Archives for February 2017

Insights After Reporting on Addiction for 3.5 Years

I felt that paradox of shock and recognition that shadows the human experience of time when I realized I had been writing and researching on addiction for Handshake Media, Inc. for 3.5 years.

Laurel Sindewald waves to leave at Maia Szalavitz's visit to Blacksburg, VA

Anne Giles and I have worked diligently together on investigating and reporting on addiction. I have felt like a detective, or a mythbuster. Anne, in her work as an addictions treatment advocate, would come across a new concept or quandary, or a common belief about addiction, and she would task me with investigating. While researching and writing for Handshake Media, I have authored 26 articles on addiction and addictions treatment. After hundreds of hours of research over the past 3.5 years, Anne asked me these questions.

What is addiction?

Addiction is a disorder or disease of the brain, of varying severity, that compromises willpower and executive functions, sensitizes the brain’s stress system, and desensitizes the reward system. Addiction is defined by a person’s inability to stop a behavior despite negative consequences.

What causes addiction?

Addiction happens when a combination of risk factors (e.g., genetics, past trauma, attachment style, co-occurring disorders, and a poor socioeconomic support system) coincide with a person’s use of substances or behaviors regularly to cope with stressful situations in place of other emotion regulation strategies.

What treats addiction?

Each person requires a personalized treatment plan based on his or her individual situation, developed in consultation with his or her doctor. Three main components can be listed, however, that are often helpful for most people most of the time for recovery from addiction.

  1. Medication-Assisted Treatment (MAT). Foremost, medications are available that directly or indirectly treat the brain problems that develop with addiction. Counseling is not required for treatment of addiction with medications to be effective.
  2. Individual or Group Counseling. Adherence to medical treatment in general averages to around 50%, and addiction is likely no exception. Counseling may help people stick with a treatment plan, and to meet their abstinence or harm-reduction goals. People with substance use disorders (the medical term for addiction) may also need assistance with developing new emotion regulation skills and strategies to replace the behaviors and/or substances they previously used when stressed. Dialectical Behavior Therapy (DBT) and Cognitive Behavioral Therapy (CBT) are two treatment options available, and may be especially helpful for people with co-occurring disorders. We don’t know whether counseling directly affects the changes in the brain resulting from addiction, but by supporting abstinence or harm reduction, counseling may play an important part in indirectly affecting those brain changes over time.
  3. Recovery Support Services (RSS). RSS is not actually treatment, but may be helpful in supporting people in recovery. Some people find support groups (also known as Mutual Help Groups or MHGs) to be helpful for social support in building a new recovery lifestyle. While 12-step groups are the most common support groups available, they are not for everyone, and they are not the only option. SMART Recovery is a secular, CBT-based support group teaching concrete skill sets to help people reduce or stop any kind of behavior. RSS is not limited to MHGs, however, and may include legal, housing, or nutritional assistance, and help with dependent care.

Is addiction a condition that would benefit from healing? Can it be healed?

Yes, addiction is a condition that benefits from healing because there are brain changes involved that require medications to stabilize, and eventually alter them. The term “healing” also implies an element of long-term care, which is helpful because the brain changes involved in addiction happened over time, and new changes also require time.

Addiction can be healed, and remission is considered stable after 5 years. Much as a habit or learned behavior can eventually be changed, an addiction can be changed too, but requires a deal of time and patience with mulligans and suffering. The brain networks of connection will always be there (one never forgets how to ride a bike or drive a car), but over time other networks will be stronger or will predominate.

Why do some people with addiction behave badly?

I believe people with addictions who behave badly are suffering – in pain – and do not know how to cope with that pain or adequately express it. When they use a substance, their ability to make decisions is further compromised and they are unable to stop or control the behavior. As addiction progresses, they lose more executive function in the brain and are unable to stop or control behavior, whether they are presently using the drug or not.

What might prevent people with addiction who behave badly from doing so again?

