Unforeseen Consequences

Posted on January 24, 2012 by admin

One of the first things I saw when I got online this morning was this article from the Comcast.com news page:

http://xfinity.comcast.net/articles/news-general/20120123/US.Meth.Severe.Burns/

It’s a report on how burn centers in some states are being forced to close due to a spike in patients who were burned making methamphetamine in their homes. Since meth-related injuries are among the most difficult and expensive to treat, and patients who sustain this kind of injury usually don’t have insurance, the cost is being absorbed by the hospitals and burn units, which is leading to the shutdown. The reason for the recent spike in meth-related burn cases is the rise of a new meth-making process which involves combining the volatile ingredients in a two-liter soda bottle, which is then shaken near the face. In contrast to fires in a meth “lab”, which people can often escape, a meltdown in the soda bottle process invariably causes debilitating burns to the face, chest, and hands, and often results in blindness.

There are several reasons why this new, more dangerous technique is taking hold in states where meth is a severe problem — the new method is more cost-effective, requires smaller amounts of controlled substances, and produces a smaller quantity of meth, for personal use rather than sale. But wouldn’t the vastly increased risk make it a less attractive option?

The fact is that one of the many symptoms of addiction is a decreased ability to appreciate risk, especially where the addictive substance is involved. The strength of an addictive craving will convince a patient to take greater risks to their health and safety in order to fulfill it, but it doesn’t end there — after prolonged use, addicted patients show a habitual desensitization to, and comprehension of, risks to themselves or others. If the risks of soda-bottle meth (called “shake-and-bake” by the linked article) were associated with any other product, they would act as a discouraging factor; but because we are dealing with a specifically vulnerable population, it cannot be assumed that the greater risk will act as a deterrent.

Knowing that, and desiring to keep their burn centers open and able to serve all patients, it seems like the only course for affected states and hospitals is to try and prevent these people from sustaining these injuries in the first place. One of the reasons given for the rise of shake-and-bake meth was “greater attempts to crack down” on traditional, larger meth labs. As an experiment, I googled “how to make methamphetamine” and found thousands of recipes and explanations. Clearly, enforcement after the fact is not working, and will probably never really work; with no way to limit the spread of information on how to make meth, and a segment of the population who are less sensitive to risk and incredibly desperate to attain their drug of choice, it is clear that all attempts to “crack down” will only drive addicts to more dangerous (and possibly lethal) methods.

I have no doubt that extensive programs to prevent meth addiction are already in place in these states where it is an epidemic, but these burn center closures are sending a clear message that whatever programs currently exist are inadequate. Programs designed to alleviate financial stress and the living standard of residents might be an improvement, since substance abuse is often tied to socioeconomic stress. And while any such program would undoubtedly be extremely expensive, it would surely fall far short of the “hundreds of millions” of taxpayer dollars currently being used to absorb the cost of treating uninsured burn victims.

This is just a symptom of a wider problem that I encounter every day — namely, the disgraceful lack of attention that is given to addiction as a wide-reaching problem on the national stage. People in positions of power, as well as most people who have never been affected by this disease, appear to think that drug addiction is “under control”, or is a problem that will never have any consequences for them. The fact is that, besides being a huge drain of human life and economic resources, addiction has shattering and unpredictable affects on all people in this country. Now, as we are seeing, victims of fires in some states will have less access to adequate care. The fact is that addiction is in no way a small or insignificant problem, and any attempt to decrease it must have just as widespread and long-lasting benefits.

Interpretations of AA

Posted on January 19, 2012 by admin

I spend a lot of time on this blog discussing 12-step programs. But what exactly constitutes a “12-step program”? The term itself is rather vague.

I tend to use this as an umbrella term to describe the group-based, discussion-heavy, and non-medicated treatment style that claims to be the spiritual successor of AA. This approach has been expanded to treat narcotic addiction, nicotine addiction, and any number of other conditions. It has also been adopted very widely, and while it’s common for treatment providers to stay close to AA’s original 12 steps, they also tend to tweak and change and “put their own spin” on the program as much as they can. What this has led to is a huge variety of treatment approaches that, to an outsider with a critical eye, all appear to share a few core principles that they have taken from the founding tenets of AA. Usually this includes belief in a Higher Power; the righting of wrongs done to others in the past; establishing a social network with other ex-addicts; and a strong moral emphasis on being “clean” rather than “dirty”; and a refusal or demonization of medication.

