It`s not 1960 anymore

I began my career as an alcoholism counselor in 1962 in a 28-day, inpatient, 12-Step, disease model alcoholism treatment program. There was no patient assessment of any kind, there was no treatment planning, and treatment consisted of 28-day immersion in the Steps and Principles of Alcoholics Anonymous (AA).

Group therapy consisted of reading and discussing a chapter in the Big Book or listening to a tape recording of someone telling his/her story at an AA meeting. The psychoeducational component consisted of Step lectures or topics such as the disease of alcoholism. What I have just described would not be considered “treatment” by today's standards.

Funny thing, though: It worked, and many patients went on to become the early alcoholism counselors after their own treatment. The fact that this approach was the precipitant for so many people to begin their recovery screams for explanation. If this was not treatment by today's standards, as valuable as it might have been, this phenomenon leads us to take a closer look at the patients back then.

A more homogeneous group

The demographic of patients 50 years ago was remarkably different from that of today's patients. They were mainly white, male and middle-aged, and used alcohol almost exclusively. For the few people who might have been using other drugs, these were prescribed medications such as barbiturates and early benzodiazepines. If an individual used illegal drugs such as heroin, he simply was not admitted to this type of program.

At that time, alcoholism and illicit drug addiction were considered two totally different disorders, and the treatment approaches were very different (for example, people in drug therapeutic communities could earn “drinking privileges”). Treatment for the two disorders was provided in separate facilities.

People with co-occurring mental health disorders were usually referred to a mental health provider, and if they were somehow admitted to alcoholism treatment they were routinely taken off all psychiatric medications. If they had criminal justice problems, they went to prison or jail instead of treatment.

Most patients were employed, often in higher-level positions or professions. If they were not employed, they most likely had lost their employment because of their drinking. Very few had not graduated from high school. Many were college graduates or had postgraduate degrees. If they were not living in an intact family, the most common reason was loss of their family due to their drinking.

I used to say, “If you wring a drunk out damp dry, you have a functional drunk!” This was accurate in that these individuals had been functional and their current dysfunction resulted directly from their alcoholism. They were truly “rehabilitatable.”

Moving ahead to today's patients, we find that many, particularly in the public sector, are not rehabilitatable but only “habilitatable.” This means learning coping and living skills for the first time, as opposed to removing the barriers (the alcoholic's drinking) to coping. And for so many of them, trauma has provided the seedbed for their addiction.

So what we have is a mismatch between yesterday's treatment and today's patients. Please understand that the old psychosocial, 12-Step, disease model treatment is not irrelevant today; rather, it is insufficient by itself to respond to the needs of today's patients.

Three-legged stool

What will it take to enhance the likelihood of successful recovery for today's patients? Relying on my 50 years of experience as a clinician, clinical supervisor, administrator, trainer and consultant, I have arrived at the conclusion that recovery for many is supported by a three-legged stool.

The seat of the stool represents recovery and the three legs represent psychosocial treatment, recovery support services (including case management), and pharmacotherapy or medication-assisted treatment.

Psychosocial treatment incorporates the 12-Step, disease model approach but is broadened by the addition of trauma care and other evidence-based treatments such as motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), hypnotherapy, neurolinguistic programming (NLP) and eye movement desensitization and reprocessing (EMDR). It also might include the Community Reinforcement Approach (CRA), family and couples therapy and assertive community treatment (ACT), depending on patients' clinical and demographic presentations.

Still, psychosocial treatment alone is inadequate to bring about recovery for many addicts. The fallacy is that while we might consider addiction to be a chronic, relapsing brain disease, we have been treating not the whole brain, but only a portion of it—the cerebral cortex, the thinking, reasoning, cognitive part of the brain. We have done this with individual and group therapies, reading and writing assignments, and psychoeducational presentations. What we have not done is treat the limbic system, the part of the brain responsible for drives such as hunger, thirst, sex, and drug craving.

