Tag Archives: Abstinence

2014’s top posts: #7

The evidence-base for 12 step recovery

photo credit: Jeff Tabaco

photo credit: Jeff Tabaco

There’s a fresh round of attacks on AA as pseudo-science in need of sober debunking. All based on one book that is getting impressive publicity. The book may contain references to support its attacks, but the interviews and articles do not. The absolute language (“everyone” and “never”) hint that this may not be the objective analysis it’s reported to be. Anna David makes the case that it’s a “hit job”.

The one source he does identify is the Cochrane Review.

Problems with the Cochrane Review of AA

About 5 years ago, I saw Sarah Zemore give a presentation that very effectively rebutted the Cochrane Review of the evidence for the effectiveness of 12 step groups. It was powerful and well organized. Here are her slides and here’s video of the presentation. (It’s old school. You have to download a mega-file.)

She made the following points in her introduction:

  • It was limited only to randomized trials and ignored the overwhelming observational evidence.
  • It included one of Zemore’s studies which was NOT a randomized study of AA.
  • She acknowledged that the randomized evidence is ambiguous.
  • Randomized trials of AA are hard to do because some subjects in other groups end up participating in AA. This happened in Project MATCH.
  • The Cochrane Review did not find Twelve-step Facilitation ineffective. It found it no more effective that CBT and MET.
  • Finally, she cited 4 randomized studies of Twelve-step Facilitation: The outpatient arm of Project MATCH, a study by her colleague Kaskutas, and two others that I missed.

It was important for me because supporters of Twelve-step Facilitation are too often painted as the equivalent of intelligent design advocates. It’s just not so and the evidence in this presentation made this unequivocally clear. Twelve-step Facilitation is not the only approach that works, but it’s an evidence based practice.

AA and the 6 Formal Criteria for Establishing Causation

Zemore’s content was summarized in an article about the conference:

Zemore presented Kaskutas’ (2009) article, “Alcoholics Anonymous Effectiveness: Faith Meets Science.” Noting diverging conclusions about AA’s effectiveness in the literature, Zemore presented Kaskutas’ approach to evaluating the evidence about AA, highlighting many categories of evidence. She took as the framework for evaluating the research 6 formal criteria for establishing causation described in Mausner and Kramer (1985): (1) strength of the association, (2) dose-response relationship, (3) consistency of the association, (4) correct temporal ordering, (5) specificity of the association, and (6) coherence with existing information. Strong evidence for Criteria 1– 4 and 6 was presented. Evidence for Criterion 5 was reported as mixed. Emphasis was made on the totality of the evidence in favor of AA as a causal agent of abstinence. This quote from the 2009 article summarizes the findings:

… the evidence for AA effectiveness is strong: rates of abstinence are approximately twice as high among those who attend AA (criteria 1, magnitude); higher levels of attendance are related to higher rates of abstinence (criteria 2, dose-response); these relationships are found for different samples and follow-up periods (criteria 3, consistency); prior AA attendance is predictive of subsequent abstinence (criteria 4, temporal); and mechanisms of action predicted by theories of behavior change are evident at AA meetings and through the AA steps and fellowship. (criteria 6, plausibility). (Kaskutas, 2009, p. 155)

Reviewing the Evidence

The article goes on to summarize the knowledge presented as follows:

  • The preponderance of evidence supports the causal pathway that AA attendance leads to abstinence (Kaskutas, Zemore).
  • 12-Step affiliation significantly enhances the odds of sustaining abstinence for multiple years among polysubstance-dependent individuals (Laudet).
  • 12-Step involvement yields benefits above and beyond meeting attendance (Kaskutas, Zemore, Laudet)—and this is especially important for women (Laudet).
  • 12-Step attendance declines over time (Laudet, Kelly). Patterns of AA and NA attendance mirror patterns of treatment attendance with multiple stop-and-start episodes (Laudet).
  • A substantial minority of recovering substance abusers in the community do not participate in 12-Step programs (Laudet).
  • For adolescents, the relationship between AA meeting attendance and percent days abstinent increase in linear and positive direction at 6 months and 12 months posttreatment (Kelly).
  • A combination of treatment and AA is most effective (Kaskutas, Zemore).
  • Among adolescents, early posttreatment attendance, even in relatively small amounts, predicts long-term helpful outcomes. Consistent attendance over time predicts favorable outcomes (Kelly).
  • Three or more AA/NA meetings per week are optimal and associated with complete abstinence. However, even one or two meetings per week are associated with sharp increases in abstinence (Kelly, White).
  • Of 1.9 million people who are addicted to drugs or alcohol, only 18% are alcohol only and only 36% are drug only (White).
  • Those who state AA is helpful have better drinking outcomes. Those who state AA is not helpful have poorer drinking outcomes (Robinson).
  • Addiction severity predicts participation in AA and NA among adults (Robinson) and adolescents (Kelly).
  • Individuals who benefit from AA identify the importance of being in a group of sober people, see AA as a source of support, benefit from others’ experiences, and search for AA meetings and members with whom they find compatibility (Robinson).

