tobacco.) Using heroin is basically an economic decision for a painkiller addict; the move to injecting it is also an economic decision — a little bit goes further, at least for a little while, but then you have the HIV and Hepatitis C and infected injection sites that come with needles. Clearly, you prevent more heroin addicts by limiting access to Vicodin, Percocet, OxyContin and the like. When I was part of it, Big Pharma had three lobbyists for every member of Congress, so good luck with this approach.

What about the current heroin addicts? The ones who are the biggest focus of treatment efforts are younger than 25, mostly because the Affordable Care Act lets these young adults stay on their parents’ health insurance until they are 26. Many are adults chronologically but teenagers developmentally. The insight and introspection that works on a 50-year-old alcoholic with a lot to lose is worthless with a young heroin addict. A long, behaviorally oriented program is emerging as the best way to treat these people, yet they still get run through residential treatment of less than a month.

It is also hard to get people in the treatment world to understand that heroin is different from any other drugs. It produces a nihilistic perception of the world and also deregulates the natural receptors involved in both pleasure and pain. This latter element is why opiates are fantastic for acute pain and horrible for chronic pain. The deregulating nature of these drugs confuses the neural pathways in the body and the brain to the point where what one perceives as pain can in fact be craving for the drug. Treatment for addiction to prescription painkillers alone is by definition mostly for older patients with chronic pain problems who have not progressed to heroin because they could maintain access to the painkillers.

A heroin addict is the ultimate dropout. I have had as clients severe alcoholics whose lives were driven by where is the next drink coming from, but they still had some interest in sports or the weather or politics or their family (even if their family was losing interest in them). Not so with the heroin addict. Nothing else matters. Cleaning up a young heroin addict is the smallest of first steps. He/she essentially needs to be resocialized. This process can take years, not weeks. The problem of old heroin addicts is moot; there aren’t very many of them.

The post-acute withdrawal from opiates is also different from other drugs (and alcohol to what we call an “alcoholic” is a drug, by the way). The “natural opiates” in the brain are gone when you stop using heroin because the heroin caused the brain to perceive an overproduction of these substances. It takes quite awhile for the brain to re-regulate itself. Craving, or the internal desire to use a substance in response to some external stimulus, can be profound in a recovering heroin addict for a long time. This makes sense because at one time the heroin was the complete focus of every aspect of the addict’s mind. It is the nature of any addict’s mind to engage in euphoric recall of the substance; that is, the times when it worked, not the times when the addict was using it only to stave off withdrawal. Remember, the heroin addict had a clear dichotomy of engage the world or disappear from it. Nothing in between. So any fear about engaging the world will produce a very strong push from the primitive part of the brain to disappear, and the heroin addict knows only one way to do that. Some begin to chip on alcohol and marijuana but it is rare for them to not move on to heroin again quickly.

This is where medication-assisted therapy (MAT) comes in. Various formulations involving the drug buprenorphine are used in this regard. I have been trained in and follow abstinence-based recovery myself, but I don’t have any problem with MAT as long as it has some defined clinical endpoint. Otherwise, it’s maintenance. Maintenance on Suboxone is superior to maintenance on methadone because the withdrawal is not so hideous if one decides to wean off Suboxone maintenance. But if it’s maintenance, call it that and don’t pretend it’s something else. Since the study of treatment and recovery in all its aspects is skewed and fragmented, I would expect the emerging research on MAT to be the same thing.

Update on Vivitrol. If you ask the addicts, which policy makers don’t do, the blocking effect of Vivitrol lasts about two weeks, not a month:

* I was told once that on a standard bell curve, there are roughly 15 percent of the people at one end “who can get sober in a liquor store.” That is, they are going to recover no matter how bad the treatment, associated medical care, AA/NA meetings and so forth are. The treatment enterprise cannot take credit for these people. At the other end of the curve are roughly 15 percent of the people who are going to die no matter what anyone does. The enterprise can’t take blame for them. That leaves the 70 percent in the middle of the curve.

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