Sunday, January 1, 2012

Do Scientists Know Nothing About Addiction?

Here's a comment I received yesterday from someone who didn't identify him or herself:

Anonymous has left a new comment on your post "ALLTYR™ Is Born!": 

From this short introduction it is very apparent that despite your credentials you know very little about recovery from substance abuse or its underlying causes.

This comment illustrates a fundamental problem we face in trying to bring addiction treatment into the 21st century and to advance the cause of addiction research and treatment. 

I wonder what it is that I don't know? I've treated thousands of patients with addictions of all sorts and run a treatment program. I've conducted research on various kinds of treatments, on AA, and on implementing evidence based practices in addiction treatment. I co-edited the first version of the VA/DOD clinical practice guidelines for the management of substance use disorders. Many of my patients tell me that I understand them and their struggles more than anyone else they've encountered. So what is it that I don't know? (I won't address how so many other people could be wrong about me.)

Since this writer didn't identify him or herself, I can't ask for clarification. I suspect my commenter has a specific idea or theory about what addiction is and how to overcome it, and sees other theories or ideas as a threat, almost as blasphemy. Perhaps even as destructive, because having a plurality of approaches might dilute the "true"message. So I suppose that I don't "know" that this one true way is in fact, the one true way

But what is it about what I write and speak about that triggers this response? I suspect it is my focus on scientific research. Science is famously viewed with suspicion by true believers. Gallileo was imprisoned for presenting scientific findings that contradicted theology. Science doesn't discriminate either. Many a pet theory scientists have been proved wrong, dashing hopes and ruining careers. So it goes. The scientific method is not perfect but it is structured precisely to minimize scientists' ability to bias the results. In recent years, new research has shown us that much of what we thought we knew about substance use and addiction was wrong or only partially right. This includes many dearly-held notions. For example, addiction is not necessarily chronic or severe or progressive. Most people recover, and most of them do so without treatment or 12 step participation. There are multiple routes to recovery. Spiritual transformation is not necessary for recovery. Multiple different types of behavioral therapy approaches work about equally if delivered well. And the list goes on.

But I worry about the schism this comment suggests, which I encounter frequently. At a recent conference, I talked about treatment for opioid addiction. I said that there was only one treatment that had been proved to be effective for opioid addiction and that was opioid agonist therapy with either methadone or buprenorphine. One of the participants challenged me, saying that the problem was that opioid addicts treated in a 12 step program didn't do well because they didn't do what they were told. Well, I suppose you could say they were told to abstain and they didn't. But I find this kind of argument distressing. For one thing, the same argument could be used for any treatment that didn't work, because treatment failure is the patient's fault, it's not that the treatment is ineffective. What this means is that a treatment could never be proved to be ineffective, because "it would be effective if they did what they were told." 

But what concerns me most is how much this schism reduces the effectiveness of our advocacy and efforts. I think this is why there is so little activity on the part of the recovering community to support more addiction research. With other diseases, research is seen as the way towards improved diagnosis and treatment, but in addiction, far too many view research only as a way to validate what they already "know." In this view, it's not that our treatments are not effective enough, it's simply that there isn't enough money for current treatments. So there may be advocacy for treatment accessibility but not for research. Furthermore, new treatments emerging from research are most often viewed with suspicion rather than embraced and widely implemented. Opioid agonist therapy and anti-relapse medications for alcohol dependence are prominent examples.

I find it very discouraging that someone would conclude based on a "short introduction" that "in spite of my credentials" I know very little about addiction or recovery, not because I'm the grand global expert but simply because it simply cannot be true on its face. I can understand disagreeing on various ideas, having a different take on certain findings or experiences. But this tendency to completely dismiss those we disagree with is a major barrier to advancing the cause of improving our understanding and treatment of addiction. Until we find a way to bridge this gap, we will continue to lose out to more integrated and better organized groups advocating for research on heart disease, Alzheimer's disease, or breast cancer.

The time is long overdue for the recovering, treatment and research communities to stop fighting and join together to promote addiction research and treatment. 

1 comment:

  1. Mark, I could not possibly have articulated this issue any better. Fundamentalists are the problem, and similar to every religion and faith/belief construct, they inhabit 12-Step communities as well. While the context is different the mentality is the same. You hit the nail on the head in identifying some of the barriers toward greater involvement in advocating for addiction research among persons in recovery. Thanks for the excellent post....Mark