Monthly Archives: June 2011

12 Steps Backward

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I’m not just against 12-step ‘recovery centers’ because we have philosophical disagreements about the definition of the word ‘addiction’. I am against them because they do real, terrible, lasting harm to many people; my patients, my patients’ families, and all the people out there who are in similar situations, but can’t find their way to help because of 12-step propaganda or ignorance.

I have recently had more than one stable, functioning patient leave my care against their will to attend a 12-step program. These are people who, for the first time in many years, were finally able to lead productive, happy lives. The medication I prescribe had done for them what medication is supposed to do — give them relief from the symptoms of their illness, and allow them to continue their lives. One patient in particular has been doing very well on Suboxone for more than a year.

These patients didn’t want to leave this program. They knew that Suboxone was helping them to feel normal. But others around them — their families, friends, employers, counselors — told them constantly that they were weak, sick, and dirty. Despite feeling better and seeing more clearly than they had in years, my patients were being pounded at from all sides with messages of defeat, invalidation, and surrender. This week, I’ve had more than one come to me in tears, desperate to stay in the program but being forced to go to some 12-step facility by family members who refused to consider their newfound well-being as an improvement. They were still taking something, so they weren’t clean.

So how do the loved ones of these patients want them to ‘get clean’? By being nauseous, achey, overtired, consumed by cravings, and locked in a group counseling session, all day every day for thirty days, and at enormous financial and emotional cost. Compared to the free, normal lives these patients could be living with basic medical assistance, the environment of an in-patient 12-step program is cruel.

The thought of this happening to my patients, the people I am caring for, infuriates me. It’s partly the fault of the 12-step programs themselves, but more than that it’s the fault of narrow-minded friends and family members, many of whom won’t come into my office to talk to me or hear about the medication from me. This is another terrible consequence of our society’s failure to treat addiction as a biochemical disease. No one would refuse to talk to a cardiologist who was treating a loved one for heart disease. The refusal to talk to qualified medical professionals, and the decision to cling to emotional, outdated prejudices instead, is frankly appalling.

That is why this blog exists. I am here to tell everyone, addicts and loved ones alike, that the barbaric 12-step facilities are not the only option. I, as a physician, follow the oldest rule of physicians: ‘First, do no harm’. I’m not convinced that 12-step programs can say the same.

Recovery and Remission

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When I started this blog, I had no idea how much time I would spend writing about definitions.  I didn’t realize how murky our language becomes when we talk about addiction, even among professionals, and how great the need is for clarity and honesty in our terms.

A few weeks ago, I wrote about ASAM’s recent statement defining the disease of addiction. Just a few days ago, I found a 2005 report from the Substance Abuse and Mental Health Services Administration (SAMHSA), outlining “Guiding Principles of Recovery” and “Systems of Care Elements” for treatment systems helping those with substance abuse problems. You can read that report here. I won’t talk about each guideline individually, because it is my opinion that the document overall is vague, noncommittal, and ultimately unhelpful to patients and physicians.

Addiction is a medical disease, with an underlying biochemical cause. Like any other disease, we treat addiction with medication, and we use scientific evidence to measure the success or failure of our treatments. Addiction patients, like all patients, deserve precision and clarity from their physicians to help them through addiction’s complex and frightening threats to their health. The SAMHSA definition of “recovery” is none of those things. It isn’t clear, precise, or scientific. It presents principles of “recovery” that are certainly desirable, but aren’t medically relevant. While I would agree that getting better from an illness should come along with “hope and gratitude”, and should be “a process of healing and self-redefinition”, those are not the things that should form the foundation of treatment. The foundation of treatment should be sound medical science, and its goal should be to achieve the best possible state of physical and mental health through the safest and surest means possible.

That’s the other major problem with “recovery”; it has no goal. I’ve seen this firsthand in non-medical, 12-step treatment programs, where “recovery” is described to patients as a state in which they must constantly strive to live, which they might fall from at any moment. It’s a vague, endless struggle that gives no promise of results. True medicine, practiced by knowledgeable physicians, should always have an end-goal, even when that end-goal is achieved by a long-term maintenance plan instead of a short-term total cure.

We already have a word that describes the goal of medication maintenance. That word is “remission”.

Addiction is a chronic disease. The goal of medication maintenance is not to instantly and completely cure it, because with our current level of technology, that isn’t possible. Until it is, we strive to get the patient to a point where their disease is well-controlled, and does not disrupt or interfere with the quality of their life.

12-step programs make a point of telling their clients that while people can be “in recovery” for decades, no one is ever truly recovered. With legitimate medical treatment, it is entirely possible for a patient to be recovered, with the requirement that they take the proper medication. This is exactly how we treat asthma, diabetes, and high blood pressure. Only in the field of addiction is vague spiritual “recovery” touted as a real alternative to simply treating disease.

Dependence and Behavior

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One of the major criticisms I hear about treating opioid dependence with buprenorphine is the claim that maintaining patients on medication is just ‘trading one addiction for another’.

A few weeks ago I talked about the new ASAM definition of ‘addiction’, but there is another important distinction that needs to be drawn when it comes to opioid addiction before we can be really clear on what it means and how it affects the lives of patients.

There are two main parts to opioid addiction, a cause and an effect. The cause, the root of the disease, is activation of the brain’s reward system, which causes physical dependence. Dependence is the condition of the brain where it thinks that a massive dose of opiates is necessary to its survival, and lack of that dose causes withdrawal symptoms. The effect, the symptoms of the disease that we try to treat, is the addicted behavior — the stealing, lying, lack of interest, neglect, and other behavioral changes that cause a patient distress and lower the quality of their life. These addictive behaviors generally arise due to a patient needing to satisfy their physical dependence; there is no evidence to suggest that these behaviors are innately present in out patients as spiritual or emotional deficits of character.

