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 Some of the older epidemiological surveys available use outdated diagnostic criteria (e.g., DSM-III or DSM-IV) to diagnose addiction, such that heavy use and physiological dependence may have qualified as addiction.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.

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 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.

Anyone is welcome to use this information and a printable packet in .pdf form – 2,700 words, 6 pages – is available here. Original segments of this post were first published by The Fix here, here and here. The .pdf was last updated 5/3/17 and this post was last updated 5/3/17.

. . . . .

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 overcome 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 what you let into your tender, 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.)

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 yourself 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 others aren’t always available. 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.

9. Do your homework, honey. Whether self-assigned or suggested by trusted sources, research reports that those who do therapeutic homework fare better than those who don’t.

10. 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…”
– Maia Szalavitz

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

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 6/20/17.

12-step folding chair

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].

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.

After the Shootings: Community Violence, Collective Trauma and Addiction

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

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

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

Statue on Virginia Tech Campus

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PDF of Research Excerpts

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

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

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

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

Insights After Reporting on Addiction for 3.5 Years

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

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

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

What is addiction?

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

What causes addiction?

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

What treats addiction?

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

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

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

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

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

Why do some people with addiction behave badly?

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

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

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

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

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

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

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

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

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

Photo from Maia Szalavitz’s visit to Blacksburg, Virginia

On Counseling and Medication-Assisted Treatment

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

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

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

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

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

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

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

. . . . .

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

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

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

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

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

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

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

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

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

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

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

Laurel Sindewald contributed to the research for this report.

Last updated 6/20/2017.

Addiction Is Not a Choice

Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health makes the current discussion we have about addiction, i.e. helping people with addiction “make better choices,” “make better decisions, or “understand the consequences of their behavior” – whether coerced through drug court or supported through counseling – well-meaning but, unfortunately, irrelevant. Addiction compromises all of those functions in the brain.

The brain no longer does what it needs to do in a person with addiction, just as a pancreas no longer does what it needs to do in a person with diabetes. Medical care for a brain illness – not tough lovearrest, commitment to a mental institution, or recovery support services – needs to be the first order of treatment, including assessment for suitability for medications. Medications need to be prescribed by qualified medical professionals, not by non-qualified court officials or lawmakers.

Surgeon General: I'll stand up for recovery with you

We would rush our neighbor with acute diabetes to the doctor. Why don’t we rush our citizens with an acute brain disease to the doctor as well? Because, at essence, contrary to scientific evidence, we still believe addiction is a choice. We believe that if people with addiction could just see the errors of their ways and would work hard on those errors (rather than be lazy, immoral, selfish, self-indulgent, or inadequately faithful or spiritual), addiction would go away.

Working hard on one’s ways may help one live a better life. Might working hard to be a better person alter the brain in targeted ways that reverse or  ameliorate addiction? Possibly. Neuroscience research may ultimately support that. Certainly on ways to live a better life, many people, both with and without academic or medical credentials, can offer helpful guidance. But, for now, what we know is that addiction is a medical condition, 1 in 7 Americans is expected to get it, a person dies of a drug overdose every 19 minutes in the U.S., and only a fraction of those who need help are receiving it. For this dire medical condition, insufficiently treated such that a public health crisis has occurred, medical care is an imperative.

Do no harm” is a principle of health care. By stubbornly holding onto the concept of “choice” – in spite of the data that says we’re simply wrong to do so – we’re harming, even killing, our own citizens when we require them to, at essence “be better and do better,” rather than provide them with medical care.

May the Surgeon General’s report inform and direct the treatment we provide our fellow citizens struggling with the grave and dangerous medical condition of addiction.

. . . . .

On 11/17/16, the U.S. Department of Health & Human Services issued Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health.

Here’s a link to the YouTube video of the 3-hour presentation of the Surgeon General’s report.

Here’s Maia Szlavitz’s commentary on the Surgeon General’s report.

This post is an updated and expanded version of my letter to the editor about the Surgeon General’s report published by the Roanoke Times on 12/13/16.