Addiction Recovery: Delaying The Inevitable

A VOICE FROM THE WILDERNESS

Andrew D. Bennett, CADC II

Contemporary cosmologists feel free to say anything that pops into their heads. Unhappy examples are everywhere: absurd schemes to model time on the basis of the complex numbers, as in Stephen Hawking’s A Brief History of Time; bizarre and ugly contraptions for cosmic inflation; universes multiplying beyond the reach of observation; white holes, black holes, worm holes, and naked singularities; theories of every stripe and variety, all of them uncorrected by any criticism beyond the trivial.
- Source: Abridged from David Berlinski, “Was There a Big Bang?” Commentary 105.2 (February 1998).

The chemical dependency treatment field is experiencing significant changes in the service of “new technologies.” We seem to have been swept away by these changes within a professional atmosphere characterized by compliance, lacking sufficient critical review.

We are currently moving to a Medical Model emphasizing a psychiatric orientation embracing dual diagnosis and bio-pharmacological interventions. The primary disease concept and the drug-free model are clearly challenged. They need to be defended.

In 1961 it was thought that alcoholics drink over underlying emotional problems and a Valium deficiency. In 2009, alcoholics and drug addicts drink and use over underlying emotional problems and a serotonin deficiency. Legions of psycho pharmacologists are pumping out new and improved nutritional, anti-depressant, anti-craving synaptic rejuvenator pills that Dorothy is eating. Dorothy is told, on the one hand, that she is powerless over alcohol and other drugs. At the same time, she is prescribed pills designed to somehow make her feel less powerless. It’s time to take a good look at how we’ve been doing business and what it is we’re selling. It’s time that CD treatment providers joined the ranks of all the other social sciences in the application of critical peer review to our work. .

The writer has no problem with competing clinical approaches to CD treatment that do not claim or pretend to fit into a 12-step context, however, if there is such a thing as a 12-step treatment model that is worth preserving, boundaries need to be put around it.

Antidepressant medication, nutritional supplements, and opiate antagonists/agonists are promoted to allay craving and other dysphonic feelings following classical detoxification. They are used, in theory, to help restore depleted neurotransmitter substances following chronic substance abuse. Agents of this kind are supposed to help restore neurological integrity at the synapse.

The short-term efficacy of this class of psychopharmacological intervention has been met with mixed reviews. More importantly, problems of experimental research design are noted.1 No amount of placebo-controlled, double blind methodological safeguards can make up for short term studies limited to a statistically compromised number of experimental subjects who are willing to be experimented upon with substances within treatment facilities willing to conduct patient drug therapy experiments. One cannot make any scientifically coherent statements about long-term efficacy applied to C.D. patients based upon a combination of methodological compromises characterized by current anti-craving medication studies. My Bachelor of Science degree tells me that these kind of trails cannot clarify whether or not offering drug addicts and alcoholics mood altering substances is generally a good thing. In an article appearing in the 8-20-03 edition of JAMA, Als-Nielsen et al support a growing body of evidence suggesting that for profit funding of experimental drug trails are significantly more likely to recommend experimental drugs than not for profit funding2.More recently, in the March/April, 07’ edition of Addiction Professional, Stuart Gitlow,MD, and Mark Gold,MD offer an enlightening review of the methodological shortcomings characteristic of current chemical dependency drug trails. Despite all of these factors, there are few, if any, long-term patient outcome studies demonstrating the efficacy of anti-craving agents. Arriving at other conclusions based on this kind of research requires a cheapening of the scientific method.

The research fails to differentiate functional or reactive dysphoria from organic or endogenous dysphoria. Patients who all of a sudden find themselves squeaky clean following a protracted chemically induced post-traumatic stress disorder will naturally be a little fuzzy around the edges, especially after looking at the mess they made. This kind of dysphoria is very different from the protracted organic dysphoria thought to occur as a symptom of chronic chemical thrashing and assault at the synaptic level. Psychogenic dysphoria is always expressed neurologically as well, altering neurotransmitter levels. The research fails to tease one out from the other. Is “craving,” following detoxification, essentially psychogenic, driven by euphoric recall (functional) or organic? My unscientific opinion, drawn from routine clinical observation, tells me psychogenic. CD patients should not be medicated for functional reasons. This is fundamental

A wide variety of anti-depressant and mood stabilizing drugs billed as non-addictive are frequently prescribed for chemically dependent patients. It would seem, on the face of it, even to a layman, that using mood-altering drugs to help addicts recover is questionable. Stung out cocaine addicts have been known to snort “non-addictive” white battery acid residue found on top of car batteries. What may be non-addictive for a normie may act very differently when processed through a well-entrenched substance dependent mind set of recovering people. Chemically dependent patients, in fact, frequently abuse these kind of substances before returning to drugs of choice.12-step Recovery fundamentally suggests that the patient is responsible for dealing with their feelings. Chemically dependent people have problems with mood altering substances. Certainly the conservative and judicious uses of psychotropic medication when applied to those patients presenting a genuine dual diagnosis have played a critical role in continued recovery. Prescriptions of this kind however, always carry with them a dangerous and very powerful message that somehow the patient is neurologically, or organically, or pharmacologically, or constitutionally compromised in tolerating their feelings and for this reason they will benefit from continuing to use “different” drugs. Before prescribing psychotropic medication, the clinician needs to decide if this is really true before advising the patient to go out on that kind of a limb.

