What makes treatment effective?

This will be my post in response to the NY Times’ series on Suboxone.

This post originally ran on 7/19/13 and addressed a lot of our concerns.

*   *   *

I’ve been catching a lot of heat recently for posts about Suboxone and methadone. (For the sake of this post, lets refer to them as opioid replacement therapy, or ORT, for the rest of this post.

One commenter who blogs for an ORT provider challenged my arguments that we should offer everyone the same kind of treatment that we offer doctors and questioned the “it works” argument from ORT advocates. He dismissed the treatment model

Another commenter is an opiate addict who objected to a post about Hazelden’s announcement that they started providing ORT maintenance. She reported suffering greatly from cravings and relapsing after drug-free treatment at Hazelden. She’s been on Suboxone for 50 days and feels like it is a better solution for her.

Another post, that has nothing to do with me, blames abstinence-oriented treatment for the recent overdose death of an actor. (Among the other problems with the article are that she slanders abstinence-based treatment by suggesting that abuse is common. She misleads readers into thinking that ORT is not widely available when federal surveys find that ORT admissions accounted for 26% of all admissions. [Not 26% of opioid addiction admissions. 26% of all addiction treatment admissions.]

So, I thought I’d take a step back and try to address the big picture in one post.

The wrong paradigm?

To some extent, these arguments remind me of hearing Bill White comment on arguments about cognitive-behavioral therapy vs. motivational interviewing vs. 12 step facilitation. He commented that, “these are all arguments within the acute care paradigm.”

I talk often about the success of health professional recovery programs and their remarkable outcomes. What makes these programs so successful? I’d boil it down to a few factors:

1. They are recovery-oriented. They treat patients with the expectation that they can fully recover and focus on facilitating and supporting recovery rather than just extinguishing symptoms of addiction.
2. They have a chronic care model. They continue to provide care and support long after the acute stage of treatment (5 years). They also focus on lifestyle changes the will support recovery and look for ways to embed support for recovery in the patient’s environment.
3. They provide adequate care. The provide multiple levels of high quality care of the appropriate intensity and duration at different stages of the patient’s recovery.

Many abstinence-oriented treatment providers have provided the first, but not the second and third. (Though one could argue that 12 step facilitation offers a long term recovery maintenance model.) They provide 10 days of inpatient care or 2 weeks of intensive outpatient and offer a passive referral to outpatient care. (Only 2% of all treatment admissions were for long term [more than 30 days] residential.) The end product looks something like a system that treats a heart attack with a few days or weeks of emergency care and then discharges the patient with no long term care plan. (Or, a weak long term care plan.) Then, we’re surprised when the patient has another cardiac event.

Many ORT providers have offered the second element, but not the first or third. The long term nature of ORT could be considered a chronic care model. However, the end product look something like palliative care for a treatable condition. It reduces opiate use (not necessarily other drug use), criminal activity and over dose. But these benefits are only realized as long as the patient is on ORT and drop-out rates are not low. And, ORT research has not been able to demonstrate the improvements in quality of life (employment, relationships, housing, life satisfaction, etc.) that we see in those health professionals who get all three elements. (Also note that opiate addicted health professionals often use VERY large doses and go undetected for long periods of time. Any neurological damage from their use does no appear to interfere with their achieving drug-free recovery in very impressive numbers.)

It’s effective!

photo credit: ntoper

One of the recurring arguments that I hear is that ORT is effective and there is tons of research that it’s effective. I don’t question that it’s effective at achieving some outcomes–reducing criminal activity, reducing opiate use and reducing overdose. If those are the only outcomes you care about, then you can say it’s effective without any qualifications.