I think that first of all, people with addiction require a medical treatment plan for a brain condition involving medication and counseling as individually required. All co-occurring disorders must also be treated appropriately, and past trauma if in evidence. People with addiction may need help with an action plan to regulate emotion when they are upset, instead of using. Many people may require socioeconomic support, legal defense, and job training to have better lives in recovery.

I believe people with addiction also need compassion and forgiveness from those they love, even if harm has been done. Tough love is not helpful, and may worsen a person’s addiction. If a person is constantly focused on repenting for past deeds or making amends, how can he or she focus on the full-time self-care required to prevent a relapse, much less to build a new life worth living? I believe forgiveness frees a person to stop self-punishment for past actions, and to instead practice self-love and self-care.

I know that my position of compassion for people with substance use disorders is fairly uncommon, because unfortunately, addiction often has concussive effects on families and communities for generations. People who are close to people with addictions may be physically or emotionally abused, stolen from, cheated on, molested, raped, or otherwise traumatized – trust broken. People are suffering who did their best to help their loved ones with addiction, over and over, and yet those loved ones behaved incomprehensibly, cruelly, despite all efforts.

The elephant in the room of addiction is raw suffering, and hopeless defeat.

My position comes from these years of research, and hard-won experience, knowing and loving people with one or more addictions who hurt me or other people I love. Yet, while my personal experience tallies with the research I’ve done, it’s the research that I rely on when I report on addiction. Good research is based on careful methodology, transparency about funding and potential bias, and conservative conclusions from carefully-analyzed data. The research I have reviewed, compiled, and reported on pulls together information about hundreds of thousands of cases of addiction. Any experiences I have are singular data points, and only helpful when viewed as a very small, biased sample of the whole, complex picture.

So, what do I advocate after 3.5 years of research and reporting no addiction?

I strongly advocate compassionate delivery of evidence-based treatment, a focus on harm reduction rather than abstinence, dollars allocated toward treatment and not punishment or incarceration, and love-love for people with addiction—never tough-love.

Photo from Maia Szalavitz’s visit to Blacksburg, Virginia

On Counseling and Medication-Assisted Treatment

Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health categorizes substance use disorders, a.k.a. addictions, with “chronic and expensive medical illnesses” such as heart disease, diabetes, cancer, hypertension, asthma, arthritis, and chronic pain. The first order of treatment for these illnesses is medical care, primarily through medication. Patients with these illnesses are not required to receive multiple counseling sessions prior to receiving medication.

Challenging Myths about Medication Assisted Treatment for Opioid Use DisorderCounseling and support groups do exist for assistance with these illnesses. But counselors help patients comply with the course of treatment determined by their physicians. Support groups can help people live life while having the illness. But counseling and support aren’t replacements for medication and medical care. Except in addictions treatment.

Counseling is not medical care for a medical condition. We need to give people with the medical condition of substance use disorders (SUDs) medical care first – which may or may not include medication-assisted treatment (MAT) – but which may include stabilizing medical treatment for co-occurring mental and physical illnesses. Confusing medical care with counseling results in what the New England Journal of Medicine reported in December 2016: “Despite the demonstrated efficacy of maintaining abstinence by treating patients with opioid agonists, patients can remain on clinic waiting lists for months, during which time they are at risk of premature death.”

With regard to MAT and counseling, my conclusions from reading the research are that for most people most of the time, counseling has no significant effect on abstinence among those receiving MAT for SUDs, whether for opioid use disorder or other SUDs. Counseling may have a larger effect on those with co-occurring SUDs and mental disorders, but those effects would occur over time. People with the medical condition of SUDs do not have time for the possibility that counseling might be effective. They are at higher risk of dying as long as they are not on opioid maintenance medication. They need medical care stat.

