A Guide for Clinicians to Initial Treatment for Alcohol Use Disorder

“Evidence-based treatment” refers to specific treatment protocols that research scientists, through rigorous research methodology, have found work for most people most of the time, better than other treatments, and better than no treatment. Research, by design, reports on groups, not on individuals.

This guide is comprised of evidence-based treatment components, rather than belief-based or theory-based components. This guide, as a whole, has not been tested by research scientists, and therefore it cannot be termed “evidence-based.” It is, however, meticulously researched to include what the latest research reports is most effective. It is intended for informational purposes only and is not a substitute for individualized medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

The intended audience is counselors and clinicians who provide care for people with alcohol use disorders. Individuals and family members investigating current, evidence-informed alcohol use disorder (AUD) treatment may find the content useful as well.

Given that only one in ten Americans with substance use disorder receives treatment, and the contact a clinician has with a client may be brief, even one-time only, this guide is intentionally brief. It is a work in progress. It is updated as the latest research on AUD is published and the author reviews it.

Introduction

The Surgeon General’s report, Facing Addiction in America, released in November, 2016, recommends a multi-pronged approach to addiction treatment, in this priority order:

1) medical care, initially from a primary care physician (PCP), to be assessed for a) suitability for medications, b) co-occurring or underlying physical conditions that may be causing stress or distress, including physical pain, and c) co-occurring mental illnesses that may be causing stress, distress, or instability.

2) individual counseling;

3) recovery support services (RSS) to reduce life stressors. Based on clients’ individual preferences, recovery-specific support group attendance may be part of RSS.

Alcohol use disorder (AUD) is defined as a disorder of the organ of the brain which requires medical treatment. Given the nature of the substance, abstinence, rather than harm reduction, is the recommended long-term treatment goal for AUD. Unfortunately, unlike with opioids, no safe dosing of ethyl alcohol exists.

The cognitive functions a person with AUD and other substance use disorders would need for abstention are the very ones impaired by the disorder itself: choice, decision-making, and recognizing the need for change, planning for it, and executing it. The neurobiology of addiction compromises the brain’s basal ganglia, extended amygdala, and prefrontal cortex and, thus, under-sensitizes one to pleasure, over-sensitizes one to pain, automates use of the substance to feel normal, weakens decision-making abilities, magnifies emotional highs and lows and incapacitates the ability to regulate them, interferes with recognizing cause-and-effect relationships, and confounds the ability to make a plan and follow through with it.

“People suffering from addictions are not morally weak; they suffer a disease that has compromised something that the rest of us take for granted: the ability to exert will and follow through with it.”
– Nora D. Volkow, M.D, Director of the National Institute on Drug Abuse (NIDA), quoted in What We Take for Granted

Other than with 1) medication and 2) time without exposure of the brain to the substance, brain structures and pathways impaired by AUD currently cannot be directly, immediately and efficiently treated for AUD. Therefore, individuals’ self-care efforts and counselors’ therapeutic efforts will focus on supporting abstinence rather than on attempting to directly treat the brain for addiction.

Alcohol use, even in small amounts, can compromise brain functioning and physical health. In those with alcohol use disorder, physical and behavioral symptoms can be life-threatening to themselves and others. Alcohol withdrawal can be a dangerous, deadly medical condition. Even nurses can be challenged by the symptoms. If a client needs emergency care, call 911. If a client needs urgent care, arrange for it.

The following guide applies to clients who are stable and not in need of urgent or emergency care.

Medical Care

Assist individuals with procuring health insurance and making appointments with medical professionals, beginning with the primary care physician (PHP). If the client does not have health insurance, query community sources for assistance.

(This is normally in the realm of case management rather than traditional clinical sessions, but helping the individual make the phone calls and appointments accommodates possible cognitive impairments associated with use and/or early abstinence. If it’s a personal fit for clinicians, they may consider accompanying individuals to medical appointments.)

Ask non-abstaining clients to keep a log of their consumption of alcohol.

Ask clients to make a rank-ordered list of physical symptoms that cause them stress or distress. (Include physical pain and issues with sleeping and/or eating.)

Ask clients to make a rank-ordered list of mental or psychiatric symptoms that cause them stress or distress.