Even with my bias for abstinence-oriented treatment, I can imagine circumstances where ORT might be the least bad option. (For example, if your child had been offered high quality treatment of adequate quality and duration more than once and they continue to relapse and be at high risk for fatal overdose.) A few weeks ago I offered an analogy that attempted to offer an approach to informed consent:

Maybe the choice is something like a person having incapacitating (socially, emotionally, occupationally, spiritually, etc.) and life-threatening but treatable cardiac disease. There are 2 treatments:

1. A pill that will reduce death and symptoms, but will have marginal impact on QoL (quality of life). Relatively little is known about long term (years) compliance rates for this option, but we do know that discontinuation of the medication leads to “near universal relapse“, so getting off it is extremely difficult. The drug has some cognitive side-effects and may also have some emotional side effects. It is known to reduce risk of death, but not eliminate it.
2. Diet and exercise can arrest all symptoms, prevent death and provide full recovery, returning the patient to a normal QoL. This is the option we use for medical professionals and they have great outcomes. Long-term compliance is the challenge and failure to comply is likely to result in relapse and may lead to death. However, we have lots of strategies and social support for making and maintaining these changes.

The catch is that you can’t do both because option 1 appears to interfere with the benefits of option 2.

Fixing treatment

Hazelden’s adoption of ORT has provided fuel to a lot of these arguments.

Hazelden was confronted with poor outcomes for their opiate addicted patients. They saw a problem and decided to act.

One option would have been to declare that a 30 day model for opiate addiction treatment is doomed to fail and build a recovery-oriented, chronic care system that delivers high quality care of the appropriate intensity and duration.

ORT seems to be the easier response, particularly with the market and cultural currents flowing in that direction.

Bill White has argued that ORT can be compatible with a recovery orientation. I’m skeptical, but I’m watching and am willing to learn from any success they have.

However, if you can get what the doctor’s having, why would you want anything else? And, shouldn’t we want every patient to get the same kind of care the doctor would get if she were the patient? If you can’t get that, you’ve got some tough decisions to make.

I’m looking for others to implement the health professional model with others, finding ways to build upon it and make it less expensive, as we have.

UPDATE: In an email exchange with a friend who disagrees, I clarified Hazelden’s options, as I see them. If it were Dawn Farm, I’d imagine we’d look at things like:

• improving our aftercare referral process–asking ourselves if we can make better active linkages to communities of recovery;
• evaluating whether the intensity, duration and quality of our aftercare recommendations were appropriate;
• embedding recovery coaching in cities around the country to provide assertive recovery support;
• improving post-treatment recovery monitoring and re-intervention.

Related articles

• Not available? (addictionandrecoverynews.wordpress.com)
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“manifestly unsuitable for (psychiatric) treatment”

Will Self reviews a recently published book on psychiatry and has some interesting observations on the relationships between addicts, mutual aid groups and psychiatry:

Interestingly there is one large sector of the “mentally ill” that Burns believes are manifestly unsuitable for treatment – drug addicts and alcoholics. He points to the ineffectiveness of almost all treatment regimens, possibly because the cosmic solecism of treating those addicted to psychoactive drugs with more psychoactive drugs hits home despite his well-padded professional armour. Elsewhere in Our Necessary Shadow he seems to embrace the idea that self-help groups of one kind or another could help to alleviate a great deal of mental illness, and it struck me as strange that he couldn’t join the dots: after all, the one treatment that does have long-term efficacy for addictive illness is precisely this one.

Psychiatrists are notoriously unwilling to endorse the 12-step programmes, and argue that statistically the results are not convincing. There may be some truth in this – but there’s also the inconvenient fact that there’s no place for psychiatrists, or indeed any of the psy professionals, in autonomously organised self-help groups. Burns agrees with Davies that our reliance on psychiatry, and by extension, psycho-pharmacology, may well be related to our increasingly alienated state of mind in mass societies with weakened family ties, and often non-existent community ones. Surely self-help groups can play a large role in facilitating the rebirth of these nurturing and supportive networks? But Burns seems to feel that just as we will always need a professional to come and mend the septic tank, so we will always need a pro to sweep out the Augean psychic stables. I’m not so sure; psychiatry has been bedevilled over the last two centuries by “treatments” and “cures” that have subsequently been revealed to be significantly harmful. From mesmerism, to lobotomy, to electroconvulsive therapy, to Valium and other benzodiazepines – the list of these nostrums is long and ignoble, and I’ve no doubt that the SSRIs will soon be added to their number.

