Do medications provide added value in addiction treatment? And, what is the downside, or potential cost, financially but more importantly on long term outcomes? I think this benefit/burden calculation is central to deciding whether they should be the standard of care or not. Opponents of medications question whether medications lead to “real” recovery, whether they are crutches, and why they are necessary when there is a clear path to recovery through AA. In many people there is an inherent gut response: “Why can’t you (or I) just stop? Isn’t taking a medication to treat a chemical addiction a contradiction in terms? Aren’t you just substituting one addiction for another?”
Let’s take a look at each question. Do medications lead to “real” recovery? It depends on how you define recovery. Most people would say that abstinence or even occasional use without problems would constitute recovery. Members of 12-step programs are more likely to assert that “real” recovery is abstinence plus something else that can only be obtained in 12-step programs: a spiritual transformation, or somewhat differently put, a major shift in values and character. My interpretation of what 12-step programs are aiming for is maturity. That is, the ability to love and be loved, to make a contribution to society, to be a good citizen of the world and to achieve a certain measure of acceptance of the world as it is and our place in it. From a medical standpoint the traditional goal of treatment is the absence of symptoms or signs of a disease, which is called remission (think of cancer.) I think 12-step “recovery” is remission plus maturity. Medical recovery is simply remission. This has implications for how one interprets the results of treatment studies, and also for how the boundaries of medical care are defined. I will write more about outcome measurement in another blog. However, for this discussion, I will adopt the assumption that the goal of professional treatment is remission, and that achieving personal growth and maturity is the responsibility of the patient.
So, if the goal of any treatment is remission, are medications effective? The unequivocal answer is yes. More people taking medications will achieve remission than those who do not. This is not a matter of personal opinion, but of scientific fact and clinical experience. Is every study positive? No. But more are positive than not, so it’s important to look at the totality (and quality) of all the studies. Look, a lot of people can stop smoking without any medication, but many other people require multiple attempts and multiple medications and counseling to quit. It’s no different for alcohol dependence. In the case of opioid (heroin, morphine, Dilaudid, Oxycontin) addiction, medication treatment is the only one showing consistent success. And in that case, long-term maintenance is usually required. So, the bottom line is: medications for treating addictions allow some people a chance at recovery who otherwise would fail at that quit attempt.
So, are these medications crutches, which implies that they are something for weak people and that one shouldn’t need them. Use of the term further implies that using them weakens the natural healing power, so that discontinuation will lead to relapse. Is there any evidence for that? Short answer: no. Unfortunately, most of the studies only provide a few weeks or months of medication treatment, so that they are discontinued at an arbitrary point rather than when it is best for the patient. Over time, after medication discontinuation, the positive medication effect fades so that the difference between medication and placebo groups decreases. However, there is no evidence that relapses suddenly rise after medication discontinuation. In fact, there remains an advantage in remission in the medication group as far out as one year even when treatment only lasted 16 weeks. In addition, at least as many people who are receiving medications also participate in community support groups like AA as those who are not. So there is no evidence that using them constitutes crutches in the negative sense of the term. Are they necessary? Well, for some people, the answer is yes. That is, they are unable to recovery without the aid of medications, at least for a specific quit attempt (most people have multiple quit attempts before one sticks.) Others don’t need them to stop. Are they substituting one addiction for another? The answer is yes, but only if you consider a diabetic addicted to insulin, or someone with high cholesterol addicted to lipid-lowering agents like statins. To me, the most important question is whether they are helpful to people and improve the odds of remission. If the answer to that is yes, and the burden or cost is reasonable, then they ought to be readily available to people. The medication treatment most often cited by medication opponents is long-term maintenance on methadone or buprenorphine (Suboxine, Subutex) for heroin or prescription narcotic addiction. Here the evidence is very stark: among those with established addiction (i.e., more than one year) long-term maintenance on an opioid medication is the only effective treatment. There are now dozens of studies, including high quality randomized controlled trials that have compared enhanced state-of-the-art behavioral treatment alone with medication-assisted treatment, and the answer is unequivocal. In my clinical work with this group of patients, I have concluded that after sufficient time addicted to opioids, the brain is changed in ways that are not reversible. In a way, this group of people suffers from an “opioid deficiency” which can only be treated with opioid supplementation.
Bottom line: Medications result in more people achieving remission (recovery) and in the case of established opioid dependence, they are the only effective treatment. They might be crutches, but when your leg is broken, you may need a crutch for a period of time to allow the bone to heal. Unfortunately, effective medications are only available for smoking cessation, alcohol dependence and opioid dependence. Unfortunately, there are no effective medications available yet for cocaine or methamphetamine or cannabis (marijuana) dependence. But there will be.
More information:
For alcohol dependence: www.niaaa.nih.gov/guide
For opioid dependence: http://csat.samhsa.gov/publications.aspx
Smoking cessation: http://www.smoking-cessation.org/
It seems like most doctors have a idealistic concept of AA, knowing that it is the mainstay of the addiction industry despite a questionable reputation. The comments in the blog sound as though the doctor has never been to AA but has only read about it. First, AA is not a clear path to recovery because even those that maintain sobriety have either transferred their addictive personality onto other substances or activities or have become dependent on AA philosophy to the exclusion of anything else. Most continue to display psychological and emotional distress. A typical AA meeting may have people professing their sobriety but smoking two packs of cigarettes a day,drinking six cups of coffee and 4 cokes while having relationship problems, anger issues, etc. Without these areas of their lives improving and with the focus only on sobriety, there is no recovery. The doctor talks about a shift in major values and character. Most people who go to rehab go over and over. Few experience lasting change. The idea of major changes in values and character is hardly ever apparent. The doctor states that through this spiritual transformation the person gains maturity. Nobody that understands alcoholics or drug addicts would refer to them becoming mature by being abstinent. Immaturity seems to be the most apparent byproduct of those recovering through a powerless message. There is a big difference between the value of religion and spiritual practices to strengthen character and to encourage growth and change and quality of life, but is quite another thing to label someone, make them affirm their weakness and dependency and then refer to them as being mature and value driven. There are people that have been in and out of AA for years whose view of themselves and others as changed little. I knew a person that spent 18 years in AA who did not even like to drink! He had emotional problems and would perhaps have a couple of beers a few times a week. Recruited into AA for some reason, he was told his emotional problems were the result of his drinking problem! This is not a spiritual transformation. To be sure, AA has saved many people who otherwise die, but to suggest that everyone is recovering by becoming more mature and developing better values and character is simply not true. This is another example in the wild wild west of addiction rhetoric where the theory, the belief, the culturally ingrained ideology is not what is actually occurring in practice for the majority of people.
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