And another response to Dr. Johnson

From The Huffington Post

Deni Carise

Chief Clinical Officer, Phoenix House
Posted: August 16, 2010 12:00 PM

Examining the Viability of Substance Abuse Treatment Today

Earlier this week, I was more than a little put off by Bankole Johnson's Washington Post editorial, "We're Addicted to Rehab. It Doesn't Even Work." It's interesting to note that this piece comes just six months before the release of his new book on medications that "conquer alcoholism," which will join countless other tomes that also claim to have the cure.

In his searing op-ed, Johnson, chair of psychiatry and neurobehavioral sciences at the University of Virginia, argues that there is little empirical evidence to suggest that substance abuse treatment programs are effective. Making sweeping generalizations, he points a finger at our country's treatment centers, including nonprofit providers, calling them both "ruinously expensive" and "divorced from state-of-the-art medical knowledge."

I take issue with these charges first and foremost as a scientist who has dedicated her career to studying the effectiveness of substance abuse treatment. In equal measure, I disagree with Johnson's allegations as a person in long-term recovery who might not be here were it not for the treatment I received.

Johnson calls substance abuse a devastating disease, yet he fails to acknowledge the limitations of treating a condition that is chronic by nature, like diabetes and hypertension. When evaluating the effectiveness of a particular medication for diabetes, treatment providers don't expect their diabetic patients to be "cured" after one treatment, nor do they define success as never having another sugar crisis. Similarly, defining successful substance abuse treatment as one that produces 100 percent abstinence for the rest of a person's life is a naïve and useless benchmark. However, if we define success as learning to manage your condition and gaining the support needed to do so, there are literally hundreds of controlled studies documenting the effectiveness of various forms of treatment. And they meet FDA levels of effectiveness.

As for Johnson's claim that substance abuse treatment is "too costly for most people," this is simply not the case. The two programs he mentions, Promises and Hazeldon, are geared toward individuals of higher socioeconomic status. However, there are many programs in our country that serve those with more modest means. When I entered substance abuse outpatient treatment in 1984, I paid just five dollars for each counseling session I attended. I later found out that the remainder of my treatment costs had been covered by the federal block grant. At Phoenix House, where our programs receive both state and federal funding, some clients stay with us even when they have no funds to cover their care. Many other non-profits do the same. Listing two expensive programs as if they are representative examples does not convey the wide range of treatment options available to people from all walks of life.

Johnson primarily aims his criticism at AA and it's true that not every substance abuser who enters AA will achieve long-term recovery. Likewise, not every diabetic who tries a particular medication will achieve long-term recovery from diabetes. As with other chronic conditions, there are many evidence-based treatment methods for substance abuse--not just the 12-step model. To discredit an entire spectrum of care that has worked for hundreds of thousands of people--and has been backed by scientific research--is to ignore the facts. It says to those of us who work with substance abusers each day that our efforts to help them are futile. And it says to those who need treatment that there is no real help available. That's inaccurate and irresponsible.

I'm certainly not dismissing the benefits of incorporating medication into substance abuse treatment. That would be irresponsible as well. But research has shown that meds alone will not produce a cure and traditional "rehab" components such as group counseling are equally important. Dr. Johnson himself runs a treatment program that includes cognitive behavioral therapy in addition to pharmacology. So why can't he acknowledge that any and all empirically-proven methods of helping people with this disease need to be included in their treatment options?

Maybe it's simply the fact that presenting a more balanced op-ed piece wouldn't sell as many books.

More on Dr. Johnson's Critique of 12-step Programs

Letters to the editor in response:

The pros and cons of 12-step rehab

Thursday, August 12, 2010

I take issue with Bankole A. Johnson's Aug. 8 Outlook commentary, "12 steps to nowhere," which essentially devalued alcohol rehabilitation in order to sell "effective medicine" to treat alcoholism.

I have been treating alcoholism in the Defense Department and the Navy for 33 years. Alcoholics Anonymous works for us. Both the Defense Department and the Navy have used AA and Twelve Step Facilitation Treatment for 40 years and have a recovery rate five years after treatment of about 75 percent. The Navy has some experience with drinking -- and it knows how to treat alcoholism. Our lives depend on it. Marines like to go to war sober.

Dr. Johnson is paid to develop drugs as the primary treatment for alcoholism. However, he knows so little about how AA works and takes quotes from the Big Book completely out of context.