Sooner or later we will all have to wake up, smell the snake oil, and realise that while medical science may bring incalculable benefit to us, medical pseudo-science remains just as capable of advance. After all, one of the drugs that Irving Kirsch’s meta‑analysis of antidepressant trials revealed as being just as efficacious as the SSRIs was … heroin.

Related articles

• Psychiatrists: the drug pushers (theguardian.com)
• Faith Lost (madinamerica.com)

Buprenorphine and emotional reactivity

The following article was shared with me by a reader. Not surprisingly, the emphasized portion below caught my eye. [emphasis mine]

Abstract

Addictions to illicit drugs are among the nation’s most critical public health and societal problems. The current opioid prescription epidemic and the need for buprenorphine/naloxone (Suboxone®; SUBX) as an opioid maintenance substance, and its growing street diversion provided impetus to determine affective states (“true ground emotionality”) in long-term SUBX patients. Toward the goal of effective monitoring, we utilized emotion-detection in speech as a measure of “true” emotionality in 36 SUBX patients compared to 44 individuals from the general population (GP) and 33 members of Alcoholics Anonymous (AA). Other less objective studies have investigated emotional reactivity of heroin, methadone and opioid abstinent patients. These studies indicate that current opioid users have abnormal emotional experience, characterized by heightened response to unpleasant stimuli and blunted response to pleasant stimuli. However, this is the first study to our knowledge to evaluate “true ground” emotionality in long-term buprenorphine/naloxone combination (Suboxone™). We found in long-term SUBX patients a significantly flat affect (p<0.01), and they had less self-awareness of being happy, sad, and anxious compared to both the GP and AA groups. We caution definitive interpretation of these seemingly important results until we compare the emotional reactivity of an opioid abstinent control using automatic detection in speech. These findings encourage continued research strategies in SUBX patients to target the specific brain regions responsible for relapse prevention of opioid addiction.

I started out skeptical of the methods and researchers, but, from what I can tell, the methods don’t seem to be fringe pseudoscience.

I don’t know what to make of the associations of Blum, it looks like he was involved in very important research on the genetics of alcoholism in 1990. Since then, it looks like he’s been involved in a lot of entrepreneurial ventures. Bios say that he’s on faculty at Department of Psychiatry and McKnight Brain Institute, but I could find no reference to him on  their website.

Berman appears to have a robust academic career and is affiliated with NIAAA, VA, Boston University and ATTC.

The article was also peer reviewed.

What do you think?

Related articles

• Not available? (addictionandrecoverynews.wordpress.com)
• What makes treatment effective? (addictionandrecoverynews.wordpress.com)
• no hint of opinion here (addictionandrecoverynews.wordpress.com)
• Overprescription of opioids is bad medicine (addictionandrecoverynews.wordpress.com)

 

What makes treatment effective?

I’ve been catching a lot of heat recently for posts about Suboxone and methadone. (For the sake of this post, lets refer to them as opioid replacement therapy, or ORT, for the rest of this post.

One commenter who blogs for an ORT provider challenged my arguments that we should offer everyone the same kind of treatment that we offer doctors and questioned the “it works” argument from ORT advocates. He dismissed the treatment model

Another commenter is an opiate addict who objected to a post about Hazelden’s announcement that they started providing ORT maintenance. She reported suffering greatly from cravings and relapsing after drug-free treatment at Hazelden. She’s been on Suboxone for 50 days and feels like it is a better solution for her.

Another post, that has nothing to do with me, blames abstinence-oriented treatment for the recent overdose death of an actor. (Among the other problems with the article are that she slanders abstinence-based treatment by suggesting that abuse is common. She misleads readers into thinking that ORT is not widely available when federal surveys find that ORT admissions accounted for 26% of all admissions. [Not 26% of opioid addiction admissions. 26% of all addiction treatment admissions.]

