A Look at the Evidence for Addiction Rehab

In the U.S., when people think of addiction they usually also think of the 28-day addiction rehab, which was long popularized by the celebrities who used them to try to recover from addiction. As recently as 2013, the magazine People published a compilation of “celebrity success stories” who recovered with the help of traditional rehab.

Yet traditional 28-day rehab, based on the 12-step-heavy, Minnesota Model founded in 1950, is not effective at producing abstinence-based outcomes for people with substance use disorders (SUDs). In fact, scientists have known 28-day rehabs to be ineffective for over three decades. Relapse rates when leaving rehab are as high as 70%, probably higher.

“The position that residential treatment centers and their abstinence-only philosophies are superior to medication ignores overwhelming data and keeps families from seeking the best care. Let’s start with Pinsky’s patients: Nearly 13 percent who appeared on Celebrity Rehab died not long afterward; most had been addicted to opioids.”
Maia Szalavitz

Facing Addiction in America’s treatment recommendations are, in priority order, medical care, including medications, individual counseling, and support. Further, for some, treatment may not be necessary; spontaneous recovery rates are estimated to occur in 4 to 46% of people with diagnosable SUD.

We delved into the research on rehab and this is what we found:

“One of [the physicians interviewed] pointed out that you could book a room at a nice hotel for a month (let’s say at $150 per night), have all your meals there ($100 per day), see a psychiatrist twice a week ($300 per visit) and a psychologist three times a week ($275 per visit), get a membership at a fitness club for the month ($100), go to a massage therapist once a week ($100), and you still wouldn’t come out close to the $30,000 that a typical rehab costs for twenty-eight days. If you add it all up, plus throw in seeing an addiction counselor three times a week at a rate of $130 per hour, the grand total for the month comes to not quite $15,000, or about half the price of many a residential rehab.”
– Anne Fletcher (Inside Rehab 98)

  • People treated in outpatient programs are less likely to return to hospital or inpatient care, which further reduces costs of treatment over time. (Annis, 2008)

“Day clinic patients showed significantly fewer hospital readmissions and fewer days hospitalized during the one year follow-up period; this finding agrees with a growing body of evidence in the mental health field indicating that alternatives to inpatient programming foster lower subsequent rates of utilization of hospital beds.”
Helen M. Annis, Ph.D. (1985)

  • Most of the revenue (about 80%) for specialty addiction programs, including inpatient rehabs, comes from taxpayer-funded, government sources. (Kimberly & McLellan, 2006)
  • Once the dominant form of addiction treatment, the 28-day rehab is no longer well-supported by insurers. Most people who receive treatment for addiction are treated on an outpatient basis. (Inside Rehab 16)

“After numerous studies showed no difference in how people fared after going to residential versus outpatient programs, insurers and other funding sources drastically cut back on paying for residential rehab. Today, various forms of outpatient help comprise more addiction treatment experiences in the United States than residential stays.”
– Anne Fletcher (Inside Rehab 16)

“Of the types of care offered at these programs, 81 percent were outpatient, accounting for nine out of ten of all clients in treatment. About a quarter of the programs offered residential (nonhospital) treatment, which accounted for about one out of ten clients in rehab.”
– Anne Fletcher (Inside Rehab 22)

  • However, specialty programs (inpatient and outpatient) focused exclusively on addictions treatment, still comprise about 80% of the nation’s addiction treatment programs. The addiction treatment system is not well-integrated with the rest of medicine. (Kimberly & McLellan, 2006)
  • New science has shown that addiction is a chronic condition, requiring years of treatment.

“The idea that someone goes away to a thirty-day rehab and comes home a new person is naïve. Rather, there’s a growing view that people with serious substance use disorders commonly require care for months or even years, just as they would for other chronic medical conditions, such as diabetes.”
– Anne Fletcher (Inside Rehab 16-17)

  • Most rehabs in the United States rely heavily or entirely upon 12-step approaches for their curricula, which is not evidence-based as treatment for addiction. (Szalavitz, 2016; Sindewald, 2017)

“When I wrote Sober for Good, more than 90 percent of rehabs in the United States were based on the twelve steps. While the ratio appears to have dropped somewhat, most programs still base their approach on the twelve steps, include a twelve-step component, require twelve-step meeting attendance, and/or hold twelve-step meetings on-site.”
– Anne Fletcher (Inside Rehab 18)

  • The first inpatient rehab for addiction, Hazelden, which was responsible for creating the “Minnesota Model” of addiction treatment later adopted almost universally by United States rehabs, was founded by members of Alcoholics Anonymous. Alcoholics Anonymous is a religious self-help group founded by non-professionals in 1935, and is most known for the 12 Steps. (Anderson, McGovern, & DuPont, 1999; Wikipedia)
  • Inpatient rehab programs rely heavily on group counseling, which is not effective as a treatment for addiction. (Surgeon General’s Report, 2016)

“While group counseling is the staple approach in the vast majority of programs, there’s little evidence that the type of group counseling used at most of them is the best way to treat addictions.”
– Anne Fletcher (Inside Rehab 17)

“…if a client is a ‘group’ person, traditional residential rehab probably will agree with him or her; if not, too bad, because there’s some type of group counseling, education, lecture, or other group activity about eight hours a day–not including meals.”
– Anne Fletcher (Inside Rehab 83)

  • Some rehabs, particularly those with heavy 12-step emphasis, do not think people with addiction should be treated with drugs. (Szalavitz, 2016)

“Research clearly shows that certain prescription medications help people addicted to drugs and alcohol get sober and stay sober. yet many rehabs are unfamiliar with them or refuse to use them because of the old-fashioned notion that drugs should not be used to treat an addict–or that they should be used very sparingly.”
– Anne Fletcher (Inside Rehab 21)

  • Of inpatient rehabs, 54% do not have physicians or psychiatrists on-staff who could prescribe the medications evidence-based for treating addiction, and less than 25% have licensed social workers or counselors on staff to provide evidence-based behavioral therapies. (Kimberly & McLellan, 2006; Knudsen, Roman, & Oser, 2010)

“In many states, anyone can open a rehab program — no licenses or accreditation are required.”
David Sheff

  • Science has developed new treatments for addiction, but rehabs have been slow to adopt new methods and pharmaceutical treatments. (Miller et al., 2006)

“…people with alcohol addiction receive care ‘consistent with scientific knowledge’ only about 10 percent of the time.”
– Anne Fletcher (Inside Rehab 29)

When we looked at what the Surgeon General’s Report, Facing Addiction in America, had to say about inpatient treatment, we were surprised, after our research, to see that the report included residential (28-day rehab and similar services) and inpatient (hospital settings) services as evidence-based treatment for addiction.

“Residential services offer organized services, also in a 24-hour setting but outside of a hospital. These programs typically provide support, structure, and an array of evidence-based clinical services. Such programs are appropriate for physically and emotionally stabilized individuals who may not have a living situation that supports recovery, may have a history of relapse, or have co-occurring physical and/ or mental illnesses.” –Facing Addiction in America

  • In a study of 151,983 patients in England with opioid dependence, successful completion of treatment, including residential rehab, was not associated with a reduction in risk of fatal drug-related poisoning. (Pierce et. al, 2015)

We were unsuccessful in finding research studies demonstrating the efficacy of rehab for abstinence-based outcomes for people with substance use disorders.

Traditional, residential rehab programs are infamous for misrepresenting their treatments’ success rates, and for not following up with clients to determine long-term outcomes. Much of what we did find concerned inpatient (residential and hospital lumped together) vs. outpatient treatment settings. Our research unequivocally showed that the two settings yield comparable results, but that treatment on an outpatient basis is much more cost-effective.

Where does that leave us with regard to evaluating the efficacy of rehab? Right now, we don’t know.

This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

More reports from Handshake Media are here.

Information Sheet on Medication for Opioid Use Disorder

This information sheet links to primary sources, secondary sources that report on multiple primary sources, informed commentary, and reports from our own literature reviews. To aid in creating printable copies with sources, we have primarily posted the link rather than linked the text.

“In the United States, a monthly injectable form of long-acting naltrexone (Vivitrol) was approved in 2010 as a third medication option for opioid addiction treatment. In the United States, opioid substitution therapy and extended release naltrexone are grouped together in the category ‘medication assisted treatment’ (MAT), to distinguish these treatments from abstinence only methods. Less than half a dozen trials of long-acting naltrexone have been published and they show promising results in terms of reducing relapse. There is little long-term data, however, and extended-release naltrexone has not been shown to reduce mortality or disease. It may even increase overdose death risk upon cessation. Vivitrol is not approved in Canada, although it is available under the country’s special access program in reaction to the opioid crisis.”

The Opioid Crisis in North America, Global Commission on Drug Policy, October, 2017

Medication for Opioid Use Disorder

A shortened, printable .pdf of the information sheet is here.

A printable .pdf of the infographic by Laurel Sindewald is here. It is updated from our original post here.

This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Related reports on addictions treatment, addictions recovery, and addictions policy from Handshake Media, Incorporated:

This post was last updated 10/31/17.