From the Surgeon General’s report, page 4-21: “Nevertheless, multiple factors create barriers to widespread use of MAT. These include provider, public, and client attitudes and beliefs about MAT…”

“Buprenorphine is an effective medication in the maintenance treatment of heroin dependence, retaining people in treatment at any dose above 2 mg, and suppressing illicit opioid use (at doses 16 mg or greater) based on placebo-controlled trials…Methadone is superior to buprenorphine in retaining people in treatment, and methadone equally suppresses illicit opioid use.”
Cochrane Database of Systematic Reviews, 2014

We need to shift our policies from belief-based practices to what the science reports is best practices addictions treatment for people with substance use disorders: medical care first. Then, we can work on secondary, individualized assistance, perhaps counseling, case management, support groups, or support services according to each client’s case.

. . . . .

“In fact, no rigorous study has ever been able to show that the addition of psychosocial services to opioid agonist therapy alone improves outcomes in the treatment of opioid use disorder.”
Lean Forward, Harvard Medical School, May 2017

“Despite the demonstrated efficacy of maintaining abstinence by treating patients with opioid agonists, patients can remain on clinic waiting lists for months, during which time they are at risk of premature death. The use of interim treatment with buprenorphine without formal counseling while patients remain on waiting lists may mitigate this risk during delays in treatment.”
New England Journal of Medicine, December 2016

“Unfortunately, despite decades of research, it cannot be concluded that general group counseling is reliably effective in reducing substance use or related problems.”
Surgeon General’s Report, November 2016

“The commonly held belief that opioid agonist treatment alone is inferior treatment to such treatment combined with psychosocial treatment (which many will understand to mean counseling) is not supported by the research evidence and it results in limitations on the use of these effective medications.”
Journal of Addiction Medicine, July/August 2016

“[T]here is little empirical evidence suggesting which psychosocial treatments work best in conjunction with medication-assisted treatment as there are relatively few studies comparing the differential effectiveness of various psychosocial approaches (eg, CM [contingency management], MI [motivational interviewing]) for individuals receiving medications for the treatment of opioid addiction.”
Journal of Addiction Medicine, March/April 2016

“Patients who received only psychological support for opioid dependence in England appear to be at greater risk of fatal opioid poisoning than those who received opioid agonist pharmacotherapy.” – Addiction, November 2015

“Clinical trials show that opioid agonist therapy (OAT) with methadone or buprenorphine is more effective than behavioral treatments, but state policymakers remain ambivalent about covering OAT for long periods…OAT is associated with lower total healthcare expenditures compared to other forms of behavioral treatment for patients with opioid addiction.”
– Journal of Substance Abuse Treatment, October 2015

“Supplementing standard medical management with cognitive-behavioural therapy did not further reduce opioid use or promote abstinence among primary care patients being maintained on buprenorphine.”
Drug and Alcohol Findings, 2013

“For the considered outcomes [retention in treatment and use], it seems that adding any psychosocial support to standard maintenance treatments do not add additional benefits.”
Cochrane Database of Systematic Reviews, 2011

“Consistent with results from a previous study of predominantly heroin-dependent patients receiving buprenorphine-naloxone in a primary care setting, individual drug counseling did not improve opioid use outcomes when added to weekly medical management visits.”
Archives of General Psychiatry, 2011

“We conducted a 24-week randomized, controlled clinical trial with 166 patients assigned to one of three treatments: standard medical management and either once-weekly or thrice-weekly medication dispensing or enhanced medical management and thrice-weekly medication dispensing…All three treatments were associated with significant reductions from baseline in the frequency of illicit opioid use, but there were no significant differences among the treatments.”
New England Journal of Medicine, July 2006

The Comprehensive Addiction and Recovery Act (CARA) requires that an MAT treatment provider be able to provide or refer patients to counseling. Other than this wording in CARA – “appropriate counseling and behavioral therapies” – neither mentions the type, length or number of sessions of counseling required. Wisely, for an individual, the law does not require him or her to receive counseling in order to receive MAT. Unwisely, in Virginia, Medicaid patients are required to receive SUD counseling in order to be covered for either methadone or buprenorphine.

Image: Challenging the Myths about Medication Assisted Treatment (MAT) for Opioid Use Disorder (OUD) from The National Council for Behavioral Health

Laurel Sindewald contributed to the research for this report.

Last updated 7/30/2017.