Tag Archives: 12-step programs

Interpretations of AA

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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 I would just like to point out the irony of this panicked accusation, seeing as the founder of AA originally made it very plain that excluding anyone on such superficial grounds was very much against the spirit of the organization.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

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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

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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.

Self-esteem and Treatment

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Addiction treatment is often a very turbulent and even painful period in a patient’s life, for reasons that may or may not be directly connected to their treatment. Often patients are driven to seek treatment by a traumatic event in their lives — the death of a loved one, the “intervention” of friends and family, or legal troubles that require them to get “clean”. This
is one reason why my office will recommend counseling to those who want it, since pure medical treatment of the disease sometimes leaves behind emotional and interpersonal issues in a patient’s life that should be addressed.

Every patient’s life is different, but one problem that I see many of my patients wrestling with a lack of self-esteem. If it seems odd that self-esteem should be an issue in addiction treatment, keep in mind that, no matter what kind of treatment is used, overcoming addiction is often a long and arduous process. Even with medication — the kind of treatment that causes the least physical suffering — an addiction patient often has to
adjust their life in major ways; whether it’s finding a new drug-free social circle or dealing with the effects their illness and treatment are having on friends and family, the challenges of addiction treatment can be ongoing and severe. Without some belief in their own strength and ability to cope, some patients can find it next to impossible.

Unlike removing their cravings for addictive drugs, this isn’t a problem I can easily solve for my patients. But it’s clear to me that something needs to be done to help give addiction patients more faith in their own ability to manage their health and cope with the hardships of treatment, they need to be empowered — the same sort of general encouragement that is often available for people recovering from other diseases, like cancer, or from major surgery. It is recognized in these areas of medicine that optimism and self-esteem are valuable tools in recovery, and they are encouraged by medical personnel and by friends and family. In addiction this, like so many other aspects of care, is largely ignored, and many treatment providers still try to shame patients out of their desire to use, which only makes things worse. A person suffering from addiction will most likely try to eliminate feelings of shame and guilt by relapsing to their drug of choice, not by pulling themselves up by their bootstraps to do a better job.
Building self-esteem and self-empowerment in this patient population is a complicated and delicate process. It is best accomplished after patient’s cravings and withdrawal  symptoms have been treated with medications as the relief of these symptoms will at least give patient the ability to refrain from using. Expecting patients to refrain from using in the face of intolerable withdrawal symptoms will only expose them to another potential
failed attempt at changing their lives and will continue to pile on the shame, guilt, and feelings of helplessness and worthlessness. The current most commonly relayed message to those suffering from the disease of addiction by most treatment programs based on 12 step phiolosphy is still shame, guilt, and helplessness. These messages to those who are addicted must stop before we can make significant progress in treatment. As I’ve said a thousand times before, addicts are sick, not evil; and sick people deserve
treatment, not punishment.
As a physician, I sometimes find it difficult to walk the thin line between encouraging my patients to think positively about the future and giving them false hopes about what addiction treatment is currently capable of. I am also mostly powerless to help them with the consequences of bad decisions in their lives, and the patterns of bad decision-making that may have accumulated over the years of their addiction. Nonetheless, as people with a serious medical condition, addiction patients deserve the same encouragement that  cancer patients routinely receive; that they are stronger than their illness, that they can beat their condition and return to their normal, healthy lives.

The Physician’s Position

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Working in the field of addiction has the tendency to put M.D.s and other health care professionals in a very unusual and often disorienting position; we are expected to give in to the instructions and demands of ‘counselors’ and other self-proclaimed addiction experts who are not professionally  or medically trained. This is often very frustrating to us when we attempt to make our voices heard. We are used to being respected for our education, the number of years that we have put into training, our professionalism, the standards we try to uphold, and our expertise regarding issues of human health and disease. Yet, in this particular field, we are often viewed by others as knowing less than the patients we treat. And it’s all because most doctors and highly-trained professionals don’t have a personal history of addiction.

I have experienced this strange anti-non-addict prejudice many times in my online discussions with representatives of 12-step programs. (In one memorable argument, I was ridiculed for having letters after my name — as though the ‘M.D.’ was a pair of mystic runes that prevented me from seeing the truth.) Trained doctors are relative newcomers in addiction-related fields. Our profession has not, historically, been the one leading the treatment of this disease. In fact, many blame us for ignoring addiction, not understanding it, offering false hopes, enabling it, or in fact being a major cause of it through our prescription pads. And while it’s true that mismanagement by uninformed doctors has been a contributing cause of addiction — particularly addiction to prescription painkillers — that is reason for more doctors to come into the field and get the education to understand this disease and its causes. Efforts to keep physicians out of addiction certainly won’t help us understand and deal with addiction as a disease.