Spontaneous Remission from Addiction: Definitions and Implications for Treatment

Spontaneous remission from addiction, when people recover from substance use disorders without treatment, is the ardent wish of people with addiction and of those who love them, particularly if remission occurs readily, speedily, and without complications. Yet, what exactly defines spontaneous remission, what causes it, and how often it occurs are mostly unknown. Estimates of the rate of spontaneous remission from addiction have ranged from 4% to nearly 60%.

Poppy in the setting sun

Why do some people spontaneously recover and others don’t? Does it mean there is hope for people who are addicted that they will one day be able to “just say no”? (Should we be angry with them if they don’t?) And what about those difficult cases treatment providers see, that never seem to improve despite the provider’s best efforts? And if someone claims a treatment cured them, might they have just “spontaneously remitted” and not know it?

Unfortunately, precise estimates of spontaneous remission are notoriously difficult to obtain because of the limits of the data available. Very little is actually known about spontaneous remission.

For one thing, different researchers use different terms to describe the phenomenon: “spontaneous remission,” “spontaneous recovery,” “aging out,” “maturing out,” “natural recovery,” “selfremitting,” “unassisted recovery,” “recovery without treatment,” and “selfchange.” Each term has slightly different connotations, and definitions may differ as to specifying complete abstinence or some moderation of use. In general, researchers seem to agree that the terms refer to people who are achieving abstinence or moderation on their own.

The definition of addiction itself is a moving target. Which people are most susceptible to which drugs with what severity changes, perhaps based on economic and social conditions. (In the 80s and 90s in the U.S., the primary concern was crack cocaine in inner cities, and in 2017 the primary concern is prescription opioids and heroin laced with fentanyl in rural areas.) Some of the older epidemiological surveys available use outdated diagnostic criteria (e.g., DSM-III or DSM-IV) to diagnose addiction, such that heavy use and physiological dependence may have qualified as addiction. Now, with DSM-Vwe distinguish between simple dependence and more complex addiction. People who are dependent but not addicted to a substance are probably more likely to remit on their own, without treatment, than people who are heavily addicted.

To determine whether remission was spontaneous, researchers also need to be able to pin down what is considered treatment, and what isn’t. For example, some researchers consider 12-step approaches to be treatment, while others don’t, accordingly influencing estimates of people who recover without treatment.

As if all of this isn’t enough of a puzzle, researchers don’t follow up with study subjects after the same amount of time. Some researchers follow up after a year, while others try to find people every five or ten years. Depending on the length of time, some subjects might have remitted and relapsed, while others might have remitted for good; the percent of subjects in remission is likely to change over time. Some subjects cannot be found again at all, and their data is typically removed from consideration, thus influencing estimates of spontaneous remission rates.

The information that is available comes mainly from three different kinds of evidence, each of which has strengths and drawbacks: individual case studies, nationwide epidemiological surveys, and meta-analyses of smaller-scale studies.

1. Individual Case Studies

Spontaneous remission is a known phenomenon in part because of the people who have stepped forward and told their stories. Maia Szalavitz wrote about one of the most famous examples, Oliver Sacks, who, “found in writing an alternative source of pleasure and purpose. His ability to take joy in this work—even when it was not his primary source of income—replaced the ‘vapid mania of amphetamines’; more critically, writing was more meaningful than taking drugs.”

Szalavitz, author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, has done extensive journalistic research into the phenomenon of spontaneous recovery. In an interview, she speculated on why and how spontaneous remission from addiction happens:

“I think in some cases, a lot of times, it’s life events, like you fall in love with somebody and because you’re just in love with somebody at that moment, you are able to give it up for them, whereas if you fell in love at another time, it wouldn’t work. Or you just got the job you’ve always wanted. Or the structure of your life changes. For a lot of people, you can’t really party the way you did in college [at age] 30. And that structurally helps a lot of people to recover, just the fact that in order to earn a living, you have to show up somewhere at 9 or 10 in the morning. And maybe those people have less severe addictions.”
Maia Szalavitz

Individual case studies and anecdotes are helpful for observing that a phenomenon sometimes occurs, but we cannot draw conclusions on how often it usually happens.  As Szalavitz notes, no generalizations can be drawn from individual anecdotes.

2. Nationwide Epidemiological Surveys

National epidemiological surveys are typically designed to estimate the prevalence of various disorders and/or diseases in the population. They are not well-suited to describing the course of a disease or disorder over a person’s life, or how often people get better from the disease or disorder (whether on their own or through treatment).

Four epidemiological surveys have been analyzed related to spontaneous remission from addiction: the Epidemiological Catchment Area survey (ECA, 1980-84), the National Comorbidity Survey (NCS-1, 1990-92), the National Comorbidity Survey Replication (NCS-R, 2001-03), and the National Epidemiological Survey on Alcohol and Related Conditions (NESARC, 2001-02). The first three were generally performed to determine the predominance of various mental health illnesses in the United States. Only the fourth was aimed at people with addiction, and it was focused on alcohol-related problems.

In-depth analysis or review of these four surveys is beyond the scope of this article, but one researcher, Gene Heyman, performed an analysis of all four in 2013, in order to try to answer questions about spontaneous remission. Based on his analysis of these four nationwide surveys, Heyman concluded that a consistent percent of people with addiction remit over time, and that most people do so by age 30. He estimated lifetime recovery rates to be around 80%.

Unfortunately, his conclusions are limited by the nature of the data he examined. Large-scale surveys are notoriously fickle when one tries to conclude anything from them beyond what they were designed to estimate.

  • They are observational, and therefore often unable to distinguish between lurking variables. For example, these surveys did not adequately answer whether people were in treatment or not when they remitted. Heyman’s estimate of 80% is not an estimate of spontaneous recovery, only lifetime remission. From these surveys, we can only say that people remitted, not why or how they did so.
  • They are a snapshot in time, not longitudinal. Therefore, the surveys are unable to show how long addiction persisted for individuals. His conclusion that a consistent number of people remit every year is based on a snapshot of people in different generations, not based on a longitudinal study following a group of people over time.
  • Surveys are also prone to misrepresenting populations. In the case of the four examined by Heyman, the people who are most severely addicted, living in impoverished neighborhoods, homeless, or in prison, were less likely to be sampled. He noted that the ECA survey attempted to compensate for this by over-sampling prison populations, but the other three did not. None of the surveys accounted for people who may have died in the course of their addictions. Heyman’s 80% statistic is only valid if the surveys adequately represent the total population of people with addiction in the U.S.

Heyman was aware of all of these limitations, and adjusted his estimate to 64% based on the critique of researchers who estimated that these surveys missed about 25% of all people with addiction. He tried to then assume that, if the missing people remitted by age 30, the rate would jump back up to 74%, but the “age 30” estimate was based on the same data that is biased by missing people. He claimed that to adjust the statistic below 64% to account for missing people, “would imply that approximately one in ten adult Americans had become addicted to an illicit drug and that most were currently addicted.” In fact, 1 in 10 was the estimate for the number of Americans over the age of 12 who were currently addicted in 2007, and about 1 in 13 (7.8%) Americans over the age of 12 were currently addicted in 2015.

While Heyman establishes a hopeful picture for overall remission rates for people with addiction, caution is warranted in trusting his conclusions. The estimates for lifetime remission, whether 64%, 74%, or 80%, are cause to be optimistic about the ability of people to recover from addiction. They are not, however, reason to become impatient with people who suffer from addiction. His statistics are also not applicable to the question of spontaneous remission, given that the surveys did not examine whether the people who remitted were in treatment or not.

Heyman’s results are potentially grounds for someone to apply for grants to do a large-scale longitudinal study. If remission rates without treatment can be known, researchers may be better able to evaluate treatment effectiveness. A longitudinal study could help determine which treatments are effective above and beyond spontaneous remission.

3. Meta-Studies

Where the nationwide surveys lack the power to describe how addiction progresses in an individual or why spontaneous recovery happens, individual studies typically lack the large sample sizes needed to generalize for all of America. For this reason, some researchers choose to use complex statistical analyses to compare results across studies and draw conclusions from their combined data, a process called meta-analysis.

In 2009, Glenn Walters did a quantitative review of the literature to determine the extent of spontaneous remission, and whether people who spontaneously remit are different in any obvious way from people who don’t. Walters included 12-step approaches under the umbrella of “formal intervention,” or treatment. He also performed the analysis for a broad definition of spontaneous remission, that the subjects had reduced the amount and/or frequency of drug intake and were free of negative consequences for 6 months, and a narrow definition of spontaneous remission, that the subjects were entirely abstinent from the substance of choice for 6 months.

Walters found that the average prevalence of spontaneous remission from alcohol, tobacco, or other drugs was 26.2% using a broad definition of remission, and 18.2% using a narrow definition of remission. Walters also managed to evaluate the principal reasons people who spontaneously remitted reported for why they quit using.

