If it wasn’t rational, cont’d

PET brain scans show chemical differences in t...
PET brain scans show chemical differences in the brain between addicts and non-addicts. The normal images in the bottom row come from non-addicts; the abnormal images in the top row come from patients with addiction disorders. These PET brain scans show that that addicts have fewer than average dopamine receptors in their brains, so that weaker dopamine signals are sent between cells. (Photo credit: Wikipedia)

Sam Wilkinson responds to the the coverage of Hart’s research (That crack and meth addicts in a lab will decline drugs for money.) and agrees that addiction is rational.

Hart has found the same thing. It isn’t the addicts are powerless; it’s that nothing on the other side of the scale weighs as much as does the benefit of the whatever-is-being-sought. Back on that Sunday in September 2006, nothing on that scale weighed as much as getting blind drunk. My perceived options in that moment were narrow. By artificially increasing the number of options, Hart shows that even the farthest gone can still make what we might be more willing to describe as the rational decision. Where we stumble is in misunderstanding that the desire the use is rational too.

He goes on to give a really wonderful description of addiction.

Addiction is so harrowing a foe because it literally becomes the solution for everything. The mind’s calculator shows the same answer no matter what the problem is. How do I solve an emotionally devastating day? Beer. How do I celebrate a beautiful day? Beer. How do I unwind after a long day? Beer. How do I endure an uncomfortable situation? Beer. How do I…? Beer. The answer is beer. It does not matter what comes after the ellipses. I wrote this several months ago after giving alcohol as a gift. I am more than six years sober and if I don’t pause long enough to think about the answer my brain is giving me, drinking suddenly starts to make an incredible amount of sense. But if I did stop short of that longer consideration, my conclusion wouldn’t be irrational, especially if I’d only thought to consider all of the good things there are about drinking. And there are good things.

I have a few thoughts.

First, I’m not sure Wilkinson and I are so far apart. During educational talks, I sometimes say, “If drugs did for you what they did for me, you’d be an addict too!” So, if he’s saying that a fundamental characteristic of addiction is that there’s something different about the way addicts/alcoholics experience drugs and that this dramatically changes the decisional balance about using, then I’d agree. I’m not sure I’d strenuously argue that this is rational. Sure, there’s an internal logic to it, but that’s only because the equation is rigged by brain dysfunction.

Second, I’m also not sure that I’d argue this means addicts have control. Hart’s experiments demonstrate that addicts have influence over their use, not that they have control–that they can delay their use, not that they can stop because of incentives. Does anyone really question what the addict is going to do with that $20 after the study is over? I mean, if I’m really hungry and you offer me $20 to skip a meal, I might take you up on that. But, eventually, no amount of money is going to be enough to get me to skip a meal. Sure, some people are super-human and have the force of will to starve themselves in the name of a cause, but that seems like a case where the exception proves the rule.

Third, Wilkinson uses his own experience to understand the matter. He’s 31, which means he was in his mid-twenties when he quit. We know that large numbers of people in their late teens and early 20s meet diagnostic criteria for alcohol dependence and that something like 60% of them will “mature out” and moderate or quit without any professional help or involvement in a mutual aid group. I believe strongly that those who mature out and those who have chronic problems have categorically different problems and we need to be very careful using the experience of one group to understand the other. I don’t know the writer and I don’t know which category he falls into, but he certainly fits the maturing out pattern.

Fourth, the degree to which we insist on free will and rationality is striking. Think for a moment about the argument that it’s rational for people to destroy their lives using drugs. We’re willing to twist ourselves in meaningless mental knots, ignore the obvious (like the fact that Hart’s subjects are very likely to use the money they get in these studies on drugs), and ignore the common sense ethical problems (experiments that put addicts up for a week, provide them with drugs and release them with a pocket full of money). All to make it fit into our monoculture.

Methadone with and without counseling

by Fearless Tall Dude Killer
by Fearless Tall Dude Killer

Drug and Alcohol Findings reviews research on the impact of counseling for methadone patients.

While across the board there was significant improvement, being assigned to standard/enhanced versus interim (no counseling) programmes did not further improve retention, illicit drug use and related problems, or make much difference to criminal activity. There was no evidence that interim patients has been substantially disadvantaged by the four-month period during which only emergency counselling was available and during which they could not ‘earn’ take-home doses by providing ‘clean’ urine tests.

The findings are consistent with other studies at typical US methadone clinics. They strongly suggest that rather than making such services obligatory, opioid agonist treatment regulations should allow for additional services where these are both helpful to and wanted by patients. As well as increasing costs by imposing services that may or may not be needed, mandating these services has the unintended consequence of denying access to more basic treatment which is demonstrably of value to patients and to society. The findings also raise questions over discharging patients simply because they have not attended the required number of counselling sessions.