Mutual Aid Mechanisms for Change

Bill White has summarized research on AA’s various mechanisms of change (Look at page 128. It includes citations.):

  • problem recognition and commitment to change;
  • regular re-motivation to continue change efforts;
  • counter-norms that buffer the effects of heavy drinking social networks and alcohol and other drug use promotion in the wider culture;
  • sustained self-monitoring;
  • increased spiritual orientation;
  • enhanced coping skills, particularly the recognition of high-risk situations and stressors;
  • increased self-efficacy;
  • social support that offsets the influence of pro-drinking social networks;
  • helping others with alcohol and other drug problems;
  • exposure to sober role models and experience-based advice on how to stay sober;
  • participation in rewarding sober activities;
  • 24-hour accessibility of assistance; and
  • potentially lifelong supports that do not require financial resources.

The Bottom Line

We’ve still got a lot to learn, but here’s some of what we know:

  • Is 12-step effective at initiating recovery? – YES
  • Are other approaches effective at initiating recovery? – YES
  • Is 12-step involvement associated with maintaining abstinence? – YES
  • Are other approaches associated with maintaining abstinence? – I haven’t seen the evidence.
  • Do 12-step programs work for everyone? – NO
  • Does anything work for everyone? – NO
  • Are there other paths to recovery? – YES
  • Do some people initiate recovery with one approach and maintain recovery by other means? – YES

We should continue to research 12-step recovery and other approaches. Learning more about the factors that contribute to the benefits of 12-step involvement might help in developing recovery maintenance strategies to help people who won’t attend 12-step groups or don’t benefit from 12-step groups.

UPDATE: DJMacUK’s comment is so good, I wanted to add it to the post to be sure you don’t miss it.

As far as randomised controlled trials go, it’s not just contamination of the control group that makes it hard to study AA. It’s a bit of a catch 22 with complex interventions like mutual aid. Keith Humphries makes good points on this: Some of this is quote and some paraphrase.

It is difficult to generalise because, most notably, of their extensive exclusion criteria ending up with a small and unrepresentative subset of patients. E.g. Exclude those with mental health disorders, physical health problems: exactly the sort of patients seen every day in treatment.

The common conviction that rcts always generate more accurate estimates of treatment effects is simply incorrect. The NEJM, perhaps the most respected source of controlled clinical trials in the world recently published literature reviews comparing the observed outcomes of medical treatments that had been studied both by randomised trials and by other evaluation approaches. Across methodologies, outcome results were almost always similar (Benson & Hartz, 2000; Concato, Shah and Horwitz, 2000)

Shifting sands: The idea that treatments are applied by outside forces before change begins and are then not affected by any subsequent changes in the patient is poorly matched to chronic dynamic disorders like addiction in which patient factors (e.g motivation, progress or regress) and treatment factors are in constant interplay (Moos 1997) Such processes are easier to understand when patients have the option of choosing which treatments they want, how they want them, when they want them and so forth, all of which is impossible in the context of a typical RCT.

RCTs depend on professional control of who receives the intervention and when and by definition, mutual aid is not professionally controllable. Participation in self help cannot specifically be denied to ‘controls’ in the way that a medication or procedure can be. Patients in the non mutual aid group arm have often gone to mutual aid anyway (this contaminated some of the project match data)

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Throwback Sunday – Pessimistic Paternalism

blank signI’m doubling up this week with two posts on harm reduction from December 2006.

I’ve written often about the subtle bigotry of low expectations, these two posts illustrate that concern. (I like my reference to “pessimistic paternalism disguised as compassionate pragmatism.”)

