Robert DuPont has something to say in response to the media blitz for Dodes’ new book attacking AA. He’s more strident than I’d be in defending AA, but he makes some great points.
. . . Dodes criticized AA and Narcotics Anonymous’ (NA) “tally” system, which recognizes incremental periods of continued sobriety by awarding chips. “The dark side is, if you have a beer after six months of sobriety, you’re back to zero in AA,” Dodes said. “That makes no sense. It’s unscientific. It’s simply crazy. If you have only a beer in six months, you’re doing beautifully.”
What’s wrong with Dodes’ thinking on the matter?
The bright line drawn by AA and NA — the sobriety date that marks the last time a recovering addict used alcohol or other drugs — is essential. It differs radically from the academic and professional standard for drug and alcohol addiction , which tolerates slips and relapses. The bright line of the sobriety date is a matter of importance and of huge pride for fellowship members — it is a core marker of identity in the fellowships, and a fundamental defining part of the disease of addiction. One of the true joys of this fellowship is attending a group celebration that commemorates a recovering addict’s “clean time” anniversary.
The all too common academic, professional views on addiction, well represented by Dodes, run counter to the AA and NA goal of sobriety. Many professionals and academics see continued alcohol and drug use as OK but “problem-generating use” as not quite as acceptable. They encourage controlled, responsible alcohol and drug use. They encourage cutting down, but not stopping. They view drug and alcohol use by addicts as a lifestyle alternative that, like sexual orientation, should not be “stigmatized.”
That is a reckless view. An addict who has one beer after six months of sobriety is not doing “beautifully.” Instead, he or she is courting catastrophe, and likely to easily fall back into active addiction. An addict cannot just have one beer, or one cigarette, or one pill. True lifelong recovery does not happen that way, and anyone who believes that it does is heading for a major relapse.
There are endless examples of skeptics like Dodes who seek alternatives to AA, or approaches that attack AA. I suggest to my patients who reject AA that they find one of these alternatives, and see what they think of it. They tell me that such programs are hard to find. I ask them, “Why do you think that is the case? Doesn’t that tell you something?”
Stigmatization may have once served to protect early humans from infectious diseases, but that strategy may do more harm than good for modern humans, according to Penn State researchers.
“The things that made stigmas a more functional strategy thousands of years ago rarely exist,” said Rachel Smith, associate professor of communication arts and sciences and human development and family studies. “Now, it won’t promote positive health behavior and, in many cases, it could actually make the situation worse.”
Stigmatizing and ostracizing members stricken with infectious diseases may have helped groups of early humans survive, said Smith, who worked with David Hughes, assistant professor of entomology and biology. Infectious agents thrive by spreading through populations, according to Smith and Hughes, who published an essay in the current issue of Communication Studies.
This article emphasizes infectious disease, but it caught my attention because I’d never considered stigma having a useful evolutionary function.
I wonder if thinking about it in these terms offers any useful insights for combating stigma.
We can see that this body of evidence stretches over 50 years and that it tells a consistent story. The worry that antipsychotics might increase the risk of relapse showed up in the NIMH’s very first one-year study. It showed up in Bockoven’s retrospective study. Next, it showed up in three long-term studies funded by the NIMH in the 1970s. Researchers then offered a biological explanation for why these outcomes were occurring. The WHO’s cross-cultural studies found better outcomes in poor countries where few patients were maintained long-term on antipsychotics. MRI studies identified a drug-induced change in brain morphology that was associated with a worsening of psychotic symptoms. Researchers who developed an animal model of psychosis concluded that drug-induced dopamine supersensitivity leads to treatment failure over time. Wunderink’s randomized study revealed a higher relapse rates between years two and seven for the medicated patients. Finally, Harrow’s long-term study, which is the best such study that has ever been conducted, found that the medicated patients were much more likely to be experiencing psychotic symptoms over the long term.
So, the real question now is, how much of the disability persistence we see associated with SPMI (severe and persistent mental illness) is iatrogenic?
We’ve long fought to delay diagnosis of mental illness in addicts to avoid false diagnosis, not just because of concern for accuracy, rather out of concern about the harm that can result from it—the effects of the medications, the adoption/imposition of a “disabled” identity, the low expectations and the passive role of the patient.