Some of the obvious possible explanations are:

  • Counseling is not effective or necessary with opiate addicts. [But, we know it’s effective with doctors.]
  • Methadone interferes with counseling, possibly leaving patients unavailable for counseling. [There’s some evidence for this with MAT. Here, here, here, here, here and here.]
  • That the dose of counseling methadone patients receive is ineffective. [It seems pretty intuitive that once-a-month counseling is likely to be a sub-therapeutic dose.]

Hazelden and Betty Ford have merged

betty ford

From USA Today:

The Betty Ford Center and the Hazelden Foundation have formally merged to become the nation’s largest nonprofit addiction treatment provider.

Officials have openly discussed their struggle to compete with a boom in boutique centers, whose spa-like programs also treat gambling and sex addictions.

Instead of a waiting list at the Betty Ford Center, the $40 million annual operation this summer had some empty beds.

English: Betty Ford Center Logo
English: Betty Ford Center Logo (Photo credit: Wikipedia)

Anna David provides some context here.

One of our staff, who visited Betty Ford Center this year, said, “I’m not too surprised that they had issues filling beds. At their price point, they’re competing against spa treatment programs and the message of Betty Ford is, ‘You can recover, but recovery requires hard work. You can’t buy recovery. You have to work for it.’ I’m not shocked that this is a hard sell.”

Let’s sensationalize recovery

It just so happens that Dawn Farm is co-sponsoring a screening of the film next week.

One Crafty Mother has a post responding to The Anonymous People.

That last bullet point is the one I want to focus on. [There are over 23 million people in long term recovery in America alone.] Changing the public’s perception of addiction by TALKING ABOUT RECOVERY. Because, everyone, RECOVERY WORKS. There are more people in recovery from addiction than there are suffering from it.

Here’s the rub, though. People don’t recover on their own. Every single recovery program focuses on community – on finding other addicts and alcoholics who understand where you are and can help you navigate life without alcohol or drugs.

It doesn’t matter what program of recovery you follow. Recovery advocacy is for EVERYONE.

You don’t have to talk about HOW you recovery, just THAT you recover.

For those of us in programs that have anonymity as a tradition and who are confused about breaking this tradition, this point is KEY. How you stay sober isn’t relevant. You do not have to be a mouthpiece for an individual program of recovery. You can talk about recovery without ever mentioning how you do it. When someone who is suffering asks you how you stay sober (and if you talk about recovery they will ask, I guarantee it), then you are free to share – in the sacredness of a one-on-one (or group) setting – how you do it.

But until the public understands that RECOVERY HAPPENS, people are going to stay stuck in addiction. People are going to misunderstand what addiction means. People aren’t going to know it is quite literally on every street in America. Every street has someone stuck in the darkness and isolation of addiction, and every street has someone thriving in recovery. We have enough coverage of the destruction of addiction. We sensationalize the stories of celebrities crashing cars, going in and out of rehab. We condemn the havoc alcoholism and addiction bring to society.

We are sensationalizing the wrong thing. Let’s sensationalize recovery.

She’s got a great message and very gracefully addresses a couple of potential pitfalls. I like encouraging advocacy while also respecting traditions of anonymity. I also like her emphasizes that there are lots of ways to be an advocate and each recovering person can find their own advocacy approach.

I love her passion and clarity. I’m going to have to watch this blog.

I’ve got one quibble with the statistic the film uses–23 million Americans in recovery. That is based on surveys asking people something to effect of, “Have you previously had a problem with drugs or alcohol and no longer have one?” That kind of question is going to get a lot of false-positives for what we think of as recovery.

The point, however, is there there are large numbers of people in long term recovery in the U.S. And, unfortunately, when people think of addiction, they don’t think of recovering people like me or friends who are doctors, nurses, lawyers, business owners, moms, dads, bothers, sisters, etc. Instead, they think of us as social parasites, or worse, scary people committing a violent or property crime.

Telling our stories is powerful. Dawn Farm often takes clients or alumni to speak to community groups like the Lions, Optimists, Rotary or school groups. The response is always the same–shock that the clients are just like their niece, nephew, neighbor, grandchild, etc.

More on choice and addiction

why oh why by larryosan
why oh why by larryosan

From Kevin McCauley:

The argument against calling addiction a disease centers on the nature of free will. This argument, which I will refer to as the Choice Argument, considers addiction to be a choice: the addict had the choice to start using drugs. Real diseases, on the other hand, are not choices: the diabetic did not have the choice to get diabetes. The Choice Argument posits that the addict can stop using drugs at any time if properly coerced.

As evidence, the Choice Argument offers this scenario: a syringe of drugs is placed in front of an intravenous drug addict and the offer is made to “Spike up!” When the addict picks up the needle and bares his arm, a gun is placed to his temple and the qualifier is added that if the addict injects the drug his brains will be blown out. Most addicts given this choice can summon the free will to choose not to use drugs. The Choice Argument claims this proves that addiction is not a disease. But in real diseases – diabetes, for instance- a gun to the head will not help because free will plays no part in the disease process. So the Choice Argument draws a distinction between behaviors – which are always choices – and diseases.