The top four reasons people reported for stopping alcohol/drugs and staying stopped were:

  1. “support from family/friends”
  2. “find new relationships/avoid old relations”
  3. “transform identity/reject addict identity”
  4. “willpower/resist the urge to use”

The top four reasons people reported for stopping tobacco and staying stopped were:

  1. “willpower/resist the urge to use”
  2. “substitute activities/dependencies”
  3. “self-confidence”
  4. tied: “change in recreational/leisure activities” and “exercise/physical fitness”

In Walters’ review, people who were able to remit (spontaneously or otherwise) were not less severely addicted or otherwise meaningfully different from those who did not remit. The exception is that, for tobacco, there is some evidence that those who had been smoking longer/more intensively were less likely to remit.

To draw conclusions with greater confidence, however, one would need to look into the sampling methodology of the studies Walters reviewed, to see whether sampling bias occurred. For instance, Walters’ estimates of spontaneous remission are much lower than those that come from the nationwide surveys. Aside from the fact that his estimates are of spontaneous remission rather than total lifetime remission, Walters’ estimates may also be more accurate due to better/more representative sampling or less accurate due to more biased sampling.

Walters himself noted that, to really understand how and why spontaneous remission occurs, and at what specific rates, a study with more rigorous methodology is needed.

“A longitudinally designed investigation of a large unselected group of untreated substance abusers would go a long way toward filling many of the gaps in our current knowledge of spontaneous remission. This group of individuals could be followed and periodically reinterviewed to determine changes in their use of substances. Such a study would allow more precise calculation of patterns of spontaneous remission, treatment remission, and relapse.”
Glenn Walters

In fact, while such a longitudinal study would be extremely expensive, it would be cost-effective in the long run, both in terms of dollars and relieving human suffering. Researchers need to know natural remission rates if they are to adequately determine the effectiveness of various treatments that surpass those natural rates. Furthermore, if spontaneous remission rates are indeed as high as 50%, then treatment funds can be used to potentially accelerate the process of spontaneous remission, or to focus on people who are unlikely to remit without help.

For now, we can only estimate spontaneous remission rates to range between 4% and 60%, and speculate about the reasons why people spontaneously remit. We can say, confidently, that spontaneous remission does happen, and possibly at fairly high frequencies. That alone has hopeful implications for the treatment of addiction.

Jennifer West from Virginia Tech’s Laboratory for Interdisciplinary Statistical Analysis contributed to this post.

This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Complex and Interacting Factors Predispose People to Addiction

Complex and interacting factors can predispose people to developing addiction, defined by the National Institute on Drug Abuse as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.” Genetics, psychology, psychiatry, and sociology are contributing to a more complicated understanding of how and why addiction develops in 1 in 7 people, or about 14%.

Detail of collage, Mary Wilson Burnette Giles, 1963

Genetics and Epigenetics

Genetics is well-known as the field that studies DNA, or the amino acid code that serves as a blueprint for living creatures. Epigenetics, being a newer sub-field of genetics, is rather less well-known. Epigenetics is a field examining the chemical compounds and proteins that attach to DNA, and influence how and whether the DNA is translated. For example, certain proteins can turn genes on or off, or modify how much protein is made from (i.e. translated from) a gene. Epigenetic changes often happen due to environmental influences throughout a person’s life, and are heritable.

An estimated 40-60% of addiction risk is genetic, but researchers don’t know yet which specific genes are at the root of the risk. This is in part because, in the case of addiction, each suspected gene has a very small influence, but all the genes together seem to have a very large influence. To identify all of the small influences of the individual genes would require experiments with very large sample sizes.

The question of which genetic factors predispose people to developing addiction is further complicated by epigenetics, such that a person’s risk may be increased or decreased depending on his or her environment. The drug itself, social interaction, or stressful life events can all alter a person’s epigenetics so that the person is at higher risk for addiction. Because of these interactions between genetics and environment, so far it is impossible to say exactly how much of addiction is due to nature (genetics/inherited epigenetics) and how much to nurture (environment/experiences). It is safe to say that people are or become predisposed to developing addiction, probably due to both genetic and epigenetic variables.

Mental Illnesses and Personality Disorders

People with addiction can have co-occurring mental illnesses and personality disorders, for which they may have been self-medicating when they developed addiction. Some of the genetic risk for addiction may be indirect, via a genetic risk for other disorders.

“In fact, the majority of genetic influence on substance use outcomes appears to be through a general predisposition that broadly influences a variety of externalizing disorders and is likely related to behavioral undercontrol and impulsivity, which is a heterogeneous construct in itself.”
Dick 2016

One study found that 28% of people with alcohol use disorders (AUDs) and 47.7% of people with drug use disorders had at least one personality disorder. Specifically, 18% of people with substance use disorders (SUDs) overall (including AUDs) have antisocial personality disorder, a rate more than four times that of the general population, which may be the source of the myth of the “addictive personality.”

Disorders that are commonly comorbid with addiction include:

  • Anxiety and mood disorders
  • Schizophrenia
  • Bipolar disorder
  • Major depressive disorder
  • Conduct disorders
  • Post-traumatic stress disorder (PTSD)
  • Attention deficit hyperactivity disorder
  • Antisocial personality disorder

When these disorders precede the development of addiction, they are said to be precursors, and may contribute to overall addiction risk. We cannot say yet, however, whether any of these precursors have definitive, causal influence in the development of addiction.

Trauma

PTSD is one of the disorders most commonly comorbid with addiction, and warrants special emphasis. The relationship between trauma and addiction is very strong, and trauma is suspected to be a causal influence in the development of addiction. An estimated 66% of people with SUDs have experienced trauma, and about half have PTSD.

Trauma may include emotional, sexual, or physical abuse, and is especially damaging for children. Adverse childhood experiences (ACEs) are known to increase addiction risk, with children who have experienced 5 or more ACEs 7 to 10 times more likely to develop addiction. Even one ACE before the age of 15 doubles a child’s risk of addiction, based on a study of the population of Sweden. People who develop PTSD or experience trauma symptoms following community violence are also known to be at elevated risk for developing addiction.

Personality and Temperament

While there is no one addictive personality, certain personality and temperament traits are associated with higher rates of addiction.

“Yes, some stand out because they are antisocial and callous – but others stand out because they are overly moralistic and sensitive. While those who are the most impulsive and eager to try new things are at highest risk, the odds of addiction are also elevated in those who are compulsive and fear novelty. It is extremes of personality and temperament – some of which are associated with talents, not deficits – that elevates risk. Giftedness and high IQ, for instance, are linked with higher rates of illegal drug use than having average intelligence.”
Maia Szalavitz

Some of these personality traits may be or become severe enough to be diagnosable as a personality disorder, but in other cases a person may simply be prone to feeling anxious or hopeless, or being impulsive or sensation-seeking. These traits would also be accurately described as being precursors to addiction, possibly increasing addiction risk.

Attachment Security

Attachment theory has been studied for decades, beginning with research on infant-parent relationships, and expanding to research on adult relationships.

Attachment theory examines the quality of infant relationships with their caregivers, and correlates these relationships with the quality of relationships people have later in life. Basically, the more securely an infant bonds with a caregiver, the more secure that infant will feel in other relationships later in life.”
– Addiction Recovery with Others is Easier than Recovery Alone

Some theorize that addiction is an attachment disorder. Dr. Philip Flores is the founder of this idea, arguing that people with poor attachment are suffering from emotion regulation difficulties, and are essentially unable to regulate their self-esteem and relationships without healthy attachment. He posits that people suffering from insecure attachment use substance or behaviors to substitute for healthy relationships, which seem at first to help but ultimately exacerbate their problems.

We do not know whether Dr. Flores is correct, but we do know that insecure attachment styles are associated with addiction and with poor emotion regulation, as well as with other mental illnesses. Insecure attachment may therefore be considered to be another precursor to the development of addiction, in close association with the risk factors of co-occurring mental disorders.

Recently, researchers are exploring whether oxytocin (the neuropeptide and hormone thought to be responsible for social bonding) and social attachment may protect against addiction and stress. The neurological systems for stress coping and for social attachment overlap, and these researchers hypothesize that oxytocin is responsible for the transition people experience from wanting/searching for social attachment to liking/loving a person.

“The authors suggest that through dopaminergic, serotonergic and endogenous opioid mechanisms, oxytocin is involved in shifting the balance between wanting and liking in corticostriatal loops by facilitating consolidation of social information from ventral reactive reward systems to dorsal internal working models that aid in prospectively selecting optimal actions in the future, increasing resilience in the face of stress and addiction.”
Tops et al., 2014

Essentially, Tops et al. suspect that the process of developing familiarity and liking for other people, with the help of oxytocin, helps people to cope with stress, and makes them more resilient and less likely to become addicted.

Socioeconomic Influences

Poverty is a source of chronic stress, which may increase a person’s risk for mental illnesses. Fatal opioid overdose rates and emergency room visits are strongly correlated with unemployment rates, increasing 3.6% and 7% respectively for each 1% increase in unemployment. People in poverty are more likely to become addicted, in part because people in poverty are more likely overall to develop mental illnesses. Furthermore, mental illnesses may make it harder for a person to gain or keep employment and/or housing, which could lead to further or worsening poverty.