It is very difficult for patients sitting in group to be able to focus on treatment when they are craving and all they can think about is how and when they can get their next drink or drug. Fortunately, there are medications that can lessen those cravings, with direct anti-craving effects (antagonist treatment) or through substitution of another drug for their drug of choice (agonist treatment). Yet in spite of extensive research pointing to medications' efficacy, there is still much resistance among many providers to use them at all, much less embrace them. This cries out for an explanation.

Use of the term “medication-assisted treatment” is unfortunate. There are chronic diseases for which medication is used as part of treatment; hypertension and diabetes are examples. But if a person is diabetic and is using insulin to control blood sugar, we don't label that “medication-assisted treatment.” It is just part of the treatment regimen, which includes testing blood sugar levels (akin to continuing to take personal inventory), managing diet (similar to going to meetings), and avoiding foods that will cause a spike in blood sugar (like staying away from “people, places and things”).

The origin of the resistance to using medication as a tool in addiction treatment may have stemmed from the early physician treatment of alcoholics, which involved the inappropriate prescribing  of other sedative-hypnotics such as barbiturates and benzodiazepines. Medication-assisted treatment became associated with only methadone, an opioid agonist, and the majority of clinicians who came out of a 12-Step, disease model orientation would say, “If you are on methadone, you are still addicted.” This belief is patently inaccurate.

It is true that if the client is not abusing methadone or any other psychoactive drug, the client remains physiologically dependent. But addiction, in contrast to physiological dependence, is characterized by loss of control, compulsion, continued use in spite of adverse consequences, and craving.

Medication options

There are three types of medications that can be employed in the treatment of addiction: aversive medications (Antabuse for alcohol use disorders); agonist medications for maintenance or withdrawal in opioid dependence treatment (methadone and buprenorphine); and antagonist medications that block the effects of the drug (Campral for alcohol dependence and naltrexone and Vivitrol for both alcohol and opioid use disorders).

There is now a significant body of research illustrating that these drugs can delay the time to first drink, reduce heavy drinking, reduce holiday drinking to almost nothing, increase abstinence (seen in alcohol and opioid treatment), enhance motivation to quit, decrease readmissions to treatment (alcohol), reduce craving (alcohol and opioids), reduce discharges against medical advice (opioids), and reduce healthcare costs (alcohol and opioids). A legitimate concern arises over whether patients on these medications will forgo attendance at continuing care and support groups. But at least one study has demonstrated increased attendance at outpatient treatment and AA among medication users.

So why the continued resistance to the use of pharmacotherapy? The answer seems to be related to the persistent belief that the use of pharmacotherapy in recovery renders the user “still addicted”; the lack of belief in the efficacy of these drugs, including a lack of commitment by senior administrative and clinical staff; the belief that pharmacotherapy is intended to replace rather than augment psychosocial treatments; the notion that these drugs are incompatible with AA or Narcotics Anonymous (NA); the fact that antagonist medications are psychoactive or addictive; and the slow acceptance of change in general in this field. Note the time it has taken for the field to accept the existence of co-occurring mental health disorders and the willingness to treat these disorders with psychiatric medications, or the slow replacement of confrontation with motivational enhancement therapy.

The third leg of the stool is recovery support services, especially needed by patients in early recovery. These are not treatment services, but they promote client engagement in the recovery process and provide services needed for support of continued recovery. Included in this category are safe and sober housing assistance for those who are homeless or should not return to past living arrangements; help in obtaining a GED; college preparation; vocational assessment and training; assistance with transportation options to and from treatment; life skills training; child care; finding a positive social support network; and access for needed physical health services or other case management services.

None of these three approaches alone is sufficient to treat today's patients, but employing all three in an integrated system can bring today's treatment forward to match patients' diverse needs, thus enhancing treatment outcome.

Gerald Shulman is a Clinical Psychologist, Master Addiction Counselor and Fellow of the American College of Addiction Treatment Administrators (ACATA), based in Jacksonville, Fla. With more than 50 years of experience in delivering and supervising treatment, he offers training and consultation in addiction services. He wrote on simple steps to delivering effective customer service in the January/February 2013 issue. His e-mail address is GDShulman@aol.com.