So, I thought I’d take a step back and try to address the big picture in one post.

The wrong paradigm?

To some extent, these arguments remind me of hearing Bill White comment on arguments about cognitive-behavioral therapy vs. motivational interviewing vs. 12 step facilitation. He commented that, “these are all arguments within the acute care paradigm.”

I talk often about the success of health professional recovery programs and their remarkable outcomes. What makes these programs so successful? I’d boil it down to a few factors:

1. They are recovery-oriented. They treat patients with the expectation that they can fully recover and focus on facilitating and supporting recovery rather than just extinguishing symptoms of addiction.
2. They have a chronic care model. They continue to provide care and support long after the acute stage of treatment (5 years). They also focus on lifestyle changes the will support recovery and look for ways to embed support for recovery in the patient’s environment.
3. They provide adequate care. The provide multiple levels of high quality care of the appropriate intensity and duration at different stages of the patient’s recovery.

Many abstinence-oriented treatment providers have provided the first, but not the second and third. (Though one could argue that 12 step facilitation offers a long term recovery maintenance model.) They provide 10 days of inpatient care or 2 weeks of intensive outpatient and offer a passive referral to outpatient care. (Only 2% of all treatment admissions were for long term [more than 30 days] residential.) The end product looks something like a system that treats a heart attack with a few days or weeks of emergency care and then discharges the patient with no long term care plan. (Or, a weak long term care plan.) Then, we’re surprised when the patient has another cardiac event.

Many ORT providers have offered the second element, but not the first or third. The long term nature of ORT could be considered a chronic care model. However, the end product look something like palliative care for a treatable condition. It reduces opiate use (not necessarily other drug use), criminal activity and over dose. But these benefits are only realized as long as the patient is on ORT and drop-out rates are not low. And, ORT research has not been able to demonstrate the improvements in quality of life (employment, relationships, housing, life satisfaction, etc.) that we see in those health professionals who get all three elements. (Also note that opiate addicted health professionals often use VERY large doses and go undetected for long periods of time. Any neurological damage from their use does no appear to interfere with their achieving drug-free recovery in very impressive numbers.)

It’s effective!

photo credit: ntoper

One of the recurring arguments that I hear is that ORT is effective and there is tons of research that it’s effective. I don’t question that it’s effective at achieving some outcomes–reducing criminal activity, reducing opiate use and reducing overdose. If those are the only outcomes you care about, then you can say it’s effective without any qualifications.

Even with my bias for abstinence-oriented treatment, I can imagine circumstances where ORT might be the least bad option. (For example, if your child had been offered high quality treatment of adequate quality and duration more than once and they continue to relapse and be at high risk for fatal overdose.) A few weeks ago I offered an analogy that attempted to offer an approach to informed consent:

Maybe the choice is something like a person having incapacitating (socially, emotionally, occupationally, spiritually, etc.) and life-threatening but treatable cardiac disease. There are 2 treatments:

1. A pill that will reduce death and symptoms, but will have marginal impact on QoL (quality of life). Relatively little is known about long term (years) compliance rates for this option, but we do know that discontinuation of the medication leads to “near universal relapse“, so getting off it is extremely difficult. The drug has some cognitive side-effects and may also have some emotional side effects. It is known to reduce risk of death, but not eliminate it.
2. Diet and exercise can arrest all symptoms, prevent death and provide full recovery, returning the patient to a normal QoL. This is the option we use for medical professionals and they have great outcomes. Long-term compliance is the challenge and failure to comply is likely to result in relapse and may lead to death. However, we have lots of strategies and social support for making and maintaining these changes.

The catch is that you can’t do both because option 1 appears to interfere with the benefits of option 2.

Fixing treatment

Hazelden’s adoption of ORT has provided fuel to a lot of these arguments.