I write about 12-step programs mostly from my own experience, because as a doctor advocating medication maintenance for addiction, I encounter a great deal of hostility and resistance from the staff of these programs. I also witness firsthand the effects that this style of treatment has on my patients, who refuse to stay healthy on maintenance because they believe they are still “dirty”. Most programs that fight against medication maintenance do so using a kind of authoritative hair-splitting; they claim that, since buprenorphine affects the opiate receptors, it takes away a patient’s right to be called “clean” or “in recovery”. I would just like to point out the irony of this panicked accusation, seeing as the founder of AA originally made it very plain that excluding anyone on such superficial grounds was very much against the spirit of the organization. You can read Bill W.’s opinion on who should be allowed to be a member of AA here.

Alcoholics Anonymous was founded in 1935 by Bill W. and Dr. Bob as a way to help alcoholics find strength and comfort in community. As part of my education in the field of addiction, I’ve read a large amount of AA literature, including the “Big Book”, considered the central text of the organization. I have reached the conclusion that the original spirit of AA was an unflinchingly inclusive one, and that the founders would not have approved of keeping an addict out of “recovery” based on what other medication they were taking, or what other measures they might be taking to control their alcoholism. Addiction is a disease, and taking regular medication for it should be no more problematic than taking regular blood pressure medication. It certainly shouldn’t be used as an excuse to keep stable and thriving patients out of the nebulous category of “in recovery”.

Yet a great deal of resistance to medication maintenance comes from a widely-held belief that medication somehow violates the principles of AA, and the 12-step programs that have descended from AA. I would argue that this belief is factually wrong, but the factual correctness of a statement like that doesn’t even matter, because every interpretation of the “principles” of AA is equally valid. AA (used here as the flagship example of the 12-step type of program) is a nebulous, widespread organization without a central authority capable of making policy decisions. It is based on a certain amount of written material, all of which is open to interpretation, and there is no one with the authority to call any interpretation right or wrong. It actually resembles many religions in this way.

I would argue that the belief that medication goes against the spirit of AA is widely-held, not because the texts support such an interpretation, but because it has become a sort of canon that has been mixed into the original philosophies of AA and passed on due to tradition and financial advantage. Thankfully, since all interpretations are equally valid, I will tell all my future patients that this ugly and discriminatory policy does not come from a place of authority and should have no power to prevent them from seeking the most effective treatment they can.

Inside the Anger

Posted on January 11, 2012 by admin

Last week, I wrote about how 12-step programs that hire exclusively from the small pool of “12-step successes” may be misleading their patients — and how patients are taken in by their own tendency to trust in anecdotes more than statistics and data. This week I want to write about a very similar trend among those who defend 12-step treatment programs against the advance of other, more scientific methods of treatment.

I spend a great deal of time on various forums online, debating the merits of different forms of addiction treatment with professionals and laypeople alike. I see it as a vital and valuable way to stay informed and relevant to the conversations going on in the community I am trying to serve. One thing I’ve noticed over the course of these discussions is that people who tend to support 12-step programs tend to be much more emotionally invested in their arguments, and often react to disagreement as though it were a personal attack.

I don’t think this has anything to do with these people in particular; I’ve gotten enraged, nearly hysterical responses from people who work at these programs, people who don’t, even people who relapsed after undergoing a 12-step treatment. I think a feeling of deep emotional attachment to the ideals of 12-step programs are a symptom of the way these programs are run. I mentioned last week that anecdotes, especially when they are highly emotionally charged and are coming from people in positions of authority, may well be the most powerful persuasive force that can act on a human mind. 12-step programs engineer situations that harness this force in their favor. They present sick, frightened, desperate patients with calm and reassuring counselors (remember, all drawn from a small percentage of addicts), and have those authority figures relate stories of how their lives were ruined and 12-step programs saved them.

The effect this has is very difficult to overstate. It is, as I said, very persuasive — but it’s persuasive on an emotional basis rather than an intellectual one. Emotional certainty can be very useful and necessary in our lives, but it can also cloud our judgement and make us miserable when we are confronted with facts that disprove the foundations of our emotional knowledge.

