We all know the standard line when it comes to addiction treatment:
Once a person is having problems with any substance or behavior they need to admit their complete loss of control and abstain from all mind-altering exposure forever if they want to have a chance at a successful life.
This is true for college students caught smoking weed or overdrinking, for people arrested for a first DUI, and for anyone arrested in possession of an illicit drug. The underlying assumption is that addiction and addiction-related problems indicate an irreversible and progressive condition that requires the complete avoidance of future exposure to mitigate. People are either addicts or they’re not, and once you cross the invisible line, you’re screwed for life.
Well I'm here to tell you that you've been sold a bad bill of goods. You've been had. You've been led to believe that anyone who is showing any trouble with alcohol, drugs, or the typically cited behaviors is by necessity an addict. You've also been led to believe that all addicts are the same. They're not. And most people who experience substance-related trouble are absolutely not addicts in the chronic, long-term, and likely unresolvable way.
In reality, substance-related problems lie on a continuum much as every other human characteristic does – height, intelligence, impulsivity and obesity are not all-or-nothing conditions and neither is addiction. In the service of simplification we’ve been mischaracterizing the very problem we’re trying to solve. We’ve been trying to amputate the leg of clients who may have simply sprained their ankle.
This is the reason behind my recent launch of an outpatient addiction treatment program in Los Angeles that does not assume our clients are chronic addicts. We offer solutions that include moderate drinking for problem drinkers and for those trying to quit other drugs but interested in still being able to drink. By reducing the stigma associated with seeking help we believe we've offering a better solution.
The evidence supporting our program and the above-mentioned facts isn't new and I've cited it before when talking about alcohol and the two (at least) very different types of alcoholics. But here's a little summary of what we do know:
1. Most people who experience alcohol related problems and who meet DSM-IV criteria for alcohol abuse or dependence at one point in their life will most likely not meet that same criteria when assessed again later in life. Even if alcohol abuse and dependence are on-again-off-again disorders experts agree that most alcohol abusers and addicts return to moderate problem-free drinking later in life.
2. Most people who try any given drug including heroin, methamphetamine, cocaine, and others do not end up developing any problems with those drugs let alone lifelong problems that would necessitate complete abstinence to resolve.
3. Most drug and alcohol abuse is not related to crime or violence although crime and violence do occur more frequently among drug users. Millions of drug users have been arrested and incarcerated over the past 30 years without much of an influence over drug use rates or reoffending for those populations. Billions of individuals have engaged in substance use without committing other crimes or engaging in violent behavior.
5. Individuals who meet criteria for the life-long chronic version of alcoholism are different in very basic ways from those who are simply experiencing alcohol-related problems.
If all of this is true, why does the notion that all substance-related problems need to be treated using the same abstinence-based low-success rate treatment methods keep holding on? There are a number of important reasons:
1. Treatment in the U.S. is far from the evidence-based, research-supported, addiction treatment that we want to believe we're offering. Some of the best and most effective treatment approaches including manual-driven cognitive-behavioral-therapy methods, motivational interviewing, and medication-supported treatment are rarely actually used by even the most expensive addiction treatment providers in the country. Read the new Ann Fletcher book "Inside Rehab" for a well-researched look at the kind of addiction treatment Americans are presently being sold.
2. Most treatment methods, including the evidence-based ones mentioned above, were developed on the most serious addicted populations. These are the addicts who ended up in jails, prisons, and mental institutions in the middle and later parts of the 20th century. Even today, when one examines most addiction research populations, we see that participants represent a very extreme version of drug users - long-term users who are non-treatment seeking and are of low socioeconomic status. While the average age of participants in many research studies is in the mid 40's or later and their average drug use daily or near daily, we know that most drug users who enter treatment in the general population are younger and less drug experienced.
3. Neuropharmacologically-based addiction research has identified key components of learning, decision-making, and reward mechanisms involved in addiction and has brought about a renewed understanding of the development of addiction. However, we have been led to believe that the biological factors important in addiction are the predominant cause for it and that they are irreversible in all individuals and not just in the extreme research samples mentioned above and in animal studies. No doubt neuropharmacology and genetics play a significant role in the addiction process, but even at approximately 50% of the picture they are still contingent on environmental and experiential factors for the actual development of the syndrome we call addiction.
When taken together these facts make it clear why so few with substance problems (approximately 10%) even seek treatment in the first place and why the success rate even among those who do is so abysmally low (5%-25% depending on who you believe). Would you seek treatment for a sprained, dislocated, or even broken heel if the only solution your physician offered was amputation?
What we need is a sensible treatment environment that is suitable for the entire addiction and substance-use disorder spectrum. We need educational components for early detected problems and more serious but still harm-reduction informed solutions for more advanced cases. Abstinence-only treatment that is modeled on the chronic-disease view of addiction should also be part of the picture but only in combinations with the rest and only when appropriate for clients who are either seeking it or have failed in other treatment attempts. We need to support our clients' recovery without stigmatizing our clients or assuming they are in denial if they disagree with us.
At Alternatives, we aim to do just that while using the most advanced and current evidence-based treatment approaches. We think it just makes sense. We are not the only harm-reduction informed addiction treatment option out there - Dr. Andrew Tatarsky's Center for Optimal Living in NYC and Dr. Patt Denning's Harm Reduction Therapy Center in San Fransisco do some amazing work. We are happy and honored to join their ranks in bringing harm reduction and alternative treatment approaches to the forefront of the addiction treatment field.
© 2013 Adi Jaffe, All Rights Reserved
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