mudpie said:
I'm skeptical, but-
I'm always interested to learn about ways to treat addiction. If you have any evidence or anything else to say about this line of thought, I'd like to hear it. Spefically I would really like to know if there is research that has led you to this opinion.
The closest thing I have heard to what you are saying is of studies done in Amsterdam where heroine addicts were given regimented amounts of heroine in exchange for work programs. The programs had a high success rate with the participants exhibiting long-term baseline functioning. But it had already long been known that heroine addicts are able to go for long periods of functioning. In contrast to the movie 'trainspotting' most heroine addicts I have known have been able to hold jobs for long periods of time before their addictions spun them out of control. Now contrast this to the average crystal meth addict, where the lack of sleep and physiological effects of the drug make it much more difficult to maintain the semblance of normality. Most people would define moderate use as once a week, but if you use crystal meth once a week, that means you lose 2-3 nights of sleep, and think of the disastrous effects that would have on your life. What I'm saying is that this treatment works for heroine addicts (if you think about it the way we treat heroine addiction is with morphine which is essentially the same drug anyways)-but that it wouldn't work for cocaine, crystal meth, has been completely proven to not work for alcoholism.
In every single experience I have had with addicts-and this has been pretty substantial-those who substituted their previous drug use with any drug, be it marijuana or alcohol, or just 'cutting back' on drinking or snorting coke or smoking meth-relapsed back into their original habits. Addicts are addicts because they are unable to use drugs moderately. I've worked with addicts in drug treatment centers and lived in areas with high drug use where I was intimately involved in the lives of those with drug addictions. You are correct that there is no cure for addiction-for an addict to get off drugs and stay off drugs requires a conscious daily commitment to their treatment, and a willingness to not make excuses or denials but to accept the problem for what it is.
I'm neither a psychologist nor a practicing physician yet, so keep that in mind. However, this is an area I have been philosophically and personally interested in for several years. Also, this topic intersects my area of interest for study as a future academic physician.
For one thing, I harbor doubts concerning the dogma that alcoholism (or drug abuse) is a disease. Personally, I am not knowledgable enough to make a judement--one way or the other--at this time, so no one should construe my comments to represent an argument that such conditions or addictions are not diseases. I merely mean to indicate that I remain unconvinced, and I am receptive to alternate theories attempting to explain the problems that these people suffer from. Similarly, I remain open to treatment methods that fall away from the AA/abstinance model of treatment.
I don't maintain that the abstinance model is an utter failure; obviously, it seems to work for some people. I have had several coworkers with serious chemical abuse/dependancy problems that persevered and remain sober after going through AA. Each of these individuals remain convinced that it was AA & God that allowed them to triumph over their addiction.
Despite the success of AA in a certain percentage of the heavy drinking population, there are many alcoholics who attempt AA (or programs similar) yet relapse. Many others abandon AA altogether and resume heavy drinking/drug use. Just as I know a number of people who persevered through AA, I know many people (friends, lovers, coworkers) who did not.
Some may construe such thinking as an attack on AA as a valid treatment option. Such is not a reasonable position to take, however. Consider depression. There is no one treatment method that works on a majority of depression sufferers. Psychoanalysis works in a fraction of the population, Cognitive therapy works in another fraction, SSRIs work in another, non-SSRIs work in another, and so on. To borrow the disease metaphor for a moment: I advocate that drug & alcohol abuse may be more similar to depression (in this way) than it is to cancer or malaria.
Our concern should be to reduce the suffering and to improve the functioning of those who suffer from addictions. Some of these people will be able to "win" through AA. Others will cycle between abstinance and periods of moderate to heavy use. Others still will fall back into heavy use. But (depending on the drug) some will find that they can manage their risks and reduce their harms, despite the fact that they can't quit drinking/snorting etc.
With these facts in mind, I think it is reasonable to open a dialog with a patient/client, find out the degree of use/abuse, and the costs to health and functioning to the patient. After finding out what the client wants, (and after making your own professional judgements about the history and their health) the proper treatment strategy can be attempted.
One treatment option is to attempt AA. Another is to try harm reduction and risk management. One has a high failure rate, but when the treatment succeeds, there is no longer any abuse. If you change the meaning of "success" for AA to count as successful those people who only rarely relapse, then revert to abstaining again for a period, then their treatment is somewhat more successful, but begins to look more like a harm reduction result.
If you define addicts as someone who cannot control their drinking, then moderation is (by definition) impossible for an addict. However, such an argument begs the question about whether or not someone with a drug addiction can actually learn to moderate their drinking and to reduce the risks to themselves and others when they do drink.
The most reasonable position to take is that
A) Heavy drinkers/users are a diverse population, and addiction a complex phenomenon.
B) AA-type treatments will work on a subset of this population.
C) Other treatments can be empoyed with the rest of the population to
i) reduce the amount of use, and thus some of the physiological harm to the patient/client
ii) build new habits of risk-reduction and risk-avoidance when using their drug or drinking their booze.
Only a fraction of the heavy drinking population has "hit bottom" in such a way that they seek treatment (20%, according to the Institutes of Medicine). The rest of these people are self-learning some of these risk & harm reduction strategies. How much better could their lives and health be if we could offer support to them in their effort to reduce (but not necessarily eliminate) their use, and could have experts counseling them on the most effective methods to reduce harms to themselves, their families, and their community?
Zero tolerance programs work in a percentage of the abusing population. We need to address the fact that the rest of the population may better respond to alternate therapies.
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Some of my opinions have been influenced by a book I read about 5 years ago: Heavy Drinking: the myth of alcoholism as a disease, by Herbert Fingarette. The book is good, but not perfect, and introduces a series of intelligent arguments that question the legitimacy of the notion of alcoholism as a disease. A subsection of his book deals with assessing the validity of various treatment methods for addiction. I reccomend this book to anyone (on either side of our discussion) for its clarity, brevity, and the honesty of the author.
Institute of Medicine (1990) Broadening the base of treatment for alcohol problems. Washington DC: National Academy Press.