Help clients compile this data: 1) consumption log (if applicable), 2) physical symptoms, 3) mental or psychiatric symptoms.

Coach clients in advocating for evidence-based treatment when they meet with their PCP. Few PCPs have time to stay up-to-date on the latest in addiction treatment given most work overtime to meet the demand for health care which exceeds capacity. Unfortunately, many PCPs continue to hold the belief that alcoholism is a personal, moral or mental problem rather than a medical one.

In the brief appointment clients will have with PCPs, they need to try to make these things happen:

1) Ask to be assessed for medical management of tapering and for medical management of potentially dangerous withdrawal symptoms, including a cost-benefit analysis of the risks of outpatient detox vs. highly stressful and disruptive inpatient detox.

Evidence-based guides to self-tapering from alcohol do not exist. This source, however, may be a place to begin for patient and physician to co-create a tapering plan based on the individual’s alcohol consumption log. Attending rehab is not an evidence-based method for achieving abstinence from substances.

2) Ask to be assessed for medications that assist with abstinence, based on use as recorded in the log. For some patients, naltrexone can be prescribed prior to abstinence, potentially improving progress towards abstinence.. (Here’s an NPR story on naltrexone for AUD.)

3) Ask to be assessed for blood work and for other diagnostic assessments to begin to treat the top items on the list of physical symptoms, or to begin to find the origins of the physical symptoms that are most problematic. Present a copy of the physical symptoms list for reference.

4) Ask for a referral to a psychiatrist now to get on the wait list for an appointment (local wait is 6-12 months). Present a copy of the psychiatric symptoms list for reference.

5) Keep the end in mind, i.e. accomplishing the tasks above, and stay self-regulated if – unfortunately possible – moralistic, judgmental, admonishing, shaming or dismissive statements are made by medical professionals during the appointment, or if follow-up treatment is delayed.

6) Make an appointment now for a follow-up visit with the PCP.

“Do not attempt to take away a person’s main means of trying to cope with pain and suffering until you have another effective coping strategy in place.”
– Alan Marlatt

Prior to the appointment with the PCP, provide clients with copies of these summary reports on first-line medications for AUD to take with them to offer as reference material if needed:

Fewer than 10% of people with AUD are offered or receive medications to treat the illness. Scientifically sound studies of the comparative efficacy of naltrexone, acamprosate, disulfram and gabapentin do not exist, although one study does compare naltrexone and camprosate. Finding the right medication, or combinations of medications, for each individual takes time.

At risk for premature death from an acute state of AUD, many clients do not have time for trial-and-error experimentation. They may have complicating physical and mental disorders as well. An expert medical opinion, ideally from a physician or psychiatrist, is crucial. We may only have one chance to medically assist a client so we need the most informed, experienced medical advice we can access on the client’s behalf.

Counseling

According to research, individual counseling is more effective than group counseling in helping people with substance use disorders achieve and maintain abstinence. Cognitive behavior therapy (CBT) and related dialectical behavior therapy (DBT), are the therapeutic modalities associated with abstinence. (Here’s a helpful self-directed guide to DBT.) Stress, distress, and exposure to environmental cues are the primary precursors for a return to use.

A fundamental skill a person with AUD needs to acquire to increase the likelihood of maintaining abstinence can be termed “self-regulation.” Individuals who can self-regulate emotions, cognitions, attention, as well as moderate ways of relating to self and others, may limit or prevent the escalation of stress or distress to the state of near-dissociation in which a return may occur.

Trained counselors can assist clients with AUD by assisting them with developing self-regulation skills. Therapeutic rapport can help mitigate the stress and distress inherent in therapy and treatment.

In individual counseling sessions, or group sessions if individual sessions are not available – taking into account cognitive limitations resulting from recent use and/or early abstinence – clinicians can assist clients increase responsiveness (vs. reactivity) to stress and distress, thus to decrease the likelihood of a return to use. Helping clients develop self-regulation requires a shift from focusing on anticipated “people, places and things,” “triggers,” or “choices,” to focusing on using self-regulation in highly unpredictable circumstances, whether with a person, a trigger, or otherwise (see Kaye, et al., 2017).

