The soul of addiction treatment

I’ve never met Scott Kellogg, but I appreciate his presence in the field. He’s struck me as a pragmatist who tries to find third ways and has a conservative temperament. There are too few people who fit that description.

His recent piece for Substance and  Pacific Standard is on “A Struggle for the Soul of Addiction Treatment.”

I’ve had growing concerns that our field has become a new battleground for the culture wars without many of us even realizing it was happening or conceiving that treatment belonged on any “side” of  a culture war.

This piece is a response to a report called “The New Paradigm for Recovery” that identifies physician health programs, pilot programs and lawyer programs as the gold standard for addiction treatment. (These programs have outstanding outcomes in terms of substance use, as wells as return to employment and other quality of life factors.)

The paper suggests that we should identify the critical elements from these programs and find ways to extend those elements into programs that are available to everyone.

Kellogg uses this response to outline the battle lines. It’s worth noting that the primary objections are philosophical rather than treatment focused.

He characterizes the new paradigm’s model as a moral model that characterizes addicts as “bad”. He suggests it’s born of stigma and perpetuates stigma.

He rejects the disease model and is troubled that treatment is not medical enough.

“The fact that they do not really believe it is a “disease” can be seen in the ongoing opposition to methadone, buprenorphine, and, to a lesser extent, psychiatric medications.”

This is odd, given that, just a few paragraphs earlier he lamented the stature of the authors.

“But it is notable that the working group that produced the report included, in addition to DuPont, such major figures in the field of addiction as Dr. Stuart Gitlow, the president of the American Society of Addiction Medicine; Dr. John Kelly, a major researcher on recovery at Harvard University; Dr. Marvin Seppala, chief medical officer at the Hazelden Foundation; Dr. Gregory Skipper, director of Professional Health Services at Promises Treatment Center; and William White, one of the leading proponents of Recovery Management and a major addiction treatment historian. What this demonstrates is that the philosophy of judgment, punishment, and control is so pervasive and engrained that highly trained, well-meaning mainstream clinicians utilize it even as they set out to do something good for their patients.”

I don’t know the positions of all of the authors, but Gitlow has worked for a buprenorphine manufacturer, Seppala very publicly started burprenorphine maintenance at Hazelden and White has been a forceful advocate for methadone.

He’s also troubled by the emphasis on external control, seeing this as evidence of a moral model.

“The report recommends that following formal treatment, the individual should become involved in an accountable system of care management that includes (1) signing an abstinence contract and (2) agreeing to be under a supervisory or monitoring authority (family, employer, legal entity) that (3) subjects them to frequent random drug testing and (4) provides negative sanctions for any lapses, relapses, or missed drug testing, while (5) encouraging or mandating attendance at mutual aid groups.”

As DuPont discussed the topic before this report was published, I also expressed some pause at his emphasis on sanctions.

I’ve got to say, though, don’t we have all sorts of behavioral economists suggesting that we learn from Odysseus and find ways to restrict our ability to make poor decisions in the future, often with the help of others. Isn’t this along those lines?

They describe monitoring authorities and sanctions as elements of these programs with good outcomes, but they do not propose making all addicts subject to some monitoring authority. However, Debra Jay recently proposed a model that creates recovery monitoring and support systems within families. I imagine that’s exactly the kind of ideas that a paper like this hopes to stimulate, and it’s free of any legal or occupational coercion.

He presents the alternative, “Scientific/Humanist Model” and presents a model of functional analysis for looking at substance use. (Again, rejecting the disease model’s assumption of pre-existing genetic and neurological factors.

I have to admit that I find it odd that a paper presenting evidence for models with outstanding outcomes for a difficult to treat illness gets labeled as moral, while the “scientific” model rejects the model on philosophical objections (rather than evidence) and rejects the scientific consensus on addiction as a disease.

There are 2 things I find very troubling about this discussion. (Not about Kellogg, rather about this larger, ongoing discussion.)

First, no alternative with similar outcomes is offered. Or, why not challenge the authors and practitioners to address his concerns, like the model’s lack of evidence for voluntary engagement? Are there lessons from harm reduction that can inform this model to maximize voluntary engagement? Again, this suggests that the objections are not pragmatic but ideological.

Second, and more concerning is that Kellogg seems to have flipped the light switch on and exposed the underlying culture war by using political jargon and calling for “progressives” to work to advance their model. (Ironic, given the egalitarian call from the paper–the rest of us should have access to the kind of care that is currently limited to a few elite groups.)

Ugh. I can’t even stomach real politics.

Bill White wrote about a struggle for addiction treatment’s soul in 2002. His take addresses some of the concerns of Kellogg’s constituency in, what I think, is a more accurate and constructive way.

The growth zone of the addiction treatment industry is not at the traditional core but in the delivery of addiction treatment services into the criminal justice system, the public health system (particularly AIDS related projects), the child welfare system, the mental health system, and the public-welfare system. If one looks at these trends as a whole, what is emerging in the 1990s is a treatment system less focused on the goal of long-term personal recovery than on social control of the addict. The goal of this evolving system is moving from a focus on the personal outcome of treatment to an assurance that the alcoholic and addict will not bother us and will cost us as little as possible.

The fate of the field will be determined by its ability to redefine its niche in an increasingly turbulent health-care and social-service ecosystem. That fate will also be dictated by more fundamental issues – the ability of the field to: 1) reconnect with the passion for service out of which it was born; 2) re-center itself clinically and ethically; 3) forge new service technologies in response to new knowledge and the changing characteristics of clients, families, and communities; and 4) the ability of the field to address the problem of leadership development and succession.

In that same book, he offered these reflections on the historical lessons that addiction treatment professionals should carry forward.

So what does this history tell us about how to conduct one’s life in this most unusual of professions? I think the lessons from those who have gone before us are very simple ones. Respect the struggles of those who have delivered the field into your hands. Respect yourself and your limits. Respect the addicts and family members who seek your help. Respect (with hopeful but healthy skepticism) the emerging addiction science. And respect the power of forces you cannot fully understand to be present in the treatment process. Above all, recognize that what addiction professionals have done for more than a century and a half is to create a setting and an opening in which the addicted can transform their identity and redefine every relationship in their lives, including their relationship with alcohol and other drugs. What we are professionally responsible for is creating a milieu of opportunity, choice and hope. What happens with that opportunity is up to the addict and his or her god. We can own neither the addiction nor the recovery, only the clarity of the presented choice, the best clinical technology we can muster, and our faith in the potential for human rebirth.

Does that betray some anchoring in a moral model? I’m sure some will find evidence of that and superstition. However, I see a model that, in its best moments, is rooted in empirical knowledge as well as experiential knowledge, choice, empowerment, hope, respect, humility, patience and love.