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Debate on abstinence

A horrifying excerpt from a debate in a British treatment provider magazine. (It’s at the bottom of both pages.) I don’t completely understand the context–whether they are debating a “motion” in a binding way for the specialty society that publishes the magazine or if it’s a devise for a magazine column.

One of the participants proposed that detox is dangerous due to the possibility of reduced tolerance and unintentional overdose in the event of a relapse. Harm reduction advocates used to argue that they represented a needed choice philosophy in working with addicts. The is the worst kind of pessimistic paternalism disguised as compassionate pragmatism–and there’s nothing representing real choice.

…Detox can be dangerous and is not very often successful. Death rates are higher in recently detoxed patients.

Many people request detox but we need to recognise that maintenance is a very worthwhile option. Maintenance patients need our support – including psychological support – and harm reduction has to be our goal.

The NTA says rehab providers have to provide mechanisms for rapid referral into maintenance programmes. Getting people off drugs is dangerous.

Bill Nelles,founder of The Alliance,said: ‘Let’s take the morality out of drug treatment and put the humanity back in’. Judy Bury [GP] said it is our job as GPs to keep people alive until they are ready to change.

There’s not much evidence for long-term effectiveness of detox,but it can reduce tolerance. People cannot do abstinence when they walk in the service. The move toward abstinence-based treatment is dangerous and will increase drug-related deaths.

=====================

“Recovery Impatience”

Lowering_The_Bar_Cover_2010.09.22Let’s hope that the concept of “recovery impatience” does not catch on. Keep in mind that this is in the context of a country with a big emphasis on methadone and 60% of the methadone recipients have expressed a preference for abstinence based treatment.

“We are now seeing the emergence of a culture of “recovery impatience”: the demand for people to move quickly to a drug-free lifestyle while denying the significance of other factors – such as low income and life in neglected communities – which make rapid achievement to a drug-free life impossible for the majority,” she said.

“The combination of totally unrealistic expectations, along with the demonisation of drug users, is having a trickle-down effect on practice, with “firmer” responses becoming more acceptable.

“We are in danger of harking back to the days when those seeking treatment were labelled as feckless and chaotic, deemed as having given up their right to be involved in their own treatment or to be treated with the dignity, respect and quality of care afforded other vulnerable groups in society.”

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Addiction research funding focused on “abstinence only”?

Federal grant search for active projects with the terms methadone, buprenorphine and naloxone

Federal grant search for active projects with the terms methadone, buprenorphine and naloxone

DJ Mac picks up on a story that also caught my eye and catches a line moaning about research bias in favor of abstinence-based programs. He pulled this quote.

The gorilla in the room around this question turns out to be the ideology of the decision makers. “There are ideological constraints tied to what gets funded,” says Ethan Nadelmann, founder and executive director of the Drug Policy Alliance in New York City. An example? The tendency to fund “abstinence only” programs and the war on drugs at the expense of drug prevention research. “There is not a lot of evidence of what works because it does not get studied. Today, kids lose their drug virginity before their sexual virginity. What’s the needle exchange of today?”

This struck me as odd, because NIDA seems to be heavily invested in promoting buprenorphine. So, I went to projectreporter.nih.gov and looked up active projects with the search terms “methadone OR buprenorphine OR naloxone”. It’s not a perfect method, but it tells you something, right?

Here’s what I found:

  • 220 active projects
  • $103,152,353 in total funding for these projects
  • These projects have generated 2028 publications that are now part of the evidence-base

“What’s the needle exchange of today?” It’s obviously naloxone, right? If you limit the search to just naloxone, you still get over $35,000,000. A search for “opioid AND abstinence” returns $41,450,238 in funding.

These results are consistent with the articles theme of research being oriented toward PhRMA, but not with Nadelmann’s argument that “abstinence only” rules the playground.

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Whose goals should drive treatment?

bh-crossroads_text-300x199DJ Mac provides an important review of a couple of recent studies look at what Scottish treatment seekers want and how they and their families define success.

He summarizes their findings this way:

On abstinence: “Many felt that stopping substance use was a prerequisite of effective treatment and created a virtuous circle of feeling better, which in turn helped to motivate more effort to make change.”

On ORT: “The use of medication, such as methadone, was discussed and especially so in the court mandated rehabilitation group. It was felt that substitute prescriptions masked the problem and were simply a parallel addiction…The use of methadone can support an individual in a controlled and managed way. It can also reduce the risk of injecting behaviour. However, SUs felt that even with these benefits, their end goal was to be free of heroin and any substitute drugs.”

