The Beginning of the End of the Abstinence Rule? - Page 2

By Maia Szalavitz 11/08/12

When Hazelden realized traditional treatment for young opiate-painkiller addicts was failing, it introduced maintenance therapy. Only a week later, the backlash has begun.

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Historic Hazelden photo

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For maintenance patients, this means that most NA meetings may be tricky to negotiate. In some, they will be seen as sober members, working a good program as long as they participate fully and honestly. In others, their recovery literally will not count and they will be banned from speaking. For people who are alcoholics as well as opioid addicts, however, AA’s policies on medications state that “we are not doctors” and that medication prescribed by a knowledgeable physician aware of the patients’ addictions is acceptable when taken as prescribed.

With the ability to integrate people on medication-assisted treatment into at least some 12-step meetings, Hazelden was able to clear a significant hurdle. But Seppala remained concerned about staff resistance, recalling a training when a real old-timer stood up. She herself had been with Hazelden for decades, first as a patient, then working in the kitchen, next as a counselor and finally as a supervisor. She had beaten heroin with 12-step abstinence and made a career out of helping others do so. Seppala was worried.

When Cheryl spoke, however, she took an unexpected stance. While abstinence had worked for her, she said, it had failed miserably for her daughter, J. Seven rehabs—including Hazelden—had not been able to break her addiction to prescription opioids. But on Suboxone, J. had managed for the first time to put together a year of recovery and regain custody of her child. “This melted everyone in the room,” Seppala says, although he knows that not everyone in the organization is totally convinced.

One reason for ongoing concern is the widespread misconception that people on Suboxone or methadone are “high” all the time—just as alcoholics would be always drunk if “maintained” on alcohol. But alcohol and opioids are different drugs, with different pharmacological effects on the brain. With alcohol, while people do develop some tolerance to the impairment in motor control and cognition caused by drinking, this tolerance is not complete and drinking always results in some deficits. By contrast, with opioids, complete tolerance develops not only to the high but also to the associated impairments. If someone takes a steady, regular dose, he or she will be as capable as anyone else of driving, being emotionally open and working productively, as many studies find.

Several private rehabs—including Hazelden itself—met in October to develop a “white paper” to shore up support for abstinence-only.

“I could tell you so many stories of people I treated who go to school, get jobs, even practice medicine,” says O’Brien of his patients on maintenance with methadone or Suboxone.

Why, then, does the myth prevail that maintenance patients are always high? Part of the problem has to do with a feature of maintenance that more often looks like a bug. That is, maintenance treatment tends to retain relapsers at a much higher rate than abstinence-based treatment. People who are actively relapsing aren’t exactly welcome in sober housing or residential rehabs—and they tend not to spend much time at 12-step meetings, either. (Although we have all known people who are actively relapsing who continue coming to AA meetings. Drunk folks at meetings are not an uncommon sight at certain meetings.) While some attend when they are ready to try to get clean again, active users who don’t want to stop have little reason to hang out at meetings. This makes those who are doing well and maintaining recovery visible in rehabs and meetings and those who are slipping and failing far less so.

Maintenance treatment, by contrast, tends to keep relapsers in care. They “use on top” rather than dropping out, which can be helpful because it at least provides some engagement with medical car, it often reduces use when not eliminating it, and it allows the choice to abstain when desired by preventing withdrawal symptoms.

This, however, makes maintenance "look" far worse than abstinence. At any given time, most people in treatment aren’t succeeding with either abstinence or maintenance. But the “maintenance failures” are visible at the clinic, while the abstinence failures are not at the rehab. Moreover, the public support for abstinence, and the stigma attached to maintenance, means that the abstinence successes tend to speak out in the media, while the failures quietly blame themselves.

What that all boils down to is that most of the maintenance patients who are visible will be using on top, which will, of course, produce a high—and that will make maintenance itself appear to be intoxicating. Although if you see someone “high” after stabilization on maintenance drugs, generally either they are not taking their medication correctly or they are using alcohol or other drugs as well. In the popular mind, this is attributed not to relapse but to the nature of the maintenance drug itself.

This difference between what you tend to see and hear about maintenance and what the research actually shows accounts for a large part of why treatment providers have often resisted believing the data, journalists have often collaborated in stigmatizing maintenance, and the public remains largely misinformed.

Hazelden has done the right thing by finally accepting the data—the appropriate response is to study the science and understand why it’s so different from what the public believes, not try to find your own tame researchers to torture the numbers into saying what you wish they said. We’ve heard a lot about the rise of quants and their success in both political campaigns and in predicting the outcome of this election. In addiction, we need to join the reality-based community and accept what the research says as well.

Hazelden has just taken a big step in the right direction. They need to be supported, and their lead followed by other programs that have traditionally avoided medication use. In cancer therapy, we don’t have some hospitals that give all patients chemo regardless of their condition, while other centers swear only by radiation. That would be malpractice. It’s long past time that addiction programs stopped doing the medical equivalent by refusing to use medication when appropriate.

Maia Szalavitz is a columnist at The Fix. She is also a health reporter at Time magazine online, and co-author, with Bruce Perry, of Born for Love: Why Empathy Is Essential—and Endangered (Morrow, 2010), and author of Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006).

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Maia Szalavitz is an author and journalist working at the intersection of brain, culture and behavior.  She has reported for Time magazine online, and is the co-author, with Bruce Perry, of Born for Love: Why Empathy Is Essential—and Endangered, and author of Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids. You can find her on Linkedin and  Twitter.