This is a powerful argument. It is also wrong.

While it is true that a gun to the head can get the addict to chose not to use drugs, the addict is still craving. The addict does not have the choice not to crave. If all you do is measure addiction by the behavior of the addict – using, not using – you miss the most important part of addiction: the patient’s suffering. The Choice Argument falls into the trap of Behavioral Solipsism.

Just as a defect in the bone can be a fracture and a defect in the pancreas can lead to diabetes, a defect in the brain leads to changes in behavior. In attempting to separate behaviors (which are always choices) from symptoms (the result of a disease process), the Choice Argument ignores almost all of the findings of neurology. Defects in the brain can cause brain processes to falter. Free will is not an all or nothing thing. It fluctuates under survival stress.

Hat tip: Matt Statman


If it wasn’t rational, cont’d

English: Cocaine user "tweaking" or ...
English: Cocaine user “tweaking” or withdrawing from cocaine searches ground for small bits of lost or overlooked crack cocaine, while standing beneath an anti-cocaine graffitum. (Photo credit: Wikipedia)

Yesterday I posted about a recent NY Times column arguing for a rational model of addictive drug use:

“When they were given an alternative to crack, they made rational economic decisions.”

When methamphetamine replaced crack as the great drug scourge in the United States, Dr. Hart brought meth addicts into his laboratory for similar experiments — and the results showed similarly rational decisions.

“If you’re living in a poor neighborhood deprived of options, there’s a certain rationality to keep taking a drug that will give you some temporary pleasure,”

I was thinking about it a little more and several people have spoken with me about it.

I have two thoughts that I’d add to yesterday’s post.

First, it might be rational if the person’s life is hopeless. This premise worth thinking deeply about.

nihilism by Brett Jordan
nihilism by Brett Jordan

Second, several people have commented on the ethics of his studies:

Dr. Hart recruited addicts by advertising in The Village Voice, offering them a chance to make $950 while smoking crack made from pharmaceutical-grade cocaine.

Um, yeah.  There is that. It never ceases to amaze me that a human subjects review board would approve this kind of study.

Happy Labor Day!

The video’s got nothing to do with recovery, but it’s a great song and is apropos for Labor Day.

While we’re on the subject of labor, Bill White had a post a while back on the subject:

In 2011, Dieter Henkel of the Institute for Addiction Research at the University of Applied Sciences in Frankfurt, Germany, conducted a comprehensive review of international studies on the relationship between substance use and employment that was published inCurrent Drug Abuse Reviews (4, 4-27).  Henkel drew the following conclusions from his review of more than 130 scientific studies:

  1. Unemployment, particularly prolonged unemployment, heightens the probability of risky alcohol and other drug (AOD) use and the development of AOD dependencies, with these risks being significantly magnified for young adults.
  2. AOD problems heighten the risks of losing unemployment and decreasing one’s odds of re-gaining employment.
  3. Those in recovery from AOD problems are at increased risk of losing their jobs and being denied employment due to stigma-related discrimination.
  4. Unemployment following recovery initiation increases the risk of resuming AOD use and experiencing more severe consequences resulting from resumed use.
  5. Unemployed men and women are more likely to smoke and to smoke greater quantities–a concern given the greater risks of AOD resumption and mortality for smokers in recovery from other addictions.

Put more affirmatively, stable work lowers the risk of developing AOD problems and is a major factor in enhancing recovery stability and quality of life in long-term recovery.

Then Bill threw down the gauntlet:

So here’s the question:  if employment is such a critical factor in recovery initiation and recovery stability, and if addiction treatment programs really are committed to science-informed addiction treatment; then why do we not see vocational education and training programs integrated as a service option within all addiction treatment programs?  Why are purchasers of care not demanding integration of these “ancillary” supports to slow the revolving door of acute addiction treatment and to improve long-term recovery outcomes?

We’re working on it.


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.

Sentences to Ponder

by karola riegler photography
by karola riegler photography

…conducting an RCT (randomized controlled trial) comparing two medical treatments (depot naltrexone and methadone.) misses the critical issue—that cure of addiction is not through medical interventions. People need social roles that provide identity other than being an addict and provide alternative rewards to drug use, in order to recover from addiction. Medical treatment cannot provide this.

…Lacking the rewards of social role and affiliation with social structures—primarily employment—an individual’s capacity to recover from drug dependence is restricted. A clear-sighted acknowledgement of what treatment can reasonably be expected to achieve is essential before pinning unrealistic hopes on new treatment options. The most likely outcome of further experience and research will be to confirm that, like methadone and buprenorphine, depot naltrexone will be helpful for some people during some periods of their addiction.—James Bell in the journal Addiction (Pay-walled)

“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.