When all else has failed – what does work when confronted with a loved one’s addiction? What does not work? What can others do to help? What does not help? What role does an individual play in supporting another person’s recovery process? These and other questions will be addressed in order to assist participants to find effective methods to successfully support another person’s recovery, avoid enabling another person’s addiction, and maintain their own health and well-being.
This AC model works well with acute trauma, and it can play a role for many in addiction recovery initiation and stabilization. Unfortunately, it does not work well with the treatment of addictions of high severity, complexity and chronicity–patterns that dominate admissions to specialized addiction treatment units. Brief episodes of crisis intervention do not support the transition from recovery initiation and stabilization through the stages of recovery maintenance and enhanced quality of personal and family life in long-term recovery.
Efforts to transform AC models of intervention into models of sustained recovery management analogou
s to the treatment of other life-threatening chronic health conditions require substantial changes in service practices. One such critical change is abandonment of the graduation ritual or reframing this ritual as something other than the “end” of treatment. No healthcare provider would think of providing a “graduation” ceremony marking the discharge of patients admitted for crisis care of diabetes, heart disease, asthma, chronic respiratory conditions or chronic pain because such interventions would not constitute the end of care and the service relationship. Discharging persons from primary addiction treatment should also not signal the end of care. It is time we altered practices that inadvertently convey this end of care message.
Keith Humphreys laments the short term focus of the evidence base for medications.
. . . the evidence base is almost useless for answering questions about the long-term costs and benefits of opioid medications. In the 41 randomized clinical trials that Furlan et al. review, the impact of the medication was evaluated for an average of only 5 weeks. That’s enough to show acute pain relief effects, but leaves us in the dark about what happens to the millions of people who take these medications over longer periods.
None of this is unique to the study of pain medication. Anti-depressants, which are prescribed long-term to tens of millions of people, are typically evaluated in 12 week trials. I suspect experts in cardiology, rheumatology and endocrinology could provide examples in their own areas of medications that are widely prescribed for the long term but only evaluated in the short term.
The primary reason for the short-termism of pharmaceutical research is that much of it is funded by the industry itself. Short-term studies are cheaper and meet the FDA requirements for demonstrating efficacy. If there are long-term problems with a medication a company is developing, it would be economically foolish of them to design a study that would reveal it.
The public of course has a different balance of interests and cares what happens to its health beyond a 5 or 12 week window. But public research money to pursue those interests scientifically is drying up, meaning that we will continue to learn about the long-term effects of many medications only by nervously watching what happens when millions of people take them in the course of receiving health care. That’s no way to protect the public health.
Last night (Wednesday), Pat Gibbons, Dawn Farm’s Medical Director and psychiatrist died suddenly. We’re stunned. He was just at Spera on Tuesday night seeing clients. It’s a terrible loss for Dawn Farm and our community.
Any words I can come up with feel entirely inadequate, but here goes.
He was a model of the power of recovery. He paid his debt forward as much as anyone I’ve ever seen.
He was a mentor and source of support for hundreds of recovering men.
He volunteered for Dawn Farm in several capacities over the years. His contributions were always quiet, but always important.
He provided free and inexpensive medical and psychiatric care to countless clients.
He helped establish and disseminate a protocol that helped benzodiazepine and alcohol dependent patients safely detox in non-medical settings.
Pat established himself as the most respected addiction psychiatrist in the region and served at University of Michigan, the Veterans Administration, Community Support and Treatment Services, the Health Professional Recovery Program, Pain Recovery Solutions and Dawn Farm.
Pat interacted with ALL of his patients in a manner that conveyed hope, many of whom had been discarded and neglected by other systems.
Facebook is being flooded with comments from friends, former patients and colleagues remembering his kindness, intelligence, wisdom, compassion, humility, sense of humor, patience and gratitude. People are giving him credit for their recovery, their careers and much more.
In the midst of all this, he was a proud father of six children.
We are grateful to have had him as part of our family. His death is going to be a terrible loss for the community. I can’t think of anyone who has done as much to improve medical and psychiatric care for our most vulnerable community members. We will miss him terribly. He was a very good man.