“Growing international evidence shows that mental ill health and poverty interact in a negative cycle in low-income and middle-income countries.”
Lund et al., 2011

Poverty is also known to have intergenerational influences, with chronic stress and poverty having epigenetic (therefore heritable) impacts on, for example, a person’s ability to cope with stress.

Other social-environmental influences may put someone at increased risk for addiction. For example, being surrounded by many people who use drugs tends to increase a person’s risk of developing an SUD, because the drugs are more available and people are more likely to use together more often. Furthermore, drug use in the home may result in more stressful situations, including poverty, that in turn put other people in the home at higher risk for addiction or other mental illnesses. Especially in cases of social isolation and poverty, such as in some rural areas of America, almost everyone in a community may develop addiction (e.g., the recent opioid epidemic).

Physiological Influences

Some people metabolize alcohol differently than others, and so are at higher risk for addiction. Some people are at heightened risk because of sleep disturbances or poor sleep quality. Others are at risk because of physical pain. People with physical disabilities, and/or traumatic brain injuries, are also known to be at higher risk for addiction. Women and men are equally likely to develop addiction, but sex, gender, race and ethnicity may influence the course addiction takes.

Developmental Stage

Adolescents are at higher risk for developing addiction, though many end up “aging out,” and recover on their own once their brains have developed. Human development is highly influenced by social environment, as well as genetics. If many of the above risk factors coincide with adolescence, a person is more likely to develop addiction.

Because of extreme variability in the precursors and predisposing conditions influencing the development of addiction, we may never have a one-size-fits-all treatment solution. By understanding all of the complex and interacting variables that predispose people to addiction, however, we can begin to determine which people are at highest risk, identify risks that we can mitigate, and create individualized treatment plans to ameliorate addiction, co-occurring mental and physical disorders, and life stressors.

Photo: Detail of collage, Mary Wilson Burnette Giles, 1963

This post was last updated 5/4/17.

Why 12-Step Approaches Are Not Evidence-Based as Addictions Treatment

When I read Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health [1], I was surprised to see Twelve-Step Facilitation (TSF) included as an evidence-based behavioral treatment for addiction. I had just done a literature review on the efficacy of 12-step-based interventions [2], and found the evidence insufficient to support the prescription of 12-step groups as treatment. TSF is a standardized form of therapy where professional counselors try to engage their patients in participating actively in 12-step groups, in part by emphasizing 12-step philosophy during therapy sessions [3].

12-step folding chair

Twelve-step philosophy stipulates that addiction is a spiritual disease born of defects of character, and that 12-step groups are the only cure, involving faith in a higher power, prayer, confession, and admission of powerlessness. In contrast, the National Institute on Drug Abuse (NIDA) defines addiction as a disease of the brain – a medical condition requiring medical treatment [4]. A spiritual disease concept is not the same as a medical disease concept. Twelve-Step Facilitation treats addiction as a spiritual and biopsychosocial disease, retaining the spiritual emphasis of 12-step philosophy [5].

TSF was classified as a professional behavioral treatment in the Surgeon General’s Report. How can a professional, medical treatment be based on a definition of addiction as a spiritual disease? Baffled, I knew I would not be able to understand if I got stuck in bias against Twelve-Step Facilitation. I had studied the research on 12-step groups, but had only dipped my toe into the research on TSF. The Surgeon General’s Report cites hundreds of studies, and over a dozen in support of TSF. So, I did what all good scientists must do: I set aside my bias, knowing that if I want truth, I must assume first that I am wrong and dig deeper.

I conducted a preliminary literature review to investigate the effectiveness of TSF as a treatment, and then examined each of the sources the Surgeon General’s Report cited in support of TSF. I looked at the methodology, results, and conclusions for each. In this article, I define “evidence-based” to mean any treatment supported by numerous scientific experiments with rigorous methods that include control groups, randomization of patients to treatments, and bias-free samples. I use “12-step approaches” to refer to all 12-step-based rehab programs, TSF, and 12-step mutual help groups.

The key to understanding research on TSF is to know why the treatment was created in the first place. Researchers had documented an association between 12-step group attendance and abstinence, but association is not causation and research had been limited in several ways:

  • Studies evaluating the effectiveness of 12-step groups could not eliminate self-selection bias, which happens when group members are not randomly selected and participants opt in or select themselves, creating biased samples. The people participating in the studies had chosen to participate, and researchers could not determine whether successes observed were due to 12-step participation or qualities in the self-selected participants, such as greater motivation to enter recovery, more resources, or greater receptivity to messages of God, faith and/or acceptance. The people who chose not to participate, or who dropped out of the study, were not always accounted for. Researchers could not determine whether the association they observed between 12-step participation and abstinence was due to the treatment or to the characteristics of the people participating.
  • Twelve-step groups have no standardized methods or conditions. Leaders of the groups are often laypeople in recovery from addiction themselves. The quality of social support in the group depends on the people who are participating. The literature is interpreted by the members, who create their own cultures around the interpretation. Twelve-step cultures also pass around other information and advice, which may or may not permeate every group. Each sponsor is a different layperson in recovery from addiction, with different character traits. Researchers could not control for all of these variables all of the time.
  • Researchers struggled to maintain rigorous control groups throughout studies. At minimum, to determine whether 12-step groups have effect, researchers needed a no-treatment control group for each study. Ethically and logistically, they could not prevent people in the control groups from receiving treatment or from attending 12-step groups.

Twelve-Step Facilitation was developed by researchers working on Project MATCH, a well-known and extensive study funded by the National Institutes of Health. Project MATCH compared TSF to Motivational Enhancement Therapy (MET) and Cognitive Behavioral Therapy (CBT), seeking to establish what patient characteristics corresponded with the best results for each treatment. The study found there “was little difference in outcomes by type of treatment” based on the primary outcome measures of percent days abstinent and drinks per drinking day [6].

By standardizing methodology for TSF, Project MATCH made some headway on strengthening the quality of evidence, but they did not find a way around self-selection bias and they did not have a control group. Many patients, however, did drop out of the assigned treatments early on in the study. Two researchers later examined the outcomes of the zero-treatment dropout group, and found that “two-thirds to three-fourths of the improvement in the full treatment group was duplicated in the zero-treatment group” [7]. This means that the people in Project MATCH’s treatment groups did not have significantly better abstinence outcomes than the people who dropped out of the study. Importantly, we do not know whether the dropout group sought treatment on their own, and it seems probable that they did. Based on their analysis, none of the interventions in Project MATCH seem to be effective, but without an actual control group the results are equivocal regardless.

Some researchers have sought to re-analyze other parts of the Project MATCH data [8,9], but their findings, while supportive of TSF, are subject to the same methodological limitations of the parent study. Many other studies cited by the Surgeon General’s Report seem to support TSF as effective for improving abstinence outcomes [1014] and/or for relatively increasing 12-step participation compared to treatment as usual (TAU) [1520], but none of these studies had control groups. The Surgeon General’s Report cited one source in support of TSF that was actually an article reviewing information about 12-step programs to educate social workers, not an experimental study [21]. The Report also cited a study in support of TSF that examined two active referral interventions, 12-step peer intervention (PI) and doctor intervention (DI), compared to no intervention (NI). The study found that while the active referral interventions significantly increased participation in 12-step groups compared to no intervention, “abstinence rates did not differ significantly across intervention groups (44% [PI], 41% [DI] and 36% [NI])” [22]. This study was the only one cited in the Surgeon General’s Report in support of TSF that approximated a control group, and it does not actually support the efficacy of TSF in increasing abstinence outcomes. The NI pseudo-control group still received a list of 12-step group meeting times and locations, but was not encouraged to attend. The PI group attended meetings twice as much as the NI group, and yet the researchers found no significant difference in abstinence outcomes. The DI group, essentially TSF, was less effective than the PI group at increasing attendance, and again, did not significantly improve abstinence.

My own literature review turned up articles the Surgeon General’s Report did not reference, both in support of TSF [5,2328] and not supporting TSF [7,29,30], but none of the studies I found had control groups either. Results of my literature review, including my assessment of the Surgeon General’s report sources, were therefore as ambivalent as the 2006 Cochrane Review, a systematic meta-study of all 12-step-based programs that found that, “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems” [31]. A more recent systematic review by the Campbell Collaboration found evidence on 12-step approaches for other drug use disorders to be weak as well, with only 9 studies meeting all of their inclusion criteria. What evidence they did find indicated no difference between 12-step approaches and other psychosocial interventions in reducing illegal drug use, and some evidence that 12-step approaches have higher dropout rates than other interventions [32]. Researchers have not been able to methodologically eliminate self-selection bias, and most often fail to utilize adequate controls in their studies of 12-step groups and TSF.

One study to date attempted to use instrumental variables models, a recently developed statistical method, to determine what percentage of increased 12-step group attendance can be attributed to TSF without self-selection bias [33]. The researchers, Humphries et al. 2014, re-analyzed data from 5 randomized clinical trials, though none of these clinical trials had control groups. They determined that TSF did significantly increase participation in 12-step groups for people who had not previously participated much or at all, though not for people who already had high levels of participation. Their methods were inadequate for determining whether increased participation is causally linked to increased abstinence, or whether increases in abstinence occurred without self-selection bias.