Hazelden was confronted with poor outcomes for their opiate addicted patients. They saw a problem and decided to act.

One option would have been to declare that a 30 day model for opiate addiction treatment is doomed to fail and build a recovery-oriented, chronic care system that delivers high quality care of the appropriate intensity and duration.

ORT seems to be the easier response, particularly with the market and cultural currents flowing in that direction.

Bill White has argued that ORT can be compatible with a recovery orientation. I’m skeptical, but I’m watching and am willing to learn from any success they have.

However, if you can get what the doctor’s having, why would you want anything else? And, shouldn’t we want every patient to get the same kind of care the doctor would get if she were the patient? If you can’t get that, you’ve got some tough decisions to make.

I’m looking for others to implement the health professional model with others, finding ways to build upon it and make it less expensive, as we have.

Related articles

• Not available? (addictionandrecoverynews.wordpress.com)
• no hint of opinion here (addictionandrecoverynews.wordpress.com)

 

The benefits of harm reduction are not as obvious as they seem

Warning: This Area Contains Tobacco Smoke (Photo credit: tbone_sandwich)

Theodore Dalrymple points out the inconsistency in the British Medical Journal’s vigorous advocacy for harm reduction where heroin is concerned and its squeamishness with harm reduction for nicotine. He pulls a passage from BMJ and inserts comments:

What, then, does the BMJ, so much in favour of harm reduction for heroin addicts, say about harm reduction for smokers?

A broad perspective suggests potential problems [from a public health perspective].

Firstly, the new nicotine containing products are not intuitively appealing; smokers will need to be persuaded of their benefits. For public health there is a key benefit: it is easier to use them than to   quit. Here I interject that the same is true of the methadone or other substitute for heroin. But for most smokers quitting is the best option and should be presented as achievable and attractive.

   So rolling out harm reduction puts public health in the contradictory position of having to emphasise both the difficulties and attractions of quitting. Why should harm reduction for heroin addiction be any different, one might ask? A related danger is that children will pick up on this apparent confusion. While previous generations were told simply that tobacco is bad, new ones would learn that nicotine is acceptable – just be careful how you access it. This is precisely the burden of public health “education” with regard to heroin and other drug addiction. Moreover, promotion of harm reduction might reduce the perceived “cost” of uptake. Would not the same effect apply to the medical treatment of drug addiction, to say nothing of the provision of free needles? Finally, the fact that e-cigarettes deliberately mimic conventional ones (even to emitting fake smoke) may result in the inadvertent modelling of smoking. Would not the prescription of injectable methadone not do the same? More broadly, the media, which in the UK have become a reliable supporter of comprehensive control measures, might also struggle with this more complex position. How much media effort, one is inclined to ask, ‘reliably’ goes into supporting ‘comprehensive control measures’ with regard to illicit drugs? Thus the benefits of harm reduction are not as obvious as they seem.

The article goes on to criticise harm reduction in tobacco because of the obvious, if not entirely consistent, commercial interests that the tobacco and pharmaceutical industries have in it.

I also recently saw this article on syringes that are much less likely to transmit HIV.

… according to a new paper in the International Journal of Drug Policy, another option should be investigated: Distributing so-called “low-dead-space syringes,” which in laboratory settings have been show to dramatically reduce the likelihood of HIV transmission.

Dead space is the part of the syringe where fluid is retained once the plunger is fully depressed. High-dead-space syringes retain fluid both in the syringe itself and in the needle; low-dead-space syringes expel all the fluid in the syringe, retaining only a small amount of fluid. (In low-dead-space syringes, the needle is not detachable.)

In experiments that mimicked drug injections, the high-dead-space syringes retained 1,000 times as many microliters of blood, even after rinsing. For people carrying HIV with viral loads between one million copies and 2,000 copies per milliliter, the capacious syringes could carry multiple copies of HIV, “whereas,” William A. Zule and his coauthors write, “low-dead-space syringes would retain even a single copy only a fraction of the time.”

