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The Evidence Gap in the Field of Substance Abuse Treatment

Patrick — Fri, 23 Jan 2009 02:15:18 +0000

A recent article published in the New York Times talks about the “evidence gap” in the field of substance abuse treatment. What they are referring to is the fact that there is very little evidence and follow-up that shows that any of the treatments out there for addiction are working at all. There is currently a push in some states (such as Oregon) to switch the industry over to “evidence-based practices.”

What are “evidence-based practices?” Essentially, this is when you switch over to a more scientific, medical approach with an emphasis on tracking and measuring so that you can better determine what works and what doesn’t. It seems to include an emphasis on using medications to control cravings or to treat addicts, and also the possibility of mandating certain approaches such as cognitive-behavioral therapy. It also might require additional training for all of the therapists and counselors out there who already attempt to work with addicts.

Another example might be a follow up program where the recovering addicts return to treatment every week after leaving and do urine drug screens and talk with a counselor. The idea is to measure outcomes so that we can know what is working and what is not.

Unfortunately, it’s all about money

Most of the therapists and counselors that work in the treatment industry are upset by this movement towards evidence-based practices. Here’s why:

1) They are being told how to do their job - if this gets mandated, basically state money to help run rehab facilities will be withheld unless the treatment center complies. Most therapists are in recovery themselves and have overcome their own addictions, so they know what works for them and attempt to pass that knowledge on to clients. But if the state steps in and says “use these evidence-based practices,” then they therapists are forced to teach or use a different style of therapy then what they are used to.

2) It will be expensive to implement – most treatment centers cannot afford the new training that will be needed to implement these new evidence-based practices. They are already stretched thin and doing the best they can. Additional money for extra training is just not there. The potential emphasis on using medication requires a doctor on staff – meaning even more money.

3) They are being forced to measure their results – No one wants to have to prove that they are doing a good job, and this puts the therapists in the impossible position of having to produce miracles in a field where success rates are traditionally very low.

The article goes further, mentioning a study done by an author who interviewed recovering addicts with at least 5 years clean and sober, determining that “a standard program might not help at all.” In other words, the study indicated that many found sobriety outside of the traditional treatment model through other means.

It all seems to add up to one thing: insurance companies and state governments that pay big money to treatment centers want to start seeing documentation that their money is actually producing decent results. In my opinion, this is not going to happen given the current situation because decent results do not really exist; it is a tough industry and very few who enter treatment will find success in sobriety. If they do, many will have to attend several treatment centers before they actually “get it.”

Now the therapists and counselors who work in the field and are recovering themselves argue back that “treatment works.” Many of them found sobriety through treatment and they have of course worked with clients and seen some direct evidence that their efforts are paying off. But the vast majority will still relapse and so the evidence gap still exists. The people who are funding treatment are saying “show us the results.” The therapists and counselors are saying “we are doing the best we can.”

So where is the middle ground here? What should happen with the evidence gap? Should the treatment industry be forced to change?

My personal philosophy

My thoughts on this is that it’s probably going to happen anyway, as budgets tighten up the states are going to keep pushing for this until evidence-based practices become mandatory. The treatment industry should do their best to embrace the changes. It might be expensive and difficult to implement but I doubt that doing so could actually make outcomes any worse. Any change would be welcome at this point because even though “treatment works” for some, the vast majority still relapse within a very short time of leaving treatment. In my opinion our current success rates are still unacceptably low and I think the industry should be scrambling to find better methods. Instead it seems to have embraced a recovery model that consistently produces poor results.

I agree with the article in that standard programs (such as the 12 step model) are not the ideal treatment for everyone. I see direct evidence of this as I work in a 12 step based treatment center myself. My own personal philosophy (the creative theory of recovery) is a push away from traditional recovery models and more towards individualization and a more customized recovery program. In other words, people have to “find their own path” and there is less emphasis on networking with others as you progress in recovery.

I’m not so sure that the creative theory could be molded into a one-size-fits-all program in the same way that the 12 step program is. There is too great a need for customization. I personally think this is a large part of why the 12 step model fails for so many people – because we are trying to fit square pegs in round holes. We take every addict and alcoholic, even though they might be completely different and with completely different needs, and try to force them into the same 12 step model of recovery. We have essentially said to the struggling addicts and alcoholics: “this is the solution. Take it or leave it.”

That’s not good enough for me and I personally welcome any mandated changes that might shake things up and get us to experiment with new therapies and techniques. What we are doing has not been working. It’s time for a change and unfortunately it looks like that change is going to be based on economics. But in the end I think it has the potential to benefit everyone as a whole.

If they mandate evidence-based practices, some treatment centers might struggle with this and fold, but others will adapt and good things may come of it. If nothing else, the change will produce a mountain of data that can guide us in forming new therapies and strategies for recovery. I am a marketer at heart and believe that we should start measuring. If we close our eyes and refuse to measure then we are just fooling ourselves.

Just my 2 cents….what does everyone else think about this?

Beating Drug Addiction and Alcoholism: Trends in Substance Abuse Therapy

Patrick — Mon, 21 Jan 2008 02:29:07 +0000

There is a noticeable trend in the field of substance abuse therapy when it comes to beating drug addiction and alcoholism. This trend points towards treating addiction with medication. Here is a recent article from Time magazine that talks about “promising research” in developing injectable vaccines for drugs such as Cocaine, Methamphetamines, and Opiates.