Since an estimated 70% of people with substance use disorder have experienced trauma, clinicians need to assess for trauma and, if present, given the likelihood of only a few therapy sessions, attempt to provide evidence-based, brief trauma therapy. (Brief interventions are few in number and are still being researched.)

Since approximately half of people with substance use disorder have co-occurring mental illnesses, clinicians need to assess for co-occurring disorders, particularly severe mental illnesses (SMIs) which may qualify clients for additional services.

Since substance use disorder is a 24-7 condition and manifests outside the clinical setting, inform and coach clients on self-care practices that support abstinence.

Recovery Support Services

Query clients about what external factors cause stress and distress in their lives. Ask clients to rank order them, then ask what small improvement would decrease stress or distress in the top three. Take steps to make the improvements happen that are beyond the client’s personal resources or network of connections, or help the client to make them happen.

Assist clients with exploring diverse interest groups, clubs, religious groups, support groups and/or other sources of social connection based on their individual interests and preferences.

Invite clients to attend support groups. (Choices in the author’s locale for recovery-specific support groups, in order of estimated numbers of attendees per year, are Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery and Celebrate Recovery. Information on local groups is here.)

On a case-by-case basis, support group attendance may be helpful to some individuals with maintaining abstinence. Support group attendance is not, however, an evidence-based treatment for the medical condition of addiction, any more than support group attendance would be treatment for the medical condition of cancer, diabetes, or other dangerous medical conditions.

Connect clients with social services agencies to assist with current stressors and needs such as employment, housing, transportation, child care, and legal issues.

“Love, evidence & respect.”
– Maia Szalavitz, via Twitter, in response to the question, “What fights addiction?”

Disclaimer: The views expressed are the author’s alone and do not necessarily reflect the positions of the author’s employers, co-workers, clients, family members or friends. 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.

Reports on substance use disorder research and treatment by Handshake Media are here.

Some Conclusions about Addiction from a Look at Some Numbers

Substance use disorders

Conclusion: Even when exposed to substances that can be used in ways that cause problems, most people don’t become addicted to them. Most people who develop addiction have problems already.

Note: For an individual, dependence, i.e. experiencing withdrawal symptoms without the substance, is not addiction, i.e. feeling compelled to persist in a behavior despite negative consequences.

Opioid use and opioid use disorder

  • 1 in 100 Americans, 12 and older, met the diagnostic criteria for opioid use disorder in 2015 (0.2 percent for heroin use disorder, and 0.8 for pain reliever use disorder). (Source)
  • 75% of people with prescription opioid addiction obtained the substance from a family member or a friend, not from a doctor. (Source)
  • 92% of people exposed to prescription opioids do not become addicted to them. (Source)
  • Heroin addiction is more than three times as common in people making less than $20,000 per year compared to those who make $50,000 or more. (Source)

Conclusion: Even when opioids – created by pharmaceutical companies – are prescribed by doctors, most people don’t become addicted to them. And socioeconomics matter.

Numbers from the New River Valley of Virginia

  • 16,000+ people in the New River Valley have alcohol and other drug problems. (Source)
  • According to local sources*, in 2015, the New River Valley had 34 cases of opioid overdose. Among those were 3 cases of heroin overdose, and 5 cases of fentanyl overdose.
  • According to local sources, in 2015, 11.4% of New River Valley high school students had misused prescription drugs in the past 30 days to “get high.” The national average is 3.2%. In 2015, 5.6% New River Valley high school students had used heroin at least once in their lifetimes. The national average is 3.2%.

Yearly death total statistics that make – and don’t make – the news in the U.S.

  • Marijuana overdose deaths: 0 (Source)
  • Terrorism-related deaths, U.S. citizens, overseas and domestic: 32 (2014: Source)
  • Opioid-related deaths: 35,000 (2015: Source)
  • Gun-related deaths: 35,000 (2014: Source)
  • Alcohol-related deaths: 88,000 (2015: Source)
  • Obesity-related deaths: 300,000 (Source)
  • Tobacco-related deaths: 480,000 (Source)

Conclusion: The selection of subjects covered by the media may not be due to high death rates.

*Grateful acknowledgement is made to New River Valley Community Services for synthesizing data from multiple sources for this post.