What’s interesting here, is that needle exchange advocates have been so busy arguing that they are the obvious answer to injection disease transmission on pragmatic and moral grounds, while insisting that there are no social costs (ignoring the fact that needle sharing persists among exchange users, discarded syringes are a problem, they often ignore treatment access problems and that they make convey despair to addicts and communities), that they seem to have never stopped to ask if we could make syringes safer.

These low-dead-space syringes in universal use might be much more effective than needle exchanges and prevent transmissions through accidental pokes. If so, will they follow the evidence?

Related articles

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Balancing pain management and public health

Advertisement for curing morphine addictions from Overland Monthly, January 1900 (Photo credit: Wikipedia)

I blogged before about the availability of opiates for pain management and the need to try to limit their diversion. While others have complained about draconian limitations on the prescribing of opiates and being too afraid to treat pain, I pointed out the explosion in opiate prescriptions and overdoses. It’s a complex problem that demands a solution that balances the needs of pain patients with the public health risks of easily available opiates.

Here’s a new study looking at the issue [emphasis mine]:

While overdose death rates related to heroin, cocaine, sedative hypnotics, and psychostimulants increased between 1999 and 2009, deaths related to pharmaceutical opioids increased most dramatically, nearly 4-fold. In 2000, the Joint Commission on the Accreditation of Health Care Organizations introduced new standards for pain management which focused on increased awareness of patient’s right to pain relief which contributed to an increase in prescribing of opioid analgesics (Phillips, 2000 and Federation of State Medical Boards of the US, 1998). The average milligrams of morphine prescribed per patient per year increased more than 600% from 1997 to 2007, which led to an increased availability of pharmaceutical opioids for illicit use (US Department of Justice, 2012). From 1999 to 2007, substance abuse treatment admissions for pharmaceutical opioid abuse increased nearly 4-fold and emergency department visit rates related to pharmaceutical opioids increased 111% from 2004 to 2008; visit rates were highest for oxycodone, hydrocodone, and methadone (SAMHSA, 2009a, SAMHSA, 2009b and SAMHSA, 2011). Risks associated with pharmaceutical opioid related overdose included taking high daily doses of opioids and seeking care from multiple healthcare providers to obtain many prescriptions (Paulozzi et al., 2012 and Hall et al., 2008). “Doctor shopping” has also been associated with opioid diversion and illicit use (SAMHSA, 2010 and Rigg et al., 2012). National survey data showed that 75% of pharmaceutical opioid users were using opioids prescribed to someone else (Substance Abuse and Mental Health Services Administration, 2010).

Related articles

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Diagnosing ADHD in detox?

Unreal. Someone’s got an awful lot of faith in their diagnostic skills. Diagnosing ADHD with addicts in a detox unit? Really?

And, now that it’s published, it’s “evidence”.

Rates of undiagnosed attention deficit hyperactivity disorder in London drug and alcohol detoxification units

Background

ADHD is a common childhood onset mental health disorder that persists into adulthood in two-thirds of cases. One of the most prevalent and impairing comorbidities of ADHD in adults are substance use disorders. We estimate rates of ADHD in patients with substance abuse disorders and delineate impairment in the co-morbid group.

Method

Screening for ADHD followed by a research diagnostic interview in people attending in-patient drug and alcohol detoxification units.

Results

We estimated prevalence of undiagnosed ADHD within substance use disorder in-patients in South London around 12%. Those individuals with substance use disorders and ADHD had significantly higher self-rated impairments across several domains of daily life; and higher rates of substance abuse and alcohol consumption, suicide attempts, and depression recorded in their case records.

Conclusions

This study demonstrates the high rates of untreated ADHD within substance use disorder populations and the association of ADHD in such patients with greater levels of impairment. These are likely to be a source of additional impairment to patients and represent an increased burden on clinical services.