Two million sober members of AA, most not on medication, will see his article and know how wrong he is for them.

Ronald Earl Smith, Bethesda
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The writer is a captain in the Navy's medical corps and a senior psychiatrist and psychoanalyst at the National Naval Medical Center.

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I attended 150 12-step meetings in 90 days (versus the prescribed 90 meetings in 90 days) and have not been to a meeting since, in about 12 years. I also have had no alcohol in that time. The pros and cons of 12-step rehab

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I agree with everything Bankole Johnson said about the problems with 12-step rehabilitation. However, he failed to appreciate that if AA works for only a minority of people who try it, for that group "it works if you work it." Let others try something else.

If Dr. Johnson and his colleagues find a better cure, more power to them. Only do not let them or anyone say that AA does not work. It does for countless thousands, and at virtually no cost but time and effort.

Philip Saunders, Dunn Loring

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In his commentary, Bankole Johnson stated that "no experimental studies have unequivocally demonstrated the effectiveness" of the 12-step approach to addiction.

In an experimental study in 2006 conducted at the Veterans Affairs Palo Alto Health Care System, randomly selected addicted patients who received a structured introduction to Alcoholics Anonymous and Narcotics Anonymous had a more than 60 percent greater reduction in the severity of their substance abuse problems six months later than did patients not receiving such an introduction. In a different experimental study, also in 2006, of a 12-step-oriented sober-living home, addicted individuals were, relative to those receiving other forms of care, twice as likely to be abstaining from substance use and three times as likely to not be incarcerated.
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Both of these widely cited studies were funded by major, peer-reviewed federal research grants and were published in high-profile peer-reviewed journals.

Dr. Johnson's failure to mention them resulted in a mischaracterization of what research has established about the effectiveness of the 12-step approach.

Keith Humphreys, Palo Alto, Calif.

Controversial editorial in Washington Post

In case you missed it, Bankole Johnson wrote an op-ed for the Washington Post that appeared 2 days ago. Here's a link: http://www.washingtonpost.com/wp-dyn/content/article/2010/08/06/AR2010080602660.html

You may need to register with the Post to see this link, but it's free and they don't hassle you in any way, such as spam or solicitations.

What do you think about his piece? I'm really interested in hearing.

The Need for Medical Treatment for Addiction

It's been some time since I've blogged. For those of you who are followers or check in on the blog I'm sorry for the lack of activity. The transition to Minnesota has taken a lot of energy, but I have a lot of progress to report.

My practice here in Minnesota has really taken off. Once the other physicians in the hospital and indeed throughout the entire community have become aware of an alternative to another run through rehab the referrals have become consistent. I was just away from the hospital for a week, and I suspect that the hospitalists who take care of most hospitalized patients have missed me. Once they got a taste of getting help with complex pain patients, difficult withdrawal problems, and a physician who was willing to take their referrals for patients with addiction in conjunction with medical and psychiatric disorders, they have gotten very enthusiastic. This is similar to my experience when I first started a clinic for medically ill alcoholics at the Minneapolis VA hospital years ago. The attitude towards alcohol dependent patients admitted with liver disease, pancreatitis, withdrawal, and other problems up to then had been hopeless, nihilistic. What was the use when a consultation resulted in a nurse or counselor suggesting another run through rehab even if the patient had already had that treatment multiple times? But when there was a clinic where these patients could receive ongoing care that incorporated medical, psychiatric and addiction treatment, you could almost feel the change throughout the medical center. Staff became enthusiastic about identifying and referring patients like this to the clinic. It took about 3 years to develop the clinic and figure out how to provide this type of treatment. After that, I received a grant from the the VA to study whether this treatment was effective. In order to do that, we had to assign study participants to either this new clinic or to usual care which consisted of referral to primary care clinic. At that point, it became difficult, because staff were so enthusiastic about this new approach they were reluctant to have patients assigned to usual care. That's the hardest thing about test new treatments; although you might believe strongly in the new treatment you have to be willing to randomized and let the chips fall where they may. It turned out that the new approach was significantly more effective: mortality was reduce by 30% after two years, and more patients were able to achieve abstinence. So I'm finding that the same thing is happening where I currently work at United Hospital in St. Paul. Only it's even better: I'm providing a much broader range of services. One thing that has become apparent: there is a tremendous need for innovation in treating complex chronic pain. Chronic pain and how to appropriately use opioid (narcotic) medication is one of the most difficult and under-appreciated areas in medicine right now.