Laurel Sindewald contributed to the research for this post.

This post was prepared as part of a packet of handouts for a talk on the opioid epidemic by Anne Giles for the Montgomery County, Virginia Democratic Party on 8/17/17.

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.

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

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 8/15/2017.

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.

A Brief Guide to Evidence-Based Self-Care for Recovery from Addiction

Intended to supplement medical and professional care for substance use disorders, this guide offers a brief, straightforward distillation of the latest information and research on addictions recovery self-care.

Organized in a series of three handouts, the guide offers compassionate, supportive assistance to individuals with substance use issues who are already receiving medical and professional care. Professionals and concerned others may want to offer it as a link or printed packet. Passages are stated simply, but link to authoritative sources for corroboration and further exploration.

Self-help does not equal treatment. Substance use disorders are complex health conditions requiring medical and professional care.

The handouts were originally written by the author as personal guidance after extensive reviews of the research on addiction, hence the use of the pronoun “you,” but they are for informational purposes only and are not a substitute for individualized medical or professional advice. Individuals are urged to consult with qualified health care professionals for personalized medical and professional advice.

Original segments of this post were first published by The Fix here, here and here.  This post was last updated 7/18/17.

. . . . .

A Brief Guide to Evidence-Based Self-Care for Recovery from Addiction

Handout 1

“Love, evidence & respect.”
– Maia Szalavitz’s answer via Twitter to the question, “What fights addiction?”

1.  Who you are does not cause addiction.

2. Nothing bad you have done, nor good you failed to do, caused addiction.

3. You do not deserve addiction, nor do you deserve not to have addiction. It’s just an unfortunate condition having no moral value one way or the other.

4. You are not the problem. Addiction is the problem. Let’s see what we can do to solve or improve this for your unique, individual situation. And we’ll do this with compassion. As Maia Szalavitz writes, “To return our brains to normal then, we need more love, not more pain.”

We need more love, not more pain

“…we need more love, not more pain.” – Maia Szalavitz

5. Get medical care for the medical condition of addiction. Forced abstinence can result in dangerous withdrawal symptoms, decreased tolerance and increased craving, an intolerable emotional and mental state, and risk of a dangerous, potentially deadly, return to use.

6. Symptoms of addiction can appear as thoughts, words, and actions perceived as irrational, anti-social, and immoral. Addiction is not, in and of itself, a thought problem, a moral problem, a spiritual problem, a mental illness, or a behavior problem. Addiction is not a personality type. It’s a brain condition, contentiously defined, uncertainly located, and uncertainly targeted for treatment, but detectable in the brain at the minutest level.

7. Unfortunately, at this time, we know of nothing you can specifically do on your own to immediately and directly treat, cure, or reverse malfunctions in brain structures associated with addiction. Until we can identify exactly which brain structures and circuits to treat with medications, stimulation or probes, and what beneficially modifies them, for now, other than directly through the medications we know of, we’ll have to use indirect means.

8. However, what can directly administer care to brain structures is protecting them from problematic substances. That’s why obtaining medical care and professional help to assist with abstinence or harm reduction is critical. Over time, helpful changes may occur in the brain in the absence of overwhelming or damaging substances.

9. Focus maximum effort on becoming aware, very specifically, of what helps you stay abstinent and what does not. If you’re practicing harm reduction, discover what helps you use less, less often, or use less problematic substances. Acute awareness takes painstaking attention, but the logic is simple. If you can become aware of inner and outer conditions that precede use, you may be able to do something about them. If you don’t know, you can’t.

10. Needing or wanting to abstain, and firmly deciding and being resolved to quit, unfortunately – as you know from former heroically determined efforts to quit followed by heartbreaking returns to use, all explained by the brain science of addiction – aren’t sufficient to achieve abstinence.

11. You must learn what each substance did for you or meant to you, how you related to it, how it worked for you, and how it eased or enhanced your experience or your life. Discovering this, and finding alternate ways to get your needs met, is difficult but worthy, essential work. Again, the logic is simple. If you can learn what substances did for you, and find alternate ways to get most of that done – regrettably, possibly never again to the extent substances did – you’re more likely to be able to do without them.