The researchers found dramatic improvements in health and that these “naturally happened with abstinence.” Service users found structure and activity important when recovering from addiction, relationships improved, but at the same time they had to let go of using and drinking friends. Participants also developed coping skills to deal with cravings.

He bottom lines the findings this way:

“Broadly speaking, the desired goal is abstinence from psychoactive substances. A second tranche of outcomes are about achieving changes that maintain the abstinence goal. A third tranche, and seen rather as a bonus, were the positive benefits of abstinence, for example, improved health. We believe that practitioners will find it helpful to be mindful of the ‘being better’ goals while recognising that the day to day business of therapy often means negotiating small steps along the way to the desired goal.”

The DORIS study reported shockingly low levels of abstinence in treatment services in Scotland. I think we are doing better now than ten years ago, but we need to do better still. Here’s the main sentence in the paper that stands out for me; the one that captures  the essence of the study in a nutshell.

“In general, it is fair to say that SUs [Service Users] look for tough criteria to define ‘being better’ – perhaps tougher than their practitioners.”

So how are we going to respond?

Of course, this study was in Scotland, but I suspect that the findings would be very similar in the U.S.

We give a lot of lip service to being client centered. But, when we see high drop-out rates for medication assisted treatment, researchers and prescribers seem to view this as noncompliance and an expression of a desire to relapse or the poor judgement of an impaired mind.

Maybe this an expression of a goal that exceeds the hopes and expectations of the helper?

Read the rest here.

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The evidence-base for 12 step recovery

photo credit: Jeff Tabaco

photo credit: Jeff Tabaco

There’s a fresh round of attacks on AA as pseudo-science in need of sober debunking. All based on one book that is getting impressive publicity. The book may contain references to support its attacks, but the interviews and articles do not. The absolute language (“everyone” and “never”) hint that this may not be the objective analysis it’s reported to be. Anna David makes the case that it’s a “hit job”.

The one source he does identify is the Cochrane Review.

Problems with the Cochrane Review of AA

About 5 years ago, I saw Sarah Zemore give a presentation that very effectively rebutted the Cochrane Review of the evidence for the effectiveness of 12 step groups. It was powerful and well organized. Here are her slides and here’s video of the presentation. (It’s old school. You have to download a mega-file.)

She made the following points in her introduction:

  • It was limited only to randomized trials and ignored the overwhelming observational evidence.
  • It included one of Zemore’s studies which was NOT a randomized study of AA.
  • She acknowledged that the randomized evidence is ambiguous.
  • Randomized trials of AA are hard to do because some subjects in other groups end up participating in AA. This happened in Project MATCH.
  • The Cochrane Review did not find Twelve-step Facilitation ineffective. It found it no more effective that CBT and MET.
  • Finally, she cited 4 randomized studies of Twelve-step Facilitation: The outpatient arm of Project MATCH, a study by her colleague Kaskutas, and two others that I missed.

It was important for me because supporters of Twelve-step Facilitation are too often painted as the equivalent of intelligent design advocates. It’s just not so and the evidence in this presentation made this unequivocally clear. Twelve-step Facilitation is not the only approach that works, but it’s an evidence based practice.

AA and the 6 Formal Criteria for Establishing Causation

Zemore’s content was summarized in an article about the conference:

Zemore presented Kaskutas’ (2009) article, “Alcoholics Anonymous Effectiveness: Faith Meets Science.” Noting diverging conclusions about AA’s effectiveness in the literature, Zemore presented Kaskutas’ approach to evaluating the evidence about AA, highlighting many categories of evidence. She took as the framework for evaluating the research 6 formal criteria for establishing causation described in Mausner and Kramer (1985): (1) strength of the association, (2) dose-response relationship, (3) consistency of the association, (4) correct temporal ordering, (5) specificity of the association, and (6) coherence with existing information. Strong evidence for Criteria 1– 4 and 6 was presented. Evidence for Criterion 5 was reported as mixed. Emphasis was made on the totality of the evidence in favor of AA as a causal agent of abstinence. This quote from the 2009 article summarizes the findings:

