Saturday, February 27, 2010

Medications -1

I've recently received a number of questions about medications used to treat alcohol dependence. The use of medications is a crucial concern. Treating alcohol or other drug dependence represents the transition from lectures and AA to modern, professional treatment. It is a symbolic as well as a concrete advance that can help many people with substance use disorder to recover. So, I'm going to devote several blogs to this topic. It deserves more, but there are so many other important topics that it will have to take it's place.

The primary concerns among consumers are: do drugs work? are there harmful side effects or other downsides? how does taking a medication fit with 12-step programs? isn't taking a medication to stay sober a "crutch?" shouldn't I be able to stay sober without taking a medication?

OK. Let's take them one at a time. Do these drugs work? Yes. Without question, yes. One might debate whether it is "right" or not, but the answer from dozens of studies is this: certain medications (currently naltrexone and topiramate) reduce the number of people having relapses in early recovery by 20-40% and increase the number who embrace ongoing abstinence as their goal. The latter statement might be news to people, because of the way that research study findings are reported. But it's true: these medications increase the number of people who are able to recover. Keep in mind that these are people who otherwise would not recover but instead would relapse and have another failed quit attempt. When looking at results like these, there are essentially two types of people: those who don't care about the results, but are focused on intention, and those who focus on the results, as long as getting there was ethical and where the benefit/burden ratio was positive. As you might expect, I fall into the latter. Pragmatists, as opposed to idealists, who don't care if you fail as long as your motives are pure. Pragmatists are primarily interested in the outcome, whether the method comports with your preconceptions or not. That's me. Results are more important than intentions alone. Just because this point seems to get so easily lost: for some people who are trying to quit, medications make the difference between successful recovery or continued suffering, injury and even death.

The bottom line is that these medications offer people a greater chance at success. Why should they be deprived of the option of using them? Who should make that decision for them? Some people will prefer to not take medications, and others will opt to do so. That is the same way it is for every other disease: take an antidepressant or try therapy, take a medication for high blood pressure or lose weight and exercise more. My point is this: consumers should have the choice, and no matter where they enter the system, they should be informed of all available scientifically supported approaches and empowered to decide for themselves. In other words, whether or not a particular professionals "believes" in a particular approach should be secondary to whether there is evidence in support of it. One of the key principles of being a professional is that one has a fiduciary duty to the client/patient/consumer. That means putting the well-being of the client ahead of one's own needs, be they financial, ideological, religious, ethnic, or otherwise. In this case, it means that full disclosure is an ethical and legal requirement for any licensed professional irrespective of their own beliefs or preferences.

As another way to bring this home, let's assume you notice a lump in your armpit. You go to your neighborhood oncologist, who performs a biopsy and determines your worst fear: you have a lymphoma, a cancer of the lymph glands. However, this particular oncologist has recently been really into the benefits to health of radical dietary changes. So, in spite of the fact that her professional community and the published research support radiation and chemotherapy, the doctor recommends a macrobiotic diet and some nutritional supplements, without informing you of the other options. You like this doctor, and she is very persuasive, so you follow her recommendations. As you lay dying a year later, you learn that the other treatments have a cure rate of 50%, while there is no support for nutritional treatment. And now, it is too late for you. How would you feel? How would your family feel? How long would it take them to consult a lawyer and sue this doctor for malpractice? How is this different from what happens every day in almost every treatment center in the country?

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