12. Repeat: Go to a doctor. Although medical treatments for directly treating the brain for most substance use disorders are currently unknown (however, methadone and buprenorphine directly affect brain areas involved in opioid use disorder), several medications can be helpful with creating the stability necessary for intensive self-learning. In addition to being assessed for medication-assisted treatment (MAT), ask to be screened for mental illnesses and physical illnesses that might be causing conscious and unconscious stress and distress, the primary precursors to a return to use. (If you don’t have health insurance and can’t afford to self-pay, try to find local organizations that will help you get health insurance or help you with costs for medical care.)

13. Abstain from self-judgment. Become aware of a learned pattern of self-harshness, now nearly automatic. It feeds shame, a primary source of inner distress. Self-discernment is a compassionate process of discovering one’s strengths. In contrast, self-judgment cruelly weakens, reduces and demoralizes. As Maia Szalavitz urges, treat yourself for addiction by loving yourself, getting evidence-based care, and respecting the gravity of this illness and the heroic effort required to handle it.

Turn towards reality and truth

Turn towards reality and truth, not away from them.

Handout 2

“Addictive disorders are a major public health concern, associated with high relapse rates, significant disability and substantial mortality. Unfortunately, current interventions are only modestly effective. Preclinical studies as well as human neuroimaging studies have provided strong evidence that the observable behaviours that characterize the addiction phenotype, such as compulsive drug consumption, impaired self-control, and behavioural inflexibility, reflect underlying dysregulation and malfunction in specific neural circuits.”
– Spagnolo and Goldman, 2017

“[W]hat if the negative thinking patterns, feelings, and behaviors that keep them stuck have powerful, unconscious advantages serving vital, even life-preserving purposes?”
David Burns, 2017

“People may not have caused all of their own problems, but they have to solve them anyway.”
Marsha Linehan , 2012

1. Expect to feel shock, grief, rage and other strong emotions over the before-and-after states addiction brings to your life. Practice self-kindness and self-compassion and find others who can support you when you experience these.

2. Seek stability. Become aware of how you define stability, what individually helps you achieve and maintain stability (emotionally, mentally, physically, occupationally, relationally, situationally), and try to make these happen for yourself. Suppression, repression, avoidance and obfuscation can backfire and destabilize. Turn towards reality and truth, not away from them. (If you have concerns about whether or not what you’re thinking is real or true, see #5 below.)

3. Get counseling. At this time, it is not known if counseling directly treats the brain in an efficient, targeted way for addiction. (For opioid use disorder, for example, multiple studies fail to prove that counseling with medication increases abstinence rates over medication alone). But counseling can help people maintain abstinence, often by assisting with awareness. The main precursors to a return to use are stress, distress, and environmental cues. Environmental cues include being around substances, in situations, and with people associated with use. Make sure the counselor offers an evidence-based therapeutic approach. The Surgeon General’s report, Facing Addiction in America, lists cognitive behavior therapy, CBT, as the top evidence-based counseling approach for assisting people with addiction maintain abstinence or harm reduction. Dialectical behavior therapy, DBT, also included in the report, is increasingly proving effective as well.

4. The more you can 1) learn to become aware of, and regulate, your inner experience of feelings, thoughts and physical sensations – optimally for you individually, not by someone else’s methods or criteria, 2) discover what needs you personally have and what uniquely and healthily meets them, and 3) help yourself avoid environmental cues or manage exposure to them, the more likely you are to be stable and, therefore, the less likely you will be to use.

5. Run even your simplest ideas by others before taking action. Your thinking may not be as clear as it will be in the future.Consulting others will help protect you from error.

6. Seek contact with people who help you clarify your feeling and thinking, who are non-judgmental, and with whom you feel safe and supported. Become aware of how you feel about yourself when you’re talking with anyone and everyone. If you don’t feel good, however you might define “good,” that’s stressful and potentially destabilizing. Find a way to have limited or no contact with those with whom you feel unsafe and unsupported, at least in the short-term.

7. Listen for fact vs. opinion when people talk with you about addiction. Are they sharing the latest science  and research reports on addiction or are they sharing opinions based on beliefs, personal experiences or outdated information? If they’re sharing an opinion, do they acknowledge it as such and explain how they derived it? Or are they stating opinions as facts? Practice caution and care with whom and with what you let into your vulnerable mind and heart.