… the evidence for AA effectiveness is strong: rates of abstinence are approximately twice as high among those who attend AA (criteria 1, magnitude); higher levels of attendance are related to higher rates of abstinence (criteria 2, dose-response); these relationships are found for different samples and follow-up periods (criteria 3, consistency); prior AA attendance is predictive of subsequent abstinence (criteria 4, temporal); and mechanisms of action predicted by theories of behavior change are evident at AA meetings and through the AA steps and fellowship. (criteria 6, plausibility). (Kaskutas, 2009, p. 155)

Reviewing the Evidence

The article goes on to summarize the knowledge presented as follows:

  • The preponderance of evidence supports the causal pathway that AA attendance leads to abstinence (Kaskutas, Zemore).
  • 12-Step affiliation significantly enhances the odds of sustaining abstinence for multiple years among polysubstance-dependent individuals (Laudet).
  • 12-Step involvement yields benefits above and beyond meeting attendance (Kaskutas, Zemore, Laudet)—and this is especially important for women (Laudet).
  • 12-Step attendance declines over time (Laudet, Kelly). Patterns of AA and NA attendance mirror patterns of treatment attendance with multiple stop-and-start episodes (Laudet).
  • A substantial minority of recovering substance abusers in the community do not participate in 12-Step programs (Laudet).
  • For adolescents, the relationship between AA meeting attendance and percent days abstinent increase in linear and positive direction at 6 months and 12 months posttreatment (Kelly).
  • A combination of treatment and AA is most effective (Kaskutas, Zemore).
  • Among adolescents, early posttreatment attendance, even in relatively small amounts, predicts long-term helpful outcomes. Consistent attendance over time predicts favorable outcomes (Kelly).
  • Three or more AA/NA meetings per week are optimal and associated with complete abstinence. However, even one or two meetings per week are associated with sharp increases in abstinence (Kelly, White).
  • Of 1.9 million people who are addicted to drugs or alcohol, only 18% are alcohol only and only 36% are drug only (White).
  • Those who state AA is helpful have better drinking outcomes. Those who state AA is not helpful have poorer drinking outcomes (Robinson).
  • Addiction severity predicts participation in AA and NA among adults (Robinson) and adolescents (Kelly).
  • Individuals who benefit from AA identify the importance of being in a group of sober people, see AA as a source of support, benefit from others’ experiences, and search for AA meetings and members with whom they find compatibility (Robinson).

Mutual Aid Mechanisms for Change

Bill White has summarized research on AA’s various mechanisms of change (Look at page 128. It includes citations.):

  • problem recognition and commitment to change;
  • regular re-motivation to continue change efforts;
  • counter-norms that buffer the effects of heavy drinking social networks and alcohol and other drug use promotion in the wider culture;
  • sustained self-monitoring;
  • increased spiritual orientation;
  • enhanced coping skills, particularly the recognition of high-risk situations and stressors;
  • increased self-efficacy;
  • social support that offsets the influence of pro-drinking social networks;
  • helping others with alcohol and other drug problems;
  • exposure to sober role models and experience-based advice on how to stay sober;
  • participation in rewarding sober activities;
  • 24-hour accessibility of assistance; and
  • potentially lifelong supports that do not require financial resources.

The Bottom Line

We’ve still got a lot to learn, but here’s some of what we know:

  • Is 12-step effective at initiating recovery? – YES
  • Are other approaches effective at initiating recovery? – YES
  • Is 12-step involvement associated with maintaining abstinence? – YES
  • Are other approaches associated with maintaining abstinence? – I haven’t seen the evidence.
  • Do 12-step programs work for everyone? – NO
  • Does anything work for everyone? – NO
  • Are there other paths to recovery? – YES
  • Do some people initiate recovery with one approach and maintain recovery by other means? – YES

We should continue to research 12-step recovery and other approaches. Learning more about the factors that contribute to the benefits of 12-step involvement might help in developing recovery maintenance strategies to help people who won’t attend 12-step groups or don’t benefit from 12-step groups.

UPDATE: DJMacUK’s comment is so good, I wanted to add it to the post to be sure you don’t miss it.

As far as randomised controlled trials go, it’s not just contamination of the control group that makes it hard to study AA. It’s a bit of a catch 22 with complex interventions like mutual aid. Keith Humphries makes good points on this: Some of this is quote and some paraphrase.

It is difficult to generalise because, most notably, of their extensive exclusion criteria ending up with a small and unrepresentative subset of patients. E.g. Exclude those with mental health disorders, physical health problems: exactly the sort of patients seen every day in treatment.