I’ve seen it said often that “nobody understands but another addict”. This attitude does not exist anywhere else in medicine, and I am not sure where it comes from. While it can certainly be helpful and emotionally supportive to speak to someone who’s shared the same problems you have, there is a limit to this idea. Cancer patients don’t refuse to be treated by doctors who have not themselves had cancer. A patient with chronic headaches won’t storm out of a doctor’s office because the doctor doesn’t have chronic headaches and “wouldn’t understand”. Physicians are trained to be able to offer help, understanding, and compassion to patients in many different situations. In fact, a physician who has specialized in treating a particular disease may “understand” better than the patient what the disease is doing to their body, and how to fix it. Most people who have a problem are anxious to explain their problems to others, to make them understand what it is like from their viewpoint, and to seek their understanding and help. Only in this field does there seem to be this rejection of assistance from those who have not had addiction problems.

I believe that the tide is changing, and that physicians do have both a stake in this disease and some very valuable ideas to offer, which is why I write this blog. There are certainly going to be some bumps in the road, and physicians will have to prove that they are compassionate and competent in treating addiction, but there is only so much proof that can be offered. I am afraid that no amount of successful care from trained professionals will convince some of those who cling to ineffective treatment methods and are not interested in learning anything new.

Medication Metaphors

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I have many patients who have been stable on Suboxone for a long time, sometimes for years, who come to me and ask to taper off their dose in the hope that they can get off the medication altogether. I have used blood pressured medication and insulin as examples to explain why Suboxone is a maintenance medication that needs to be taken continuously, but these patients never seem convinced. They feel that they are not ‘succeeding’ or are not ‘sober’ while they are taking the medication, even if they are living full, healthy, happy lives. I’ve talked a lot on this blog about why I believe people come to feel this way, and why I disagree with their reasoning. I haven’t spent as much time talking about the reason why I try to dissuade my patients from trying to taper off. The reason is very simple: it doesn’t work.

With some medicines, tapering off is a valid strategy. Antibiotics work like catapults or bombs; they are a way to kill a large number of invading enemy organisms very quickly. Once most of the invaders are dead, the problem is over, and more antibiotics won’t do any good. There’s no point in firing weapons at an empty field with no enemy soldiers on it. After following the prescribed course, the patient can stop taking the antibiotics and return to their normal lives, feeling perfectly healthy. Other medicines, like non-narcotic painkillers, are given only for a short time because the human body can heal itself without their help. Something you would need to take painkillers for — say, a cut from a surgical procedure, or a broken bone –  will repair itself whether or not you take medication; the painkillers are only to help you feel more comfortable along the way. Once the body’s healing process is finished, there’s no need for you to feel more comfortable, so the painkillers can (and should) be stopped with no ill effects.

Buprenorphine works very differently from either of these examples. Addiction isn’t caused by any invading organism, so taking one massive dose and then stopping the medication won’t do any good. Many people seem to think that buprenorphine will work like other painkillers, and that the brain will repair itself while they take it, but for the vast majority of people this simply isn’t the case. The damage caused by addiction affects a very delicate part of the brain, which won’t heal on its own the way a broken bone will. Our current understanding of the disease of addiction is that  the damage caused by addiction is permanent, so the symptoms will also be permanent, unless they are treated by a maintenance medication like buprenorphine. 12-step and counseling programs sometimes tell their clients that the brain can repair itself after a certain amount of time and counseling, but there is absolutely no solid science to back up such a claim. As soon as a patient stops taking buprenorphine, the underlying damage asserts itself again and the symptoms return, which very often leads to relapse.

A good way to think about this is to imagine the damage caused by addiction as a leaking crack in a dam, and imagine that the dam is holding back a reservoir from flooding the town where you live. It’s fairly easy, and VERY important, to put a patch over the crack to keep it closed; if you don’t, then the water pressure will make it wider, and it will be harder and more difficult to seal up later. As long as the patch holds, life can go on as normal in the town, but the patch isn’t fixing the underlying crack or causing it to “heal” itself magically. All the patch is doing is keeping the damage from getting worse, and keeping the people in the town from suffering the consequences of a break. If the patch is ever removed, the water will immediately start leaking through again, pushing the crack wider and causing a flood.

Using this image, we can think of buprenorphine as a patch over the damaged parts of the brain, holding back the flood of symptoms, cravings, and damaging behaviors that addiction will cause if left untreated. It doesn’t fix any of the underlying damage. It only keeps it from getting worse and keeps it from negatively affecting a patient’s life. In my experience, patients who taper off their medicine because they feel that they aren’t fully ‘clean’ will suffer a relapse in almost all cases.

Providing patients with the complete truth is very important when they have questions or concerns. I always tell my patients that while it is possible for a very few people to taper off Suboxone successfully, for most people it is harmful and counter-productive, and I rarely recommend it. Understanding how buprenorphine works and what it does and does not do is essential to a comprehensive and effective treatment program, and I would hope that all prescribers of buprenorphine take the education of their patients and their loved ones very seriously.

Anecdotes and Data

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Of all the people offering addiction treatment, those who are not trained professionals tend to be laypeople who have struggled with addiction problems in their own past. They may describe themselves as “ex-addicts” or still in recovery, but they offer a common reassurance: that they have experienced all the troubles that addiction brings, and they understand what their clients are going through. Often, they market their particular
treatment program as something that worked for them personally, which they
want to share with others.