8. Practice engaging, disengaging, and shifting your attention. Discover and focus your attention on what is preferable to you, rather than attempting to force your mind to think what you believe will please or protect, or letting it grind in patterns that have simply become habitual rather than helpful. This power over your attention can give you enormous power to enjoy your life, to assist yourself with enjoying the company of others, and to increase others’ pleasure in your company. Impossible as it sounds, exercising your power to focus your attention may exercise brain functions atrophied from substance use. Many people with substance use disorders have experienced trauma and find using the mind for meditation distressing. Meditation, therefore, may not be advised. Marsha Linehan, inventor of dialectical behavior therapy, DBT, recommends what she terms “mindfulness” instead. A simple, DBT-based mindfulness practice involves using your attention to observe what’s going on within and without and to describe those to yourself. (Here’s a brief YouTube video of Marsha Linehan explaining mindfulness, part of a series of videos on the core principles of DBT.) Some people find the Headspace app helpful.

9. Become aware of what helps you feel better. Whether it’s just for a few moments or for longer, become aware of what uniquely helps you via your senses – sight, hearing, smell, touch, taste – to ease, reassure, and comfort yourself. Google the term “self-soothing” and you’ll find lots of ideas to try.

10. Believe that you, yourself, can do this. In addictions recovery circles, you may hear about admitting powerlessness, surrendering, relinquishing control, and the dangers of “self-will.” The opposite is true. The more self-aware you are and the more self-power you see yourself as having – the more “self-efficacy” you possess – the more likely you are to stay abstinent. You be you.

11. Practice “love love”  not “tough love” with yourself and others. “Tough love” is a euphemism for smiling while wielding a 2″ x 4″ of hostile methods to exert psychological control. Practice self-kindness and other-kindness. And distance yourself from those who profess to be treating you with the “tough love” they think you “need” or “deserve.” In fact, with the whole concept of “tough love,” practice hostility. But briefly. Then compassionately self-regulate and return your attention to recovery-enhancing stability.

Seek out supportive others

Seek out supportive others.

Handout 3

“…but seven years is long enough and all of us
deserve a visit now and then
to the house where we were born
before everything got written so far wrong”
– Peter Meinke, “Liquid Paper”

“The most natural way for human beings to calm themselves when they are upset is by clinging to another person.”
– Bessel van Der Kolk, M.D., The Body Keeps the Score

“Do not attempt to take away a person’s main means of trying to cope with pain and suffering until you have another effective coping strategy in place.”
Alan Marlatt

“I don’t believe in getting ‘in the moment’ and then exercising will-power. I believe in avoiding ‘the moment.’ I believe in being absolutely clear with myself about why I am having a second drink, and why I am not; why I am going to a party, and why I am not. I believe that the battle is lost at Happy Hour, not at the hotel. I am not a ‘good man.’  But I am prepared to be an honorable one.”
Ta-Nehesi Coates

“It’s my life. Don’t you forget.”
Talk, Talk

1. Attach to yourself. Discover the curl within you of your truest self, “before everything got written so far wrong.” Gently begin to view yourself as someone with whom the vulnerable essence of you can feel safe. Many people with addiction have experienced abuse and neglect from caregivers  and have attachment challenges. What shouldn’t have happened did, and what should have happened didn’t. They may feel undeserving and unqualified to care for themselves. They may believe they can’t be entrusted with themselves and fear the piece-of-shit messages they’ve heard all their lives might be true. Given what many people have been through, having these beliefs is sadly understandable. Still. Kindly and protectively begin to identify yourself more by who you are, and less and less by what you’ve done or what has happened to you.

2. Take care of yourself. Try to imagine finding the truth of who you are showing up as a foster child on your doorstep right now. What do you need?! What do you want?! Remember the best of what you’ve learned, experienced and observed. Start with basic needs. Do you need to be invited in or given some time to adjust? Do you need something to eat, a nap, something interesting to do, a hug? Experiment and see what seems to work. What a huge responsibility! But what a relief! Finally, finally, after all that’s gone down, you can have your own consistent, kind, reliable, present, attentive caregiver who knows you better than anyone else on the planet and who wants the best for you, no matter what. And you don’t have to be a perfect self-caregiver. Good enough will do. Addiction – like life – is a 24-7 condition and other people aren’t always available to help. But you can be there for yourself. Whenever you need or want to, you can cling to your own good-enough self.