You can see how, though dependence often causes these behaviors, the dependence and behaviors can also exist apart from each other. People can suffer the behavioral and emotional impacts of addiction without being physically dependent on opiates — they may be psychologically dependent, or they may be suffering from other stress factors that cause them to treat the substance as though it was necessary for survival.

The opposite situation is also true. Many patients who are treated for chronic pain are certainly physically dependent on opiates, but do not demonstrate addictive behaviors.  The current state of our knowledge of the brain’s opiate system is that, when a patient has been physically dependent on opiates for a long time, the damage done to the reward pathways is most likely permanent. At our current level of understanding there is no way to reset these  pathways;  the patient will always be physically dependent on opiates.

But medication maintenance can help us separate the cause of the disease — the physical dependence — from the effects that cause the patients pain and distress. Physical dependence is never going to go away, so the goal of medication maintenance is physical dependence without painful addicted behavior. We accomplish this by using medications that eliminate a patient’s cravings and withdrawal symptoms, so they can go about their lives normally, as though their brains weren’t dependent on anything.

So it’s true that patients being maintained on medication have traded one dependence for another, because there’s no way to make the dependence go away. But their addiction, as expressed in their emotions and behavior, can be — and is — successfully treated. To reject the medication method of treatment, to criminalize it because it doesn’t manage to eliminate the underlying dependence along with the addicted behaviors, does nothing but harm those patients who could most benefit from this chance to regain their lives.

This is Your Brain on Drugs

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Addiction is a disease of the reward pathways in the brain.

The exact receptors affected differ from substance to substance, and the largely uncharted complexity of the brain makes it difficult to pinpoint the exact location where a drug might be acting, but we do know which systems and pathways are altered by addiction. They resemble the pathways that manage other activities that the brain rewards us for — activities as vital as eating, sex, sleep, and escaping from danger.

These functions are so important to survival that the systems controlling them are some of the most powerful systems we have. Failing to eat will lead to illness and death, so finding enough food becomes the first priority for survival; and only brains that could motivate eating and food-seeking were able to survive. A successful brain has to cause the animal it controls, in this case a human, to neglect everything it considers nonessential for survival in order to find food, and then reward the animal with powerful positive sensations so that it won’t go without food for too long again.

This is basic reward theory, and it doesn’t only apply to us humans. All animals have some version of a reward system, though it might not resemble ours physiologically. It’s a safe bet that these pathways of craving and reward have been part of our brains since long before we split from the chimpanzees. These are the pathways that drugs work on, usually by mimicking the chemicals that our brain naturally produces to give us reward sensations.

Addiction affects the reward pathways, but counseling and 12-step-based treatment programs don’t treat the reward pathways. They treat the prefrontal cortex.

The prefrontal cortex is, roughly, the part of the brain that allows us to anticipate complex series of future events, consider our different options when solving a  problem, think logically, and control our own behavior. The prefrontal cortex is often considered the part of the brain responsible for inhibitions and gauging what behavior is socially acceptable. It’s what  many people would say separates us from the other animals.

The human prefrontal cortex is highly developed, more so than in any animal except our closest evolutionary cousins. But that development was a relatively recent one, and while complex, logical thinking is definitely necessary for our survival, it isn’t on the same basic, primordial level as food and sleep.  This is why the reward pathways can override the prefrontal cortex.

We know this is true. It happens all the time in our everyday lives, whenever we find ourselves doing something that we want to do but know might be bad for us — whether it’s driving over the speed limit, or eating a second cookie, or smoking. It’s true that most of us can avoid these behaviors some of the time by willpower — by the prefrontal cortex shouting down the reward pathways. Education is a powerful tool in this regard, since knowing the bad consequences of our actions can strengthen the efforts of our prefrontal cortex to prevent it. Social motivators, like guilt and embarassment, can also be effective at drowning out the reward pathways. But education, willpower, and social motivation can only go so far. Just as you can’t educate or guilt yourself out of being hungry, there comes a point where the basic survival mechanisms of the reward pathways can’t be contained by the prefrontal cortex.

This is the case in addiction. It is a biological disease which affects the brain, fooling the reward pathways into believing that the addictive substance is absolutely necessary for a person’s continued survival. Teaching people about the negative effects of drugs won’t fix this, because education works in the prefrontal cortex, and that’s not where the source of the illness is. Guilting or shaming people might enable them to temporarily contain the desires of the reward pathway through willpower, but eventually the reward pathways can overcome the influence of the thinking parts of the brain, and drive the addicted person to seek their substance of choice regardless of anything else.

But there’s hope. There’s a treatment for the true source of the illness now, one that fixes the reward pathways — and once the reward pathways have been satisfied, then counseling, education, and social therapy can work on the prefrontal cortex, and the patient can improve his or her behavior. As long as the reward pathways are damaged, it’s very unlikely that a patient can fix their behavior on their own, because their behavior isn’t entirely under their conscious control.

Everything wrong right now in the field of addiction medicine relates to a misunderstanding of the relationship between these structures in the brain. Addicts and counselors have been aggressively attempting to treat the symptoms of addiction for decades, but it simply wasn’t possible as long as the root of the problem was going unaddressed. Now we can fix the underlying illness, and all the treatments which have been wasted up until this point can, on the basis of medication, become truly effective and truly helpful.

Counseling has its place in the treatment of addiction and addictive behavior, but that place should be secondary, behind medication maintenance. Addiction creates all kinds of social and emotional problems in patients’ lives that education and counseling can help, but none of that will be effective until we can calm the reward pathways and put the patient back in control.