The desire to share something that helped you, so that it can also help others in your situation, is a good and noble impulse. But it often happens that the results of that impulse do more harm than good. Brain chemistry and behavior are complex, finicky things, so much so that even our oldest and best-tested methods of treatment often have wide margins of error. In this field, moreso than any other, what works for one person may do no good, or even harm, to someone else. In this field more than any other, we need large
studies and statistics to collect data on huge amounts of people and categorize it so that we can filter out individual eccentricities and find strategies that will help almost everyone.

Anecdotes, personal stories, and testimonials can sometimes be helpful, but they are not medical data. They are often incomplete, exaggerated, or inaccurate, disregarding the people who have strong financial motives to outright lie. People suffering from addiction are often desperate, frightened, and may be functioning at less than their full mental capacity, which makes them perfect prey for unscrupulous con-men selling a program
that they claimed worked for them. Even programs run by honest people who truly were helped by them are often grossly unsuited to help others. Stories and anecdotes tend to be more compelling than statistics, because it is easy to relate to someone telling their story, and the emotional impact of a person standing in front of you telling you about their life is very hard to ignore. But for those same reasons, anecdotes are incredibly unreliable as
the basis for seeking medical treatment. Many people distrust statistics, thinking that they might be fabricated or biased, but the fact is that medical statistics from credible sources (such as the CDC or ASAM) go through a much more rigorous fact-checking process than the founding myth of any nonmedical treatment program ever will. It is the stories of such
programs that are more likely to mislead their clients or put them in harm’s way.

This is only one more way in which we need to bring the field of addiction up to the same scientific standard as other fields, such as dentistry and cardiology. Very few people would, say, switch to an all-banana diet because they heard a story from a neighbor’s friend who said it had cured his cavities. Yet people routinely pay tens of thousands of dollars for the promise of a nebulous “spiritual transformation”, or for a bizarre program
of vitamins, horses, sauna treatments, and other provisions that have nothing to do with addiction, all because they have been fed bad information through “patient testimonials” and other stories.

Healthcare and medicine are based on truth; on what, in reality, actually can be proven to help people. I have seen many peoples’ lives improve after they come through my program, but I won’t ask that people come to my office just because I say that. I prescribe opioid maintenance treatment because its use has been continuously and irrefutably supported by the scientific study of brain chemistry and how it can be altered to improve the lives of people suffering from this disease.

Buyer Beware

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I recently heard the story of a woman in California who was lied to by a Scientology-based addiction treatment facility, Narconon, and is now suing them to try and regain some of her lost money.

I went to investigate the website of the facility in question, the Narconon facility in Vista Bay, CA. The website is impressive and appears very professional, and uses many of the buzzwords common to nonscientific treatment programs, including vague promises of “lifelong recovery”, warnings against medication, and an unspecific list of treatments including “vitamins, exercise, and… our sauna”. They claim several times that their method is “proven”, but nowhere on the site do they offer any scientific journals, papers, or research studies that support this claim, and a few of the statements about addiction supposedly made by M.D.s on the Narconon staff are dubious at best. One of many opposing sites, Narconon Exposed, makes an attempt to catalog the problems with Narconon, especially those relating to the organization’s supposed ties to Scientology.

The suffering of those who have been misled by Narconon’s advertising is cause for outrage, but Narconon is also merely a symptom of larger problems in the addiction-care system. I’ve written previously on this blog about the lack of standardization in addiction care, and the tragic consequences it can have for underinformed addicts and their families. The sad fact is that Narconon is licensed by the state of California to adminster addiction treatment, a fact which is flaunted at great length on the website, which includes scans of many impressive-looking official documents. It would be very, very easy for someone who wasn’t aware of the many problems to be taken in by Narconon’s marketing, and sign themselves up for treatment that is not only ineffective, but potentially harmful.

The licensing of Narconon has been blamed on the understaffing and low budget of the California government offices responsible for vetting and approving treatment facilities, and it is likely that as our nation faces growing cuts to public services in the face of the recent budget crisis, such oversights will only grow more common. It is more vital now than ever before for people suffering from any illness to inform themselves on all their treatment options, and carefully investigate any program or facility before they pay for what may be fraudulent care. Snake oil salesmen thrive in times of uncertainty, and decades of misinformation have made people suffering from addiction prime targets.

Narconon’s program is unusually harmful, even cruel, but there are many, many more programs out there that claim to treat addiction with regimens that are stunningly ineffective. I’ve written a great deal about various 12-step programs on this blog, and I am sad to see that Narconon displays many of the same traits that 12-step programs use to market themselves; a warning against all medications, an emphasis on permanent recovery and “cure”, and affiliation with a religion or “spiritual” approach. It just happens that Narconon is affiliated with the Scientologist religious model instead of the vaguely Judeo-Christian one that most 12-step programs are based on.

Snake oil salesmen of this type have been around as long as humanity, and the only way to weed them out is to combat their misinformation with proven medicine, sound science, and rigorous oversight. It has happened in other fields of medicine, and it will undoubtedly happen in the field of addiction, though it may take several years. I am confident that, if we continue to move ahead with research and treatment using medicine to treat the disease of addiction, that the patients who are being taken in by these scams now will be among the last to be fooled.

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.