No offense Harry, but your posts are outside a reality that happens in clinical settings for many patients. I agree with that patients should aim for the getting off of Suboxone, but as was mentioned above, the evidence doesn't support making people get off of it. My own treatment approach used to be closer to your opinions years ago but the reality I was seeing, and not seeing any evidence to back it up either made me change my views in light of the facts. Further, doctors have very limited ability in making our patients "spiritually" recover. While I would hope that a patient's recovery is on that level and that I could help with that, it's not like I can start preaching to my patients in a manner that really is outside my boundaries that ultimately could harm a treatment relationship especially if this is not the approach the patient wants.
As for your passionate support for 12-step programs, the evidence doesn't strongly support them either.
http://www.ncbi.nlm.nih.gov/pubmed/16856072
Some studies show some benefits with AA, and other 12 steps, others don't, but even in regards to the studies showing it has benefits, it's not an overwhelming convincing argument in the sense that your post makes it out to be. It does work for some, but only some.
I've seen patients do very well with 12-step programs. I've seen others not do so well. My own approach to patients is if it works for them, go for it. If not, then don't blame yourself if you made an honest attempt and don't think you cannot succeed because it didn't work. It's not for everyone. The data doesn't support it is for everyone.
The first part of what is written above definitely holds true and is a source of frustration for our field, but what that means to me is that we need to work harder, from the basic sciences to clinical practice in order to address America's number one public health problem.
However, I have much disdain for psychiatrists' dismissal of 12 Step Programs because "the evidence does not support them." Is a Cochrane review really going to be able to reliably tell us whether AA works or not, in the same way that it can tell us to give aspirin after an MI? Of course not. My Evidence Based Medicine course director from Medical School, who is internationally known both in the EBM circles (ie, in Gordon Guyatt's circle) as well as his primary clinical specialty described SR/MAs as like "bouillabaise"- one bad fish can ruin the entire stew. I would hardly describe clinical trials investigating AA as being of strong methodological quality. I realize that most literature across all disciplines cannot adhere to the strict principles of EBM, but regarding the clinical question of AA effectiveness, I think we can safely ignore what most trials say purely based on methodological quality. I strive to be a practitioner of evidence based medicine, but regarding 12 Step Programs, I think anecdotal evidence is without question the best evidence.
Furthermore, contrary to how studies are designed and what most psychiatrists think, 12 Step Recovery is NOT just about attending meetings. The Program of Recovery, that produces the spiritual experience necessary to overcome alcohol, is the 12 Steps themselves. A person can go to 10 meetings a day, but until he or she works the Steps with a sponsor in an honest and thorough manner, he or she has not Recovered. And living through the principles outlined in the 12 Steps must occur on a daily basis, and slowly, over time, the alcoholic/addict's behavior, attitude, and outlook begin to change, and in talking to people who have been sober for decades, this change 1) takes work, 2) takes time, and 3)is a continuous process. Most studies that I have seen tend to de emphasize actual AA involvement. There is an AA involvement inventory from 1996 (I tried to find the actual paper on PubMed but could not), but beyond that there is not much to actually qualify (or quantify) participation in 12 Step Programs. Plus, most of the success stories remain Anonymous.
One of the most interesting "studies" on AA was conducted by the early members themselves. Just using raw data and their own observations, about 50 % of the early AA members who seriously worked the 12 Steps achieved sobriety, another 25% achieved it after one relapse (and of course reworking the 12 Steps), and even more after a second relapse (and working the Steps). Though this hardly holds up by todays standards, I think it is very telling. Our job as psychiatrists is to 1) Get people motivated to work the 12 Steps (and this is where Suboxone as a reward comes in, among non pharmacologic measures as well) and 2) of the ones who seriously try, prepare the patient to work the Steps so that the success rate is as close to 100% as possible. The actual Harry Tiebout was very clear on this; his writings are most certainly relevant today.
Finally, what I firmly refute is the statement that mental health professionals make consistently: "AA is not for everyone". (My response is, yeah, it's only for true alcoholics/addicts who want to quit and not be miserable) Truthfully, there is no reason why someone cannot succeed in a 12 Step Program. Concerns about spiritual matters? 1/2 of the original membership considered themselves either athiest or agnostic, yet they all had the conversion experience that William James described when they became willing, honest, and open minded. Boundary issues with the opposite sex? Plenty of men's only/women's only meetings. Paranoid schizophrenia? (patient believes everyone in meeting is talking about him/her). Though meeting attendance might not be the best idea, at least initially, the patient can still Recover from alcoholism through working the 12 Steps. And his/her psychiatrist should be the one to encourage this. I can go on and on, but again, as long as patients are willing, honest, and open minded, they can succeed in the 12 Step Program. It is our job as psychiatrists to get them there.