3. Seek out supportive others. Social connection can assist with abstinence. Stress and distress are part of human relationships, but the benefits of de-stressing need to outweigh the costs of stressing. No gathering with others will leave you stress-free. The goal is to find people with whom – enough of the time – you can feel good enough and safe enough to feel stable.

4. Try a variety of places and situations in which people gather in groups without use of problematic substances. Consider asking someone you trust to accompany you. Become aware of how you feel afterwards. If you feel neutral or better, you might return. If you feel worse, try another group, or, perhaps, try it a few more times and see. Keep visiting groups of any kind, whether recovery support groups, community groups, or hobby groups, until you find places that feel safe, supportive and helpful. If you don’t find established groups that are a fit for you, try to find individuals with whom you can meet one-on-one or in small, informal groups.

5. To further develop stability, establish priorities, schedules, routines and budgets. Figure out what you can do at the same time each day that’s helpful and do those things. Become aware of foods that fuel you and create a menu for yourself featuring those foods. Note which physical activities support your overall energy level throughout the day and do those. Figure out how much it costs to be you and find ways to supplement what’s missing and to modify spending for shortfalls. Discover the uniqueness that is you and set yourself up individually to thrive as only you would know, understand and be able to do.

6. Use “enough” vs. “all” as a standard. While you may want to examine your values, principles and beliefs more closely and decide what might work best for you individually going forward, for now, strive to get enough of your needs met enough of the time, to feel pretty good enough of the time, and to be with people with whom you usually feel safely supported. Since no one can deliver “all,” expecting all one’s needs to be met all of the time will result in disappointment which is stressful and destabilizing.

7. Stigma is real. Give yourself private time to take care of yourself and to feel better before you consider whether or not to share your condition with others. Keep your circle of confidantes thoughtfully selected and discuss your motivations and the pros and cons of self-disclosure with trusted others when you feel or think you might want to share your situation with others.

8. Approach the idea of “acceptance” gently. Research on wisdom posits “five integral components of wisdom: emotional regulation; humor; critical life experiences; reminiscence and life reflection.” Research on emotion regulation equates acceptance and regulation, i.e. rejecting what is upsets; accepting what is calms. Acceptance is not approval, agreement, or taking responsibility for what is or what happened. It’s just a simple acknowledgement: The grass is green, the sun is yellow, and what happened happened and what’s happening right now is happening. Attempting to force, demand, or will oneself into acceptance, or worse, attempting to submit or surrender to acceptance – especially when others behaved unacceptably, even heinously – results in pain. As Maia Szalavitz wrote, our brains need more love, not more pain. Practice radical self-kindness when considering the idea of acceptance, radical or otherwise.

9. You are a unique individual with an individual case of addiction. What helps you with your particular case will be unique to you. You are the expert on that and, ultimately, you are the decider. As you should be. Even if you have the regrettable condition of addiction, it’s still your life, your one precious life.

. . . . .

Anne Giles, M.A., M.S., is the founder of Handshake Media, Incorporated. She is a counselor and writer and lives in Blacksburg, Virginia.

The opinions expressed here the author’s alone and do not necessarily reflect the positions of clients, employers, co-workers, family members or friends. 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.

A Packet of Evidence-Based Addictions Recovery Guidance

This post has been moved here.

 

Medication-Assisted Treatment for Opioid Use Disorder – Infographic

Medication-assisted treatment (MAT) with methadone and buprenorphine is the only known treatment – not abstinence, not counseling, not 12-step approaches – to cut death rates from opioid use disorder by 50-70% or more.