Photo by Kreg

Imagine a time in the near future when babies or toddlers are given a catch-all substance abuse vaccine, protecting them from the potential ills of drug addiction for an entire lifetime. While this might sound like science fiction, the article from Time magazine gives the impression that such a vaccine could be FDA approved within a year’s time.

Pharmaceutical Research is on the Rise

The trend we are seeing in the medical and pharmaceutical community is a push for an easy solution to the problem of addiction. The problem of chemical abuse has proven to be a tough nut to crack, and the idea of fixing the entire problem through medication is indeed seductive. Our society has become geared towards instant gratification, so the medical approach to solving the drug problem appeals very much to the average substance abuser. Drug companies realize this, and the race is on to develop a medical cure for the various substance classes that people get addicted to: alcohol, opiates, amphetamines, and so on. One magic bullet that can significantly treat one of those drug classes can potentially engage an enormous market. This is no longer just about replacement therapies, such as with Methadone, as drugs are emerging that can reduce cravings. Or, in the case above, to block the effects of certain drugs altogether through the use of a vaccine.

Messing with Mother Nature

Using drugs to fight drug addiction can be a slippery slope, and no doubt some of these medical advances are worthwhile, but what about the future ramifications of vaccinating children against all of these chemicals? Some of these drugs also have justifiable medical use. For example, how would we manage severe chronic pain in the future if our children have been vaccinated from opiates? Or what if the long term effects of an opiate vaccination eventually weakens the effectiveness of non-opioid painkillers as well? Surely there is some risk in altering the way our body processes certain chemicals.

Apparently a Spiritual Solution is Simply Too Much Work

Traditional twelve step programs such as Alcoholics Anonymous don’t necessarily enjoy a tremendous success rate, but the spiritual solution provided by the 12 steps arguably offers a more fulfilling and lasting sobriety–once an addict finally “gets it.” Many people in recovery have commented that they struggled to find lasting sobriety within a twelve step program until the spiritual element finally “clicked” for them. For most recovering addicts and alcoholics, this spiritual solution is the only thing that really works for them in terms of maintaining any sort of long term sobriety. Medications are merely a patch-up approach to a problem that runs much deeper.

Many addicts, myself included, point out that they are grateful to be an addict, because this condition ultimately led them to a spiritual awakening in recovery. Had I not become addicted to drugs and alcohol, I might have floated through life with a minimal awareness, and never connected with my higher power in a meaningful way, or developed any sort of real faith. The gift of desperation leads to spiritual salvation.

Photo by christopher.vanbelle

A Typical Disclaimer: This Medication Requires Accompanying Therapy

As if in acknowledgment that pharmaceuticals almost never constitute a magic bullet, almost every pill out there that targets addiction includes the disclaimer “when taken in conjunction with group therapy or counseling.” My concern here is that a combining a pill with therapy is only enough to offer a short stint of sobriety, but not enough of a “complete life overhaul” to enjoy any kind of lasting changes. If a pill requires accompanying therapy in order for it to work, doesn’t that speak volumes as to the effectiveness of the treatment?

A Spiritual Experience Elicits a Lasting Change

The reason a spiritual experience offers lasting sobriety is because it embodies a complete change in personality. I finally overcame my addiction when I met it with overwhelming force and completely overhauled my entire life. I asked for help from other recovering addicts and started taking their suggestions to live a spiritual life. I also started praying, meditating, and seeking on a daily basis. This was not a small initiative on my part. I had to completely immerse myself in recovery and spiritual seeking. I was finally able to do this through the help of long term treatment. My personality shifted from complete self-centeredness to a genuine interest in other recovering addicts. This complete change in my personality has been essential to my ongoing sobriety.

Even though science might someday “cure” an addiction through the use of pills and vaccines, would this really be a desired outcome? I don’t want to discourage people from trying these new medications, but I question the quality of their resulting recovery, and wonder if it might turn into a trap of short lived sobriety. Instead of looking to pills as a quick fix, I think there is an opportunity for people to embrace the spiritual solution and thus change their lives on a much deeper level.

Photo by trekkyandy

Prediction: This Trend Towards Medication Will Continue

There are at least three groups of people who might prefer medical treatments for addiction and substance abuse instead of the more traditional spiritual solution.

1) Addicts and Alcoholics – the push towards instant gratification and quick fixes in today’s society have the youth of today preferring to take a softer and easier path when it comes to treatment

2) Pharmaceutical Companies - If there is a market for medication to treat addiction, then drug companies are sure to do the research in an attempt to meet the demand. Really, who can blame them?

3) The Treatment Industry – Administering a spiritual solution is not an exact science. Medication combined with behavior modification programs are much more “scientific” and the results are probably a bit easier to measure. Any medication that truly revolutionizes addiction treatments could greatly simplify the substance abuse industry.

What’s wrong with Combining Medication with Other Therapies – Such as the 12 Step Program?

Nothing, really….provided that people who use these new medications are still motivated to change their lives in a deep and meaningful way, so that they might achieve a real and lasting sobriety. The threat is that medications will become a convenience that traps people in a cycle of short lived sobriety and relapse. The quicker and easier a “fix” is, the more likely that it will become a shallow form of treatment that eventually leads people to relapse.

What do you think? Is medication a viable option for treating addiction? Or does it potentially distract from making real changes and finding meaningful sobriety?