Intellectual conflicts of interest

Allen Frances, Chair of the DSM-IV Task Force lets loose on the DSM-5. He acknowledges the noxious effects of professional interests on research and practice in a way that is rarely seen from leaders of his stature. [emphasis mine]

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the ten changes that make no sense.

…

The motives of the people working on DSM 5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Their’s is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).

More evidence for 12-step approaches

photo credit: Jeff Tabaco

Another study finding the 12-step involvement is associated with continuous abstinence:

Abstract

A longitudinal analysis of 12-step involvement was conducted among a U.S. sample of patients exiting treatment for substance dependence. Categorical involvement in a set of 12-step activities and summary scores of involvement from the Alcoholics Anonymous Affiliation Scale were examined in relation to continuous abstinence and aftercare (Oxford House or usual care) condition. Participants who were categorically involved in 12-step activities were significantly more likely to maintain continuous abstinence at 2 years compared with those who were less involved, predicting a greater likelihood of complete abstinence than summary scores of involvement. In addition, participants in the Oxford House condition were significantly more likely to remain continuously abstinent throughout the course of this randomized clinical trial. Findings suggest that categorical involvement in a set of 12-step activities and communal-living settings such as Oxford Houses are independent factors associated with continuous abstinence from both alcohol and illicit drugs among substance dependent persons.

In case you’re wondering what “categorical 12-step involvment is, here’s the definition:

Categorical 12-step involvement is a term used to indicate simultaneous involvement in several 12-step activities

 

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Motivational Interviewing works, but no better than other treatments

Cochrane conducts a meta-analysis of motivational interviewing (MI) and concludes that it’s no more effective than other treatments.

More than 76 million people worldwide have alcohol problems, and another 15 million have drug problems. Motivational interviewing (MI) is a psychological treatment that aims to help people cut down or stop using drugs and alcohol. The drug abuser and counsellor typically meet between one and four times for about one hour each time. The counsellor expresses that he or she understands how the clients feel about their problem and supports the clients in making their own decisions. He or she does not try to convince the client to change anything, but discusses with the client possible consequences of changing or staying the same. Finally, they discuss the clients’ goals and where they are today relative to these goals. We searched for studies that had included people with alcohol or drug problems and that had divided them by chance into MI or a control group that either received nothing or some other treatment. We included only studies that had checked video or sound recordings of the therapies in order to be certain that what was given really was MI. The results in this review are based on 59 studies. The results show that people who have received MI have reduced their use of substances more than people who have not received any treatment. However, it seems that other active treatments, treatment as usual and being assessed and receiving feedback can be as effective as motivational interviewing. There was not enough data to conclude about the effects of MI on retention in treatment, readiness to change, or repeat convictions.The quality of the research forces us to be careful about our conclusions, and new research may change them.

This is a great example of a major flaw in research. There are so many assumptions in every study. One wrong assumption can lead to bad findings. For example, that motivational interviewing is an especially effective and sufficient intervention to treat alcoholism.

MI is being integrated into treatment for all sorts of medical problems, chronic health problems in particular, where part of treatment is recruiting the patient into participating in a treatment that is known to be effective but often suffers from low rates of patient compliance.

The difference here is that researchers seem to be interested in replacing existing treatments for addiction with MI.

One big problem here is that this inserts the assumption that alcoholism is resolved be increasing motivation to quit or reduce drinking.

I believe that these assumptions may be correct for low severity alcohol problems and that MI may be an effective intervention for these problems.

I also believe that MI is probably a valuable tool for more severe alcohol problems, but, in these cases, its proper use is to get patients to accept and participate in treatments that are known to be effective when patients comply. Twelve step facilitation, for example.

Why is there this push for MI as a replacement treatment rather than a treatment inducement tool? Does this constitute a bias on the part of researchers? I don’t know, but note that I’m not the one tossing out the baby with the bath water. I’m suggesting MI might be very important but that they are just asking the wrong questions. It’s also a little ironic that the push to use MI to replace other treatments actually weakens the case for MI having an important role in treating alcoholism.