My review answers a question that cannot be answered by simply counting the number of studies apparently supporting or not supporting 12-step approaches like TSF. Are 12-step approaches evidence-based for treating addiction – supported by numerous scientific experiments with rigorous methods that include control groups, randomization of patients to treatments, and bias-free samples? No, 12-step approaches are not evidence-based, because no studies decisively demonstrate their effectiveness. In fact, research on 12-step approaches faces insurmountable obstacles. Practically speaking, researchers cannot ethically design and conduct experiments that eliminate self-selection bias and utilize adequate controls.

In medical science, if a treatment is ineffective or faces prohibitive methodological challenges, the treatment is either revised or abandoned. Twelve-step philosophy prohibits either approach. Twelve-step literature is comparable to the Bible for Christians or the Qur’an for Muslims; if the literature is removed, the identity of the group goes with it. The same basic text has been used for AA since the publication of its “Big Book,” Alcoholics Anonymous, in 1939. Twelve-step literature also explicitly states that, “Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average” [34]. Twelve-step philosophy, by taking this position, is asserting that its methods can never be wrong. If the 12 Steps do not work for people, 12-step philosophy explicitly states it is their fault, and that the fault is inborn and irreversible. The 12 Steps and attendant literature, however, are not modified.

Research does support the concept that changing “people, places, and things” and finding a network of people with a culture of abstinence can improve chances of recovery [35]. However, mutual help groups other than 12-step groups do exist that may provide the social support needed by people in recovery. A study by Zemore et al. [36], compared the relative, personal satisfaction of participants in 12-step groups vs. 12-step alternatives: SMART Recovery, LifeRing, and Women For Sobriety. The study did not examine abstinence or drinking/using outcomes among participants, but interviewed all participants on demographics, level of participation in their mutual help group (MHG) of choice, and level of satisfaction and group cohesion they experienced in their MHG. They found that, “despite lower levels of in-person meeting attendance, members of all the 12-step alternatives showed equivalent activity involvement and higher levels of satisfaction and cohesion, compared to 12-step members.” The participants who engaged in alternative MHGs tended to be less religious, and to have higher levels of education and income. The study demonstrates that alternative MHGs not only exist, but are of comparable efficacy in terms of social support. People who are not religious may be able to make 12-step groups work for them as social support if they have no other choices [37], but other options will most often be available.

Social support may be subjectively helpful as an individual seeks medical treatment, but ultimately medical treatment is necessary to ameliorate disorder symptoms. Social support is also not sufficient to prevent addiction from developing. Researchers using statistical analysis to determine whether social support and social networks reduced the odds of developing AUD following stressful life events and chronic stressors, among other disorders, found no statistically significant effect of social support or networks on later rates or effects of AUD [38].

A study in 2001 by Humphreys and Moos [39] found that TSF may reduce health care costs for people in recovery by emphasizing reliance on free 12-step groups, as opposed to cognitive behavioral therapy. Yet their conclusions that the study indicates people should be diverted from CBT to TSF because it is ultimately cheaper amounts to advocating malpractice. TSF itself is not free and is not decisively supported by evidence; twelve-step groups, while free, are not evidence-based or treatment, and other available mutual help groups are equally free options for social support. Even if TSF were demonstrably effective at promoting abstinence for some people, 12-step philosophy is heavily spiritual (specifically Christian-based), so it would be unethical to recommend TSF simply because it might save money.

In Unbroken Brain: A Revolutionary New Way of Understanding Addiction [40], Maia Szalavitz, citing Anne M. Fletcher’s Inside Rehab: The Surprising Truth About Addiction Treatment–and How to Get Help That Works [41], reports that 12-step approaches are “a required curriculum” in 80% of American addiction treatment programs. Many addictions treatment facilities state that that they are 12-step based. Based on my literature review, that means that these facilities are not offering effective, evidence-based treatment.

After extensive research, I assert with confidence that 12-step approaches are not evidence-based treatments. They may be strong recovery support options for people to choose in addition to a medical treatment plan, but 12-step approaches—including TSF—are not established as evidence-based for treating addiction. Due to the methodological limitations identified in this article, I question continuing to spend thousands of dollars, hundreds of hours, and limited expertise on researching a spiritually-based treatment for addiction that cannot be proven to be effective for most people most of the time compared to “spontaneous,” or natural, remission rates. It is time to relegate 12-step approaches to the realm of recovery support services (RSS, as defined in the Surgeon General’s Report) and allocate our research resources to promising treatments that can be studied rigorously and without such crippling methodological limitations.

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Laurel Sindewald is a writer and researcher for Handshake Media, IncorporatedAnne Giles contributed to this report.

A version of this report was originally published by The Fix as “AA Is Not Evidence-Based Treatment” on 3/16/17. We broaden the scope, update with the latest research, and provide full citations using APA style guidelines. We will continue to update the report as new research warrants. This report was last updated on 6/23/17.

After the Shootings: Community Violence, Collective Trauma and Addiction

It’s Fourth of July in a small town in America, and people of all ages and races, classes and creeds are gathered in a park for the fireworks display. People in lawn chairs are chatting over drinks. Here and there people are stretched out on old blankets or beach towels, reading or scrolling through Facebook. Kids are tearing up and down the playground equipment, playing with glowsticks or laughing at gravity on the swings. Everywhere the people breath deep and smell wafting barbecue above fresh grass, spiced with smoke from exhausted sparklers.

The community seems happy with the warmth of summer, and nothing around could show you the difference between this town and so many other small towns in America. But the people of this town have been changed. One April ten years ago, someone walked onto the local college campus, entered a building and locked the doors, killed 32 people and wounded 17 before committing suicide.

About 500 people are gathered to see the fireworks. Because of that violent event, research suggests that 75 of those gathered are suffering symptoms of trauma severe enough to be diagnosed with post-traumatic stress disorder (PTSD).

Statue on Virginia Tech Campus

Photo: “The Garden Sprite” statue on Virginia Tech Campus in the Hahn Horticulture Garden, a rendition of Frank Lloyd Wright’s “Maid in the Mud”

Mass shootings are one type of community violence, a term that includes terrorist attacks, riots, gang wars, workplace assaults, torture, bombings, war, and many other acts of violence. Community violence has far-reaching effects very different from some other forms of trauma, and impacts people who may not have been directly present at the violent event.

“Several aspects of community violence make it different from other types of trauma. Although there are warnings for some traumas, community violence usually happens without warning and comes as a sudden and terrifying shock. Because of this, communities that suffer from violence often experience increased fear and a feeling that the world is unsafe and that harm could come at any time. Although some traumas only affect one individual or a small group of people, community violence can permanently destroy entire neighborhoods. Finally, although some types of trauma are accidental, community violence is intentional, which can lead survivors to feel an extreme sense of betrayal and distrust toward other people.”
– Hamblen and Goguen, US Department of Veterans Affairs, 2016

An estimated 1015% of people who experience community violence report severe PTSD symptoms afterward. (Researchers estimate that 15-30% of people in the Blacksburg community experienced PTSD symptoms after the Virginia Tech shootings.)

Risk factors include female gender, proximity to the violence, knowing victims of the violence, pre-existing psychological conditions, emotion regulation difficulties, anxiety sensitivity, and low social support (Lowe and Galea, 2017; Bardeen et al., 2013; Grills-Taquechel et al., 2011; Stephenson et al., 2009; Scarpa et al., 2006Norris et al., 2002; North et al., 1994). The mental health effects include “psychological distress and clinically significant elevations in posttraumatic stress, depression, and anxiety symptoms in relation to the degree of physical exposure and social proximity to the shooting incident” (Schultz et al., 2014).

Researchers report that people in the surrounding community may also experience these effects, even if they did not witness the violence first-hand. For example, people who experience stronger emotional reactions, regardless of proximity, are at higher risk for later PTSD symptoms.

“For some people it’s water off a duck’s back. Some people are drowning.”
– Anne Giles, private interview

People who were unable to contact or locate loved ones during the Virginia Tech shootings were subject to trauma symptoms, even years later, as Victoria Sagstetter discovered.

“As an English teacher, she found herself re-reading student poems that seemed unusually dark, looking for the kind of clues Cho left behind in his writings before his killing spree.”
Jacob Demmitt of The Roanoke Times

After the Virginia Tech shootings, 4.5 years went by before some people sought treatment for trauma. Among the mental health effects people experience after trauma are substance use disorders (SUDs) and other addictions. The connection between trauma and addiction is well-documented, and current research indicates that trauma is a causal factor leading to addiction.

“Consistent with the self-medication hypothesis, the theory that people use substances to cope with psychological distress, PTSD tends to precede and predict SUD.”
Trauma and Addiction: Common Origins and Integrated Treatment

About 34% of people diagnosed with PTSD also suffer from addiction, and about two-thirds of people with addiction have experienced past trauma. Therefore, of the revelers at the Fourth of July celebration, an estimated 25 are at risk for developing addiction due to the event of community violence alone.