Some researchers point to longer treatment retention for patients who are prescribed antidepressant and/or anti-craving medication. It is not surprising that a drug-addicted patient, having a great investment in pharmacology, may hold out longer when offered anti-craving substances within facilities that invite patients to use anti-craving substances. A subjective decrease in drug hunger will act to improve short-term patient resolve. Researchers point to a reduced AMA rate for patients who are prescribed antidepressant/anti-craving medication. If some patients were given methamphetamine they would stay in treatment even longer.

It has been said that in some ways, 12-step programs are against human nature. Willingness to work a 12-step program requires an enormous motivational force. The patient must accept “being whipped”. For this reason The Big Book makes reference to “incomprehensible demoralization”. The use of anti-craving agents is most likely to fortify the patients’ normal resistance to 12-step programs. In this way, higher short-term abstinence rates may contribute, paradoxically, to lower long-term rates of recovery.

Physician colleagues point out that chemical dependency counselors are not qualified to fully understand the therapeutic effects of psychotropic drugs. This is true. Chemical Dependency counselors are, however, experts on how they can hurt people. Powerlessness and craving are precisely what drives people into 12-step programs, in this way, the most dangerous thing about anti-craving agents are if they work as intended.

Methadone and other drug maintenance protocols have earned their place in the sun. Although the writer isn’t qualified to comment on the efficacy of these regimes, I believe they cut down on drug related crime. Chemical Dependency treatment however, used to be about helping patients to recover from Chemical Dependency. Since the advent of Suboxone, Ricette Benchkser pharmaceuticals want Chemical Dependency Recovery service providers to adopt the Orwellian position of helping chemically dependent patients to successfully remain chemically dependent longer. Ricette Benchkser then suggest that Suboxone patients can somehow conform to 12-step principals where they are advised that they are powerless over alcohol and other drugs. Step 1 makes no qualifications concerning the contrary opinions and the advice of the pharmaceutical companies and the physicians who provided the substances required to cause the problem in the first place.

Extended Suboxone ambulatory detox is really less like detox and more like “trying to cut down”. “I’ll quit tomorrow”. CD patients have already tried that one before arriving at the treatment center.

The inclusion of Suboxone maintained patients within a 12-step abstinence based treatment model will fundamentally compromise the integrity of the peer group by undercutting the common task of adjusting to becoming clean. The alcoholic, cocaine, benzodiazepine and methamphetamine peer group members are left to wonder why their Opioid dependent peers are encouraged to remain on their drug of choice, antagonist properties notwithstanding. An Opiod followed by some kind of Naltarxone chaser? “Methadone with a shoe shine”?

The Medical Model appropriately charges the technologist with providing treatment for the patient. Recovery services however, are often more spiritual and less technological in nature. 12-step Chemical dependency counseling also involves a greater emphasis on peer support, patient compliance and responsibility. A Medical Model philosophy for a cancer patient can have an enabling effect when applied to an alcoholic.

Alcoholism and chemical dependency have been described as baffling, cunning, and powerful. While undoubtedly driven by psychosocial forces, chemical dependency is essentially biogenic in nature. Being among the most complex of diseases, the debate concerning its etiology and treatment rages on. Recovery, however, carries with it a spiritual component that has proven itself to respond favorably to a “moral psychology,” as proposed in the Big Book by William D. Silkworth, M.D. Discussions about clinical theory and treatment protocol are crucial. They define what we do as professionals. They help us to describe and to improve upon our skills. Discussions of this kind however, continually remind me to recognize the limitations of technological solutions for spiritual problems.

1. Psychological addiction is the crux of Chemical Dependency.
2. Psychological addiction is driven by Euphoric Recall.
3. Anti-craving agents fail to diminish Euphoric Recall.
4. Anti-craving agents continue Chemical Dependency.
Q.E.D.

1 Stuart Gitlow MD, Mark Gold,MD The Inadequacies of the Evidence. Addiction Professional, March/April, 2007, pg. 17-25.

2 Als-Nielsen, W. Owen,C Glud, L Kjaergard, Association of and Conclusions in Randomized Drug Trails: A Reflection of Treatment Effect or Adverse Effects? JAMA, 2003; 290: 921-928, 8-03.

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