One dad’s crusade to save his daughters from addiction
October 9, 2019 7:46 PM   Subscribe

There are treatments that work, but rehab facilities don’t have to use them. One family learned that the hard way. Michel estimates that he spent about $200,000 on treatments for his daughters over the next decade. His itemized tax deduction for “drug treatment facility and therapy” totaled $82,350 in 2009 alone. Most of the treatment facilities his daughters attended rejected evidence-based treatments and practices, but Michel — like many parents and loved ones — didn’t realize that at the time.
Walled off from the rest of the American health care system, the rehab industry has failed to meet the same standards as other medical providers. Regulation, primarily by the states, is lax, letting facilities offer care that doesn’t meet rigorous scientific or clinical standards. Even though addiction is widely understood to be a medical condition that requires medical treatment, it’s still not often treated as one — with rehab facilities sometimes not employing even a single nurse or doctor.

Once Michel’s daughters received medication-based treatment, they got better. Unlike many costly treatments, studies have found that medication can be effective in helping patients overcome addiction. And it’s frequently far less expensive. Both daughters are now in recovery: the older for more than two years and the younger since early 2019.

Michel is not alone. As part of The Rehab Racket, Vox’s investigation into the US addiction treatment industry, hundreds of people have reached out through our survey to share their stories about spending tens or hundreds of thousands of dollars on addiction care only to receive inadequate or even damaging treatment — all in the middle of an opioid epidemic killing tens of thousands of Americans each year.

Among the many responses, there are success stories that make clear that recovery from addiction is possible. Treatment, when evidence-focused and accessible, can help.
Vox is investigating addiction treatment in America. This is the second story.
(previously)
posted by Homo neanderthalensis (79 comments total) 48 users marked this as a favorite
 
I'd wager a significant sum of money, after being involved in a few litigations around these issues, that more staff members at rehabs are ex-addicts (with a strong ideological attachment to the program they advocate) than are clinicians not in recovery.

Maybe that should change.
posted by snuffleupagus at 8:16 PM on October 9 [19 favorites]


About 70 percent of addiction treatment facilities use the 12 steps. And even when 12-step facilities claim they embrace other forms of care, they often don’t in practice — and shame those who try the alternatives, especially medications.

...

This is typical: The majority of addiction treatment facilities in the US don’t offer any of the three FDA-approved medications (buprenorphine, methadone, and naltrexone). And those that do offer medications often limit their use to detox instead of the longer-term maintenance therapy that’s frequently needed for opioid addiction.


The moralizing, unscientific, holier-than-thou approach of the 12-step program has always grated on me. It just seems so unhelpful and close-minded. I know it works for some (and I'd be happy to hear from folks here who may have more experience and disagree with me!), but it seems like with a more conscientious approach it could work better for many more.

It's a crying ass shame and yet I'm completely unsurprised to find that the greater part of rehabs are pulling this BS. In our capitalist society where corporations are selling out their morals in pursuit of the almighty dollar, it's entirely to be expected that this industry would be doing the same - bilking families and insurance companies out of their money for all they can. Intentionally creating repeat customers of their services, instead of promoting actual scientifically proven better treatments.

That's some next level evil right there, good on Vox for working to expose it.

And thanks for the post! I volunteer with a community center in a part of my city that sees many people going into / coming out of rehab programs. I'm lucky to count many of them as friends, and am looking forward to sharing this new knowledge with them and their families.
posted by allkindsoftime at 8:18 PM on October 9 [26 favorites]


The majority of addiction treatment facilities in the US don’t offer any of the three FDA-approved medications (buprenorphine, methadone, and naltrexone).

There's also baclofen which is FDA-approved as a muscle relaxant. Your (US) doctor can prescribe it to you "off-label".

Here's an easy-to-read deep dive into baclofen.
posted by bendy at 8:44 PM on October 9 [8 favorites]


It's a crying ass shame and yet I'm completely unsurprised to find that the greater part of rehabs are pulling this BS. In our capitalist society where corporations are selling out their morals in pursuit of the almighty dollar, it's entirely to be expected that this industry would be doing the same - bilking families and insurance companies out of their money for all they can. Intentionally creating repeat customers of their services, instead of promoting actual scientifically proven better treatments.

I've gotten sober through a 12 step program, and I've seen 12 step programs work dramatic change in many a soul, but you are absolutely right here. Inpatient facilities are frequently run by 12 steppers, they frequently teach out of 12 step literature, but they are institutions that put bread on the table for many full time employees.

Real 12 step meetings are attended by the free will of their attendees, and supported organizationally and financially by their attendees. Most meetings only "cost" a dollar or two (nobody yells at you if you don't pitch in), which goes to rent and coffee. The 12 traditions explicitly state that meetings aren't staffed and run by professional AA instructors.

As a result, as moralizing, unscientific, and holier-than-thou as a 12-step meeting may be (and they vary dramatically from meeting to meeting), they at least have the cardinal merit that if you don't like them and you don't think they work, you aren't out any money, and you are free to leave and either go to another meeting or just say to hell with it.

Society has put up institutional pressures that mess with that cardinal merit to varying degrees, but it seems clear to me that the inpatient setup blasts away at it hard. And if you don't like your inpatient institution, you could feel pretty stuck.

I know enough people who work at rehabs to know that they don't intend to bilk families and insurance companies, but I've heard enough stories to know that what you describe is exactly what they are accomplishing, regardless of their intentions.
posted by billjings at 8:53 PM on October 9 [56 favorites]


(I want to clarify: I don't agree entirely with allkindsoftime above. They claimed that inpatient institutions intentionally create repeat customers. I did not go that far: I believe that even well-intentioned inpatient clinics are creating repeat customers. If we don't have the accountability to keep up ones who are not well-intentioned, though, that's a dangerous state of affairs that will almost certainly mean that we have ill intentioned clinics out there.)
posted by billjings at 8:59 PM on October 9 [9 favorites]


Anecdata: Stout Street Foundation worked (2yr+) for one of my peeps. Non-drug clinical approach. I personally am a harm-reduction dude - there's no dead people in recovery. Meds if ya need em. TFA is on track - people need alternatives.
posted by j_curiouser at 9:00 PM on October 9 [3 favorites]


I wish that I could multi-favorite billjings' comment.
posted by Halloween Jack at 9:12 PM on October 9 [3 favorites]


I've seen two eye opening documentaries on this in the past year. American Relapse and The Business of Recovery. I think treatment centers are doing this, the evidence