If people have experienced other traumatic events in their lives, as 1 in 4 American children have (CDC 2014; Felitti et al., 1998), they will be at even higher risk for addiction. For example, women who had experienced sexual trauma prior to the Virginia Tech shootings reported significantly more depressive symptoms, shooting-related PTSD, and lower belief in benevolence and family support.

“Maia Szalavitz, in her book Unbroken Brain, reports that, ‘Even just one extreme adversity – like losing a parent or witnessing domestic violence – before age 15 doubles the odds of substance use disorders, according to a study of the entire Swedish population’ (Unbroken Brain, 65).”
– Trauma and Addiction: Common Origins and Integrated Treatment

The estimated 75 people with trauma and 25 people with addiction watching the fireworks display are therefore a low estimate of the true risk for trauma and addiction in this small American town. Trauma and addiction are already very likely to occur, and an event of community violence such as the mass shootings in this community means trauma and addiction are almost certain to happen.

After community violence happens, everyone should be screened for trauma. (If resources are limited, those exhibiting risk factors should be prioritized, as should those with pre-existing disorders that put them at higher risk for addiction.) Community members must be aware that their friends and family and neighbors are at risk for developing addiction, and that if they do, they need treatment not tough love.

Some variables are known to reduce the risk of PTSD (and therefore addiction) after community violence. If a person has a belief in his or her ability to handle the trauma, i.e., self-efficacy, he or she will be less likely to experience PTSD symptoms. After community violence, in-person social support is known to mitigate resource loss (social or physical) and compensate for low levels of self-efficacy, reducing PTSD risk (Warner et al., 2015; Hawdon et al., 2012; Littleton et al., 2009). Specifically, sharing about thoughts and emotions with others may attenuate PTSD risk, but sharing bare facts will likely not help, and may increase the risk of developing PTSD.

“Thus, it is argued here that efforts to reduce risk and resource inequities, engage local people in mitigation, create organizational linkages, boost and protect social supports, cultivate trusted and responsible information resources, and enhance decision-making skills will augment more specific intervention efforts to promote safety, calming, efficacy, hope, and connectedness in the aftermath of mass trauma.”
Norris and Stevens, 2007

People in a community have a choice to make after community violence. What they choose determines how long and how badly the violence continues to affect their community. People who come together, in person, to share thoughts and feelings about the violence during and after it occurs are less likely to suffer from PTSD and addiction in the future. People who continue to come together, who recognize that some of their friends and neighbors will inevitably be suffering, and who affirm their own and others’ abilities to cope with the violence will be more likely to heal.

Let’s say you’re sitting on a towel on the 4th of July in that small town, surrounded by your friends and neighbors as the fireworks begin. You share, together, openly and shamelessly, about the trauma or addiction with which you may struggle.  In a special place created by “safety, calming, efficacy, hope, and connectedness,” you may start to feel a little bit better.

Author’s note: To estimate the number of people in my imagined 500 likely to develop PTSD, I reviewed the literature. One source estimated 10-15%, another estimated 15.4%, and a third estimated 15-30% of people who experience a mass shooting (directly or indirectly) develop PTSD. I chose 15% as a conservative estimate, because I do not have access to the data sets for each of these three sources. I multiplied 500 by 0.15, and arrived at my estimate of 75 people at high risk for PTSD in my imagined gathering of 500.

To estimate the number of people in my imagined 500 likely to develop addiction, I again reviewed the literature and found that 34% of people diagnosed with PTSD also have addiction. I multiplied 75 by 0.34 to arrive at 25 estimated people with addiction in the gathering of 500. One may also multiply 0.15 by 0.34 to obtain 0.05, or 5%, and multiply the full 500 by 0.05, again equaling 25 people at risk for addiction.

In a gathering of 500 people who experienced community violence, 15% are at risk for PTSD, or 75, and 5% are at risk for addiction, or 25 – due to the event of community violence alone.

PDF of Research Excerpts

Photo: Laurel Sindewald, statue, Hahn Horticulture Garden, Virginia Tech

A personal note from Anne Giles, added 4/5/17: I am one among a likely cohort of 300 who developed addiction in Blacksburg, Virginia after the Virginia Tech shootings. Of the 40,000+ people living in Blacksburg in 2007, research predicts 15% of them would develop PTSD. That would be 6,000. Of that 6,000, research predicts 5% would develop addiction. That’s 300.

Handshake Media maintains a list of addiction recovery resources for people living in the Blacksburg, Virginia area.

This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

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

Why Opioid Maintenance Does Not Replace One Addiction with Another

Opioid addiction has been declared a national epidemic in America. President Obama called for $1.1 billion in new funding for opioid addiction treatment and research early in 2016.

Opioids are drugs that relieve physical and emotional pain. Opioids include opiates, which is an older term for drugs derived from opium, such as morphine. Common opioids include prescription painkillers such as OxyContin, hydrocodone, Percocet, methadone and Vicodin, as well as drugs like morphine and heroin. Opioids cause a rush of dopamine in the brain, conditioning the brain over time and altering pathways dealing with pleasure, memory, learning, and decision-making.

With continued use, the human body develops tolerance to opioids, which means the body no longer responds to the drugs unless the dose is increased. A person with a highly developed opioid tolerance may take doses to get high that would be lethal for a person without an opioid tolerance.

Unfortunately, people taking opioids illicitly may have an irregular supply, causing their tolerance to fluctuate. Illegal opioids are also of variable potency, and may be laced with stronger, faster-acting opioids like fentanyl. The combination of fluctuating tolerance and unpredictable potency creates a dangerous situation for people using illicit opioids. For example, someone using heroin whose tolerance has dropped may inject what they think is a manageable dose of heroin, not knowing it is laced with fentanyl; the added potency and reduced tolerance could cause an overdose, and this person could be at risk of dying.

Since 2000, opioid overdose deaths in the U.S. have increased 200%.

A nuanced discussion rather than a black-and-white debate

Some discussions about opioid maintenance involve black-and-white/good-or-bad thinking. Let’s explore the nuances of how opioid maintenance works for people with opioid addictions.

Why Opioid Maintenance Treatments Are the Best We Have

The opioid epidemic is alarming especially because so many people with families, dreams, and skills – like anyone else – are affected. People with opioid addictions are taxpayers and citizens of many races, religions, and backgrounds; they are people and they are valuable. How can we prevent them from dying?

Addiction is defined by NIDA as a chronic, relapsing brain disease characterized by repeated behavior despite negative consequences. Relapse rates for addiction are comparable to other chronic illnesses, such as diabetes and hypertension.

Given that relapse is likely and given that reduced tolerance is a primary risk factor for fatal overdose, it follows that maintaining tolerance would reduce overdose deaths. Sure enough, scientific research on opioid maintenance shows that stable doses of full or partial opioid agonists (drugs that completely or partially activate opioid receptors) maintain tolerance and reduce risk of death if a relapse occurs.

“If we really want to stop the overdose epidemic, we need to get serious about providing the only treatment known to reduce the death rate by 50 percent to 70 percent or more: indefinite, potentially lifelong, maintenance on a legal opioid drug like methadone or buprenorphine. The data on maintenance is clear. If you increase access to it, deathcrime and infectious disease drop; if you cut it short, all of those harms rise.”
– Maia Szalavitz, The public scorns the addiction treatment Prince was going to try. They shouldn’t.

How Opioid Maintenance Works

“The principle behind MAT is this: Because opioid addiction permanently alters the brain receptors, taking the drug completely out of someone’s system can leave them less able to naturally cope with physical or emotional stress…”
– Maia Szalavitz

Two drugs are supported by scientific evidence as effective opioid maintenance treatments: buprenorphine, and methadone. A continuous, prescribed dose of either buprenorphine or methadone prevents people from experiencing withdrawals, stabilizes them in recovery, and reduces risk of fatal overdose. These medications do this by maintaining tolerance to opioids. People who are in opioid maintenance programs are not high when they take doses as prescribed (also because of tolerance), and are quite capable of driving a vehicle, going to work, providing childcare, and otherwise living life. Pregnant women who are addicted to opioids are advised to take buprenorphine (Subutex) to stabilize themselves and their babies until delivery.

Buprenorphine

Buprenorphine is a partial opioid agonist, which means that it binds to opioid receptors in the brain with only partial efficacy compared to full agonists (like morphine, oxycodone, and fentanyl). Effects of buprenorphine also have a ceiling dose, beyond which higher doses have no effect. This ceiling effect also means overdose from buprenorphine is less likely. Buprenorphine also affects the mμ receptor, which reduces the effects of additional opioid use.

Because it is safer than methadone, buprenorphine can be prescribed by physicians as pills or sublingual films, often under the brand names Suboxone or Subutex. Subutex is buprenorphine alone, while Suboxone also contains naloxone, an opioid antagonist. Suboxone was created to discourage misuse. When Suboxone is taken orally as directed, the opioid partial-agonist effects of buprenorphine predominate. If Suboxone is injected, however, the naloxone blocks opioid receptors and prevents the person from getting high. In an opioid dependent individual, the naloxone precipitates withdrawal effects.

Methadone

Methadone is a full opioid agonist, and does not have ceiling effects like buprenorphine. For this reason, it is considered to have higher misuse potential and is only administered by SAMHSA-certified opioid treatment programs, usually methadone clinics. However, a 2014 Cochrane review of studies comparing methadone and buprenorphine determined that people are less likely to drop out of methadone programs.

Given the complexity of addiction, and the complexity of factors uniquely affecting each person, individuals with addiction need individualized treatment. Only the individual, in consultation with one or more physicians well-educated in opioid use disorder and its treatment, may decide.

“Extensive literature and systematic reviews show that maintenance treatment with either methadone or buprenorphine is associated with retention in treatment, reduction in illicit opiate use, decreased craving, and improved social function. … Further work is needed to directly compare each medication and determine individual factors that can assist in medication selection. Until such time, selection of medication should be based on informed choice following a discussion of outcomes, risks, and benefits of each medication.
Dr. Gavin Bart, 2012 (Emphasis added)

How Opioid Maintenance Treatments Discourage Misuse

Just as it is impossible to eliminate all supplies of illegal drugs, law enforcement and treatment providers cannot wholly prevent diversion and misuse of buprenorphine or methadone. In fact, in trying to reduce misuse of buprenorphine, authorities have restricted access to buprenorphine maintenance treatment, limiting the number of buprenorphine patients a doctor can treat at any one time.

Still, treatment providers, pharmaceutical manufacturers, legislators, and law enforcement continue to try to limit the potential negative impacts of opioid maintenance treatments. Methadone, for example, is only given in take-home doses if patients can provide drug-free urine for several months.

However, because Suboxone can be diverted to people who were not prescribed the medication, it can still be misused. People who do not have a tolerance for opioids can still get high on Suboxone, up to the ceiling effect. Arguably, it’s a safer high than heroin because it is less likely to cause fatal overdose, but it’s still an illegal high.

In this case, as citizens, we have to weigh the risks of the diversion of partial agonist, buprenorphine, with full agonists like heroin, morphine, fentanyl, and oxycodone. If the goal is to reduce overdose deaths and crime associated with the opioid epidemic, buprenorphine will remain an important tool despite diversion.

Why People Dependent on Drugs Are Not Addicted

People taking medicine for depression, diabetes, and many other chronic illnesses become physically, literally dependent on their drugs to stay healthy. In most of these cases, however, these people are not addicted to their medicines. Even chronic pain patients, who become physically dependent on their painkillers and suffer withdrawals without them, typically do not develop addiction – only 8-12% of chronic pain patients become addicted to pain medication.

Dependence and addiction are very different, and understanding this may sometimes make the difference between life and death. Addiction is defined by persisting in a behavior despite negative consequences. People who are only dependent on a drug suffer withdrawals, and are then free to continue their lives – they do not go looking for more of the drug or persist despite negative consequences. People who are dependent and addicted, however, will continue to seek the drug even after withdrawals are over.

In the case of opioid addiction, people are still at risk for relapse after withdrawals are through, and may die from a relapse if their tolerance drops. To treat opioid addiction, rather than only opioid dependence, opioid maintenance treatment – recommended by the World Health Organization, the Office of National Drug Control Policy, and others to be continued indefinitely, perhaps life-long – is necessary to keep people stable and to prevent fatal overdoses.

How Opioid Maintenance Disrupts Addiction Patterns

Addiction happens when people at risk due to trauma history, mental illness and other factors take a drug which they are predisposed to experience as extraordinarily rewarding. In the brain, when a person has an exciting new experience, the reward system responds with a release of dopamine and other neurotransmitters telling us it’s something we want to do again. Certain drugs are more likely to cause a magnified reward response in the brain, releasing far more dopamine than ordinary experiences.

The reward system helps people to learn which experiences are good and which are bad. Because some people biologically experience some drugs as more rewarding than anything else, they learn to associate the drug, and any cues relating to its use (paraphernalia, locations, people, symbols) with immense reward. Their brains begin to respond to the cues, more even than the drug itself, which reinforces use.

Opioid maintenance does not involve the cues to which people with opioid addictions respond. Commuting to a methadone clinic is very different from shooting up heroin. Receiving one dose of Suboxone from a designated family member is very different from self-administering indefinite pills. The “people, places, and things” associated with use are changed when a person enters opioid maintenance. Opioid maintenance treatment helps keep neurocognitive cravings and physiological withdrawals at bay while the person rebuilds his or her life to remove cues for use.

In this way, opioid maintenance disrupts the addiction pattern of cue > pursuit of drug > use. Essentially, opioid maintenance attempts to replace an addiction with simpler dependence, rather than with another addiction. The difference between physical dependence and addiction is crucial to understanding why opioid maintenance does not replace one addiction with another.

How Opioid Maintenance Supports Healthy Recovery

At this point, it may seem overly simple to say that because opioid maintenance prevents people from dying, it supports lives in recovery. Still, this is a key truth. Beyond keeping people alive, opioid maintenance allows people to find enough stability to build new lives in recovery.

Many people believe that a person must abstain completely from all drugs in order to truly be in recovery. However, if a person in recovery from addiction needed medical treatment for diabetes and were prescribed insulin, that person would certainly not be expected to abstain from insulin for the ideal of abstinence. Nor would a person refuse needed antibiotics on the principle that they must not take any drugs if they are to be in recovery. Opioid maintenance is no different from these examples of medication for medical necessity.

A person in opioid maintenance treatment is not high. The steady dose of a partial or full-agonist opioid basically establishes a “new normal” biologically – biochemically – without which normalcy is disrupted. A person with depression who benefits from an anti-depressant is said to have a chemical imbalance, which is stabilized by the anti-depressant. Similarly, a person with an opioid addiction has a chemical imbalance from chronic opioid use, and may be unstable without some level of continued opioid administration.

People in recovery from opioid addictions will still need to do everything a healthy person must do to survive and succeed, such as keep a job, pay bills, provide child, pet, or elder care, or maintain a household. In order to be stable enough to manage all of these challenges and the attendant stress, people in recovery from opioid addictions need access to opioid maintenance.

To Sum it Up

  • People with opioid addictions are at risk of dying. As health professionals, concerned citizens, or families and friends, we owe it to people with opioid addictions to do what we can to prevent this.
  • Buprenorphine/methadone maintenance is the only evidence-based treatment that reduces death risk by 50%. To prescribe other treatments without considering maintenance is, frankly, malpractice.
  • People are not high when taking buprenorphine or methadone as prescribed. Opioids produce tolerance in the human body, such that consistent doses no longer make the person high.
  • Opioid maintenance treatments include measures to prevent or discourage misuse. Buprenorphine, as a partial agonist, has a “ceiling” dose, beyond which further amounts have no effect. Suboxone discourages injection misuse by the action of naloxone, which precipitates withdrawal symptoms in opioid dependent individuals. Methadone is primarily delivered in controlled, daily doses in a clinical setting.
  • Addiction is different from dependence. Addiction involves a learned behavior that continues despite negative consequences. Dependence is only the body’s physical adjustment to a drug, and can happen without addiction. Unlike addiction, dependence does not involve persisting in use despite negative consequences.
  • Maintenance disrupts addiction because doses are not rewarding and are not associated with addiction cues. People in opioid maintenance programs are receiving their stable doses of methadone or buprenorphine under very different circumstances than their usual addiction-related rituals. By disrupting the patterns of addiction and providing doses that are not rewarding (do not get the person high), maintenance maintains tolerance and dependence without maintaining or creating addiction.
  • Indefinite maintenance allows people to focus on improving their lives in recovery. Opioid maintenance treatments allow people to lead lives in recovery without worrying about coping with withdrawal symptoms or risking fatal overdose. In the event of a relapse, people can focus on learning which cues to avoid next time – how to prevent another relapse – rather than recovering from a severe overdose or dying.

Further reading:

Why We Have Wait Lists for Opioid Addiction Treatment

What the Opioid Epidemic Means in Virginia

How Ithaca, NY is Addressing America’s Opioid Epidemic

Addiction or Dependence: A Life and Death Difference

How to Talk with Someone About Getting Help with Addiction

This post was last updated on 10/27/16.

Addiction or Dependence: A Life and Death Difference

In the 1980s, when addiction science professionals sat down to agree on terminology for the DSM-IV, the room decided by only one vote to call addiction “dependence.” The issue did not rest there. The latest Diagnostic and Statistical Manual of Mental Disorders, DSM-5, labels addictions as “substance use disorders,” because “dependence” does not quite cover what addiction really is.

Addiction and Dependence : Apples and Oranges

Dependence is when a person becomes physically reliant on a substance, and experiences withdrawals without it. While dependence often happens as addiction develops, full addiction is much more complex, and is defined by continuing to use drugs or engage in behaviors despite negative consequences.