This is what I believe is going on today in the ongoing war between 12-step supporters and medical professionals who advocate maintenance therapy for addiction. 12-step programs have become almost a kind of religion; they introduce their patients to an entire moral worldview, one based on willpower and a “Higher Power”, complete with narratives of sin and redemption. They introduce this system in very stressful and vulnerable situations, and encourage their patients to rebuild their lives on this foundation. There would be nothing wrong with this, if the foundation itself wasn’t fundamentally, factually flawed. It turns out that addiction is not solely a moral failing, and often cannot be overcome by willpower alone, the same way that willpower can’t overcome diabetes. But statistics and science that try to make that point are rejected and even attacked, because they threaten the deep emotional foundation on which 12-step patients have constructed their world. Because it’s an emotional threat, the reaction is emotional as well; I, as a physician, don’t have a particular emotional attachment to any one mode of treatment, and I’m willing to debate them all on intellectual grounds. That’s why I’m often caught off-guard by the intensity of the anger that I find when talking to those who have been through this 12-step persuasive process.

I want to say again that I don’t think these people are “stupid”, or weak, or that they have some kind of innate problem. I believe they have been taken advantage of by a system that, wittingly or not, has been fine-tuned over decades to make its patients believe that no other method or provider can be trusted.

It is my hope that, through education and continual refinement of the science behind addiction treatment, we can replace this manipulative system with one based in factual reality, which will hopefully help more patients to live healthier lives.

12-Step Statistics

Posted on January 2, 2012 by admin

It’s common for addiction treatment centers and 28-day rehabs to advertise that their staff is made up only of ex-addicts. They treat it as a selling point that patients won’t talk to anyone who hasn’t found success fighting addiction — if not at that particular center, then almost certainly through similar methods of abstinence, willpower, roleplaying, and lectures.

There’s a valuable element of encouragement for patients to see and talk to role models who have overcome the problems they’re facing. It is completely natural and commendable for people who have struggled with addiction to want to help others who are currently struggling. But by hiring only one subset of people, these treatment programs end up spreading a deeply misleading and harmful idea of addiction, which can delay or even stop their patients who are on their own “roads to recovery”.

First of all, hiring only those who have “succeeded” on 12-step programs is playing a statistics game. Out of all comers — anyone who considers themselves an addict or alcoholic and attends at least one 12-step meeting — between 90 and 95% find the program doesn’t work, and leave. Success rates given by 12-step treatment centers are often framed with the understanding that these 90% of people don’t count — the program has an “80% success rate”, which means “successes” are 80% of those who were in the 10% who stayed. While this might be a good argument that the 12-step treatment works well for a certain kind of people who find the program helpful, it is not a compelling reason to say the treatment will work for all addicts. When you further narrow the field by choosing an arbitrary definition of “success” — three years clean, or five, or ten — the end result is that the program works for a very, very small percentage of the total addicted population. 12-step centers then go on to hire exclusively from this very small pool. What this means is that, although the whole point is to show patients that they, too, can become “successful” like the staff has, the reality is that it is very unlikely any particular patient will be part of the same tiny percentage of the population that all of the staff are drawn from. (It is also worth noting that when I say “very small”, I don’t mean that the total number of successes is small. It might be several million; that doesn’t matter. All that matters is that, for every success, there are many millions more addicts who 12-step programs would call a failure.)

So the “inspiring” message that patients can become like the staff is likely very misleading. What can make it harmful, though, is a fact of human psychology; human beings tend to find anecdotes more convincing than data. Especially to patients in a treatment center, who are often sick and frightened, a personal story of redemption told by an authority figure (a counselor or administrator) is much more powerful than a presentation on statistics of the kind I’ve discussed.

This is a very well-known fact of how human brains work, and there’s no getting around it. It’s the reason people buy lottery tickets, or refuse to fly on airplanes, or do any number of things that don’t make much sense from a statistical point of view. It can sometimes be very helpful to our survival, but it can also do us a great deal of harm. I personally have had patients leave my practice because I have statistics, data, FDA reports and medical science behind me, but I can’t offer a personal anecdote of having been at “rock bottom”. This emphasis on personal stories means that, not only are patients in 12-step treatment centers being told stories that are unlikely to apply to them, they are being taught to trust those stories more than any hard data they might see in the future. For the vast majority of people who won’t turn out to succeed in 12-step programs, the anecdotes they heard from ex-addict staff may prevent them from seeking other methods of treatment that might work better for them. It sends them back into ineffective 12-step programs again and again, utterly convinced that they can overcome all odds, projections,and medical facts, just because they heard that some other person once did (or thought they did).

While it may seem heartless to say that people shouldn’t try to beat the odds, the fact is that the odds are there for a reason. Moreover, acknowledging the facts and acting accordingly will almost always lead to a healthier and happier life for the larger number of patients.

We at the Bel Air Center for Addictions hope that all of you have a healthy and happy New Year.