“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…”

U.S. federal officials decry opioid misuse as a public health crisis, yet federal rules limit access to the only known effective treatment. Due to federal restrictions, few health care professionals are approved to dispense methadone or prescribe buprenorphine. Further, laws dictate how many patients those few can prescribe and, increasingly to whom, in what form, and how much medication can be prescribed. People suffer, even die, on wait lists to receive medication. In contrast, countries that effectively address their overdose crises, loosen, not tighten restrictions. Indeed, Stefan G. Kertesz, M.D. states, “The dominant priority should be the assurance of subsidized access to evidence-based medication-assisted treatment for opioid use disorder.”

In the event that lack of understanding of MAT may be contributing to restricting access to it, we offer this simple infographic explaining medication-assisted treatment (MAT) for opioid use disorder (OUD).

Medication-Assisted Treatment for Opioid Use Disorder

Medication-assisted treatment (MAT) does not replace one addiction with another. It creates stability by treating the medical condition of addiction. Currently, effective medications for addiction create dependence – negative symptoms from withdrawal if doses are discontinued – but not addiction, which, per its definition, involves continued use despite negative consequences.

Tolerance occurs when people’s bodies adapt to a drug over time, responding less and less to the same dose. In order to have an effect, doses must keep increasing for people to continue to get high, or to keep from getting sick. When people use opioids regularly, therefore, they tend to use more and more of the drug over time. Even if they stop using, then return to use, they are at risk for overdose because illegal drugs are not monitored, and so they may be cut with much more powerful drugs, such as heroin with fentanyl.

(Recent increased rates in drug overdose are due to heroin and illicit fentanyl, not prescription pain medications. Reported deaths in 2015 from opioids by prescription account for under 15%. Of those addicted to prescription pain medications, 75% received them from a family member, friend or dealer, not through medication prescribed to them.)

When people with OUDs enter abstinence-based treatment, or otherwise stop using, their tolerance drops. They may not know their tolerance is diminished, or they may not know how much it has decreased, and if they take an opioid at the high dose they were once used to, they are likely to overdose and die.

People who are given MAT for OUD take an opioid (buprenorphine or methadone) at a consistent dose, which effectively stabilizes them. Once stabilized on an effective dose, they do not experience withdrawals, cravings, or highs. They can provide child or dependent care, hold a job, adhere to treatment, and comply with the law.

In contrast, people who are not on MAT will experience withdrawal symptoms and strong cravings, especially when under stress. People with OUDs permitted only abstinence-based treatment are at high risk for all of the same problems people with untreated addiction are at risk for: recidivism and crime, unemployment, contracting and transmitting diseases, overdose and hospitalization, and fatal overdose. Up to 90% of people with opioid use disorder relapse when not on medication-assisted treatment.

Maintenance may need to be long-term, or even life-long, because while addiction lasts, people who terminate maintenance treatments are at elevated risk for fatal overdose.

The US opioid epidemic has changed profoundly in the last 3 years, in ways that require substantial recalibration of the US policy response…Heroin and fentanyl have come to dominate an escalating epidemic of lethal opioid overdose, whereas opioids commonly obtained by prescription play a minor role, accounting for no more than 15% of reported deaths in 2015…The observed changes in the opioid epidemic are particularly remarkable because they have emerged despite sustained reductions in opioid prescribing and sustained reductions in prescription opioid misuse. Among US adults, past-year prescription opioid misuse is at its lowest level since 2002. Among 12th graders it is at its lowest level in 20 years. A credible epidemiologic account of the opioid epidemic is as follows: although opioid prescribing by physicians appears to have unleashed the epidemic prior to 2012, physician prescribing no longer plays a major role in sustaining it. The accelerating pace of the opioid epidemic in 2015–2016 requires a serious reconsideration of governmental policy initiatives that continue to focus on reductions in opioid prescribing. The dominant priority should be the assurance of subsidized access to evidence-based medication-assisted treatment for opioid use disorder. Such treatment is lacking across much of the United States at this time. Further aggressive focus on prescription reduction is likely to obtain diminishing returns while creating significant risks for patients.
– Stefan G. Kertesz, M.D.

People with opioid addiction can live full lives as family members and citizens. MAT benefits the general public health, employers, law enforcement, taxpayers, and the human beings who need our help.

Infographic by Laurel Sindewald. A printable .pdf version is here.

Laurel Sindewald contributed to this article.

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

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.

References

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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.