As an example, physical dependence can happen with many different medications. People who take antidepressants, for example, become dependent on them and undergo withdrawal symptoms if they stop taking the medications. In this case, these patients are dependent on antidepressants but are not addicted to them, and antidepressants are not considered to be addictive.

People in pain go to their doctors for relief, take pain medicine as prescribed, and if they take it long enough, their bodies get used to the medication, expect it, and throw a fit without it. When (if) their chronic or acute pain is over, doctors know to taper patients from pain medicine if physical dependence happens, and to treat withdrawal symptoms to ease the process. The patients may or may not know they are feeling sick because of withdrawal, but if they are otherwise happy in their lives they won’t bother with trying to find opioids illegally on the streets.

They do not persist in using the drug despite negative consequences, which defines addiction. They were dependent on the drug, but not addicted to it.

(Note: Among pain patients prescribed pain medication, only 8-12% develop addiction. Maia Szalavitz reports for Scientific American that “75 percent of all opioid misuse starts with people using medication that wasn’t prescribed for them—obtained from a friend, family member or dealer.”)

Addiction develops in 10-20% of people when multiple risk factors coincide with drug use (whether prescribed or recreational). If people have genetic predispositions, a history of trauma, and/or mental illness(es), they will be vulnerable to developing addiction. Even for these individuals, addiction takes time as they learn to associate the substance or activity with pleasure or relief, and the absence of the substance or activity with misery.

Individuals addicted to opioids are usually also physically dependent on them. Often a first line of treatment is to enter people with opioid substance use disorders into detox, where withdrawal symptoms may be treated while the person is monitored by medical staff. What happens next unfortunately depends on which doctor is managing the case (not all treatments are equally effective).

But to whatever treatment they are referred, individuals with opioid use disorder are at risk for relapse long after withdrawal symptoms are gone. This is why addictions, or substance use disorders, are very different from physical dependence. Once a person has gone through withdrawals and been abstinent from the substance for a period of time, the body readjusts and is no longer dependent on the substance. But people with substance use disorders still crave the drug.

Moreover, with certain drugs, like opioids, the body builds up tolerance with repeated use, which means the drug no longer affects the body unless the dose is increased. When a person enters a period of abstinence, their tolerance drops substantially.

Sadly, people with opioid use disorders often relapse and die when trying abstinence-based treatment, because they’re still addicted and their tolerance is gone. When they take the opioid at their usual dose, they overdose. What was once an okay amount is now fatal. Buprenorphine and methadone maintenance are recommended to keep people alive by keeping tolerance stable (without being high). Life-long maintenance may be necessary. If a person is tapered or otherwise terminates maintenance treatment, they are at higher risk of fatal overdose.

In the case of addiction, distinguishing between “substance use disorder” and “dependence” is a life and death debate. Understanding that substance use disorders – addictions – are more than physical dependence means we will help these individuals long after withdrawals are gone and for as long as they need treatment.

This post was last updated 5/4/17.

Are Twelve Step Approaches Evidence-Based for Addictions Recovery?

For a long time since Bill Wilson and Dr. Bob Smith founded Alcoholics Anonymous (AA) in 1935, AA’s twelve steps were the standard of care in addictions treatment. AA is a mutual help group for people with alcohol use disorders, guided by standard literature and twelve steps aimed at helping people make amends, develop spiritually, and connect with others in similar situations.

Original 12-Steps of Alcoholics Anonymous

AA’s model has been adopted by other groups such as Narcotics Anonymous (NA), Gambler’s Anonymous (GA), Overeater’s Anonymous (OA), and other variations. In each case, these groups continue to rely on the twelve steps, with minor adaptations, and have been generally known as 12-step support groups.

People in 12-step groups help each other with bits of collective wisdom beyond official literature, including the admonition to change “people, places, things” to remove triggers for use; the acronym HALT, reminding members never to get too Hungry, Angry, Lonely, or Tired; and the serenity prayer:

God, grant me the serenity to accept the things I cannot change,
Courage to change the things I can,
And wisdom to know the difference.

While meeting formats vary, they tend to include members sharing about their experiences and struggles while living in recovery and readings and discussions of the 12-step literature. Twelve-step groups also encourage members to find sponsors to provide advice based on their own recovery experience. Generally, people who have been abstinent for awhile become sponsors for other, newer members.

Many hundreds of people have testified that 12-step support groups saved their lives, and some scientific research seems to support the efficacy of 12-step groups (Humphreys et al., 2014Witbrodt et al., 2014; Moos & Moos, 2006).

Other people have criticized 12-step groups, pointing to the high rates of dropout, the heavy spiritual and moralistic emphasis, the inconsistent and contradictory logic in its literature, and the variability of groups depending on who is in them. Furthermore, about half of women who have participated in AA have experienced “13th-stepping,” the practice where group members, usually men, target new members, usually women, for dating or sex. In some cases this common practice has resulted in rape.

Despite their limitations, 12-step support groups remain an important part of many peoples’ lives in recovery, particularly if they feel belonging to their group. Research shows that social support is an important part of recovering from addiction. People who are a part of a strong group of people committed to sobriety are more likely to stay abstinent than people surrounded by old friends who may still be drinking or drugging.

Twelve-step groups are not the only addictions support group option, however. For people who want the social support without the spiritual emphasis, other mutual help groups exist, such as SMART Recovery (Self-Management and Recovery Training) and Moderation Management.

The Minnesota Model and Modern Rehab

The ubiquity of 12-step support groups was expanded to treatment in the 1950s by the Minnesota Model, a 12-step-based program developed by two people (not yet trained in addictions) working in a state mental hospital that was quickly adopted by the Hazelden Foundation, one of the oldest and most well-known rehab centers. The Minnesota Model is an intensive program including mandatory 12-step meetings, lectures, and counseling.

Rehab centers like Hazelden provide this type of care for 28-day periods on an inpatient basis. For many people with addiction, inpatient rehab may be their first contact with addictions treatment. Rehab centers have been criticized for high relapse rates, and for not following up with patients following discharge. Research on the efficacy of standard, 28-day rehab programs is notoriously scarce.

Twelve Step Facilitation (TSF)

Much later, in the 1990s, Twelve Step Facilitation was developed as a standardized adaptation of 12-step support groups, intended as an early, individual therapy delivered by a counselor. TSF helps to introduce many of the concepts of 12-step support groups, and encourages patients to engage in support groups following therapy. However, TSF is distinct from AA and other 12-step support groups.

“TSF is not officially related to or sanctioned by AA. It is available as a manual for standardized use by addiction treatment facilitators with a focus on abstinence as a treatment goal. Participation in AA meetings and other official AA activities (such as service and AA social events) is encouraged as a means to that end.” – Nowinski, Baker, & Carroll, 1999.

Some studies have demonstrated that Twelve Step Facilitation has helped people use 12-step support groups to support abstinent lifestyles, though when compared with TSF, cognitive behavioral therapy may be better for long-term support. As a first step toward engagement in 12-step support groups, TSF seems to be helpful and is often used in inpatient rehab settings.

Despite the ubiquity of 12-step groups and programs, scientific studies evaluating how well they work have not yet established, conclusively, whether 12-step-based approaches are effective. Reviews of the literature find mixed results, with some studies finding positive effects, some finding negative effects, and some detecting no statistically significant influence. Studies face methodological challenges (particularly self-selection bias), and most often do not distinguish between 12-step support groups, inpatient rehab, and TSF (perhaps because their content is so similar).

The first mandate of medical treatment is to do no harm. Because some studies have found 12-step programs to be detrimental to people, and because their effects are otherwise inconsistent and inconclusive, 12-step-based treatments cannot be considered to be evidence-based. Evidence-based treatments for addiction do exist, and include cognitive behavioral and dialectical behavior therapies, mindfulness training, and a range of pharmaceutical treatments. Typically, addictions treatments must be individualized, and must account for the type of substance or behavior used, co-occurring mental disorders, and trauma history.

With a scarcity of evidence, treatment providers must decide on a case-by-case basis whether 12-step groups, inpatient rehab, TSF, or some alternative is best for a person in recovery. Twelve-step groups and facilitation do work for many people, but they are not for everyone.

The primary benefit of 12-step support groups and programs is subjective, depending on the quality of the human relationships in a given group and on the importance of spirituality to the person in recovery. Social support is recommended for people in recovery from addictions, but other mutual help groups may provide this without the problematic aspects of the 12-step approach.

After extensive research, the most balanced recommendation I can make is if you are a person in recovery, consult your doctor first, and choose the treatments that work for you. The goal is to create a stable and positive life in recovery, and if a treatment is not adding to this goal, it is not for you. In this case, if the medicine tastes bad, it is bad.

If you are a treatment provider or a drug court judge, please be advised that 12-step groups and programs are not evidence-based, may sometimes do harm, and therefore, if recommended at all, should be one of many treatment and recovery support options offered.

I wrote this post following a discussion with Anne Giles, in which she requested balanced research on the efficacy of and difference between 12-step support groups, inpatient rehab, and Twelve Step Facilitation. The positions I take in this post are mine, and cannot speak for her, or for Handshake Media, Inc.