The common conviction that rcts always generate more accurate estimates of treatment effects is simply incorrect. The NEJM, perhaps the most respected source of controlled clinical trials in the world recently published literature reviews comparing the observed outcomes of medical treatments that had been studied both by randomised trials and by other evaluation approaches. Across methodologies, outcome results were almost always similar (Benson & Hartz, 2000; Concato, Shah and Horwitz, 2000)

Shifting sands: The idea that treatments are applied by outside forces before change begins and are then not affected by any subsequent changes in the patient is poorly matched to chronic dynamic disorders like addiction in which patient factors (e.g motivation, progress or regress) and treatment factors are in constant interplay (Moos 1997) Such processes are easier to understand when patients have the option of choosing which treatments they want, how they want them, when they want them and so forth, all of which is impossible in the context of a typical RCT.

RCTs depend on professional control of who receives the intervention and when and by definition, mutual aid is not professionally controllable. Participation in self help cannot specifically be denied to ‘controls’ in the way that a medication or procedure can be. Patients in the non mutual aid group arm have often gone to mutual aid anyway (this contaminated some of the project match data)

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Tribes of the Recovering Community

complogo-2010_noshad_400This week’s tribe is LifeRing Secular Recovery:

LifeRing Secular Recovery is an abstinence-based, worldwide network of people who are choosing to live in recovery from alcohol and other drugs. We encourage individuals to build their own personal recovery programs based on three principles: sobriety, secularity, and self-direction.

We believe our personal recoveries require communication and connection with others in addition to our individual practice of abstinence. In LifeRing, as we talk about recovery and share tools that have worked for us, we find our sober intellectual, analytical, and emotional selves engaged, nurtured, strengthened … and empowered.

Recovery requires hard work and perseverance. If you are self-directed and want to create a personal recovery program that is yours and yours alone, you owe it to yourself to check out LifeRing.

(The “Tribes of the recovering community” series is intended to demonstrate the diversity within the recovering community.I have no first hand knowledge of most of the tribes, so inclusion in this series should not be considered an endorsement.)

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how do you want your loved one to return?

Red_Drug_Pill---recoveryAnna David has an interview with Earl Hightower that really gets at the informed consent issues I’ve been talking about here.

AD: Should the parents just accept the first recommendation or should they ask for more?
EH: I think the first question they should ask should be one they ask themselves, which is how they want their son to return.

AD: What does that mean?

EH: Well, the majority of the treatment centers out there are 12-step based, which means that the goal for them is for their clients to achieve abstinence. This would be the choice to make if the parents want to get their son back in the same condition that he was in before he got on drugs: drug-free.

AD: But you can’t say for certain that a 19-year-old who was doing Oxy for nine months is definitely an addict who will need 12-step.

EH: You can’t. Maybe he was just dabbling; treatment would be able to help determine that. But maybe treatment will prove something else—maybe treatment will prove that this wasn’t an isolated incident. Maybe he’ll get in there and confess that he’s been using pot since he was 12 and maybe other conversations will turn up the fact that there’s a genetic predisposition toward addiction in the family. And if that’s the case, I believe he will need community-based support in staying clean once he returns home. It could go either way: good ongoing clinical assessment is the backbone of early treatment to determine the direction of care.

AD: But not all rehabs recommend 12-step or even full abstinence.

EH: Yes. And that’s why parents—people—need to know is that if an addict is going to a facility which subscribes to medication-assisted treatment and recovery, the goal is different. Loved ones need to know what medication-assisted treatment really means, which is that treatment will be radically re-defined and their child could be put on a medication which he would remain on for a long time, if not the rest of his life.

AD: So that’s what you mean when you talk about parents asking themselves how they want their child to return.

EH: Yes. But I can tell you from 30 years of doing this work that most parents want their child to come home drug-free—or they at least they want a shot at that. But some members of the treatment community will tell parents—or the addicts themselves—that we have to let go of this notion of abstinence and move more in the direction of medication-assisted treatment. And that means that people who could thrive without being on anything at all are leaving treatment centers on very powerful opiate replacement drugs.

Of course, Hightower has a strong bias toward abstinence-based treatment, but he’s describing a choice patients and parents never really get to make for themselves, with treatment providers of all types. As with a lot of health care decisions, there’s a problem of asymmetrical information and patients are at the mercy of whatever practitioner they land in front of.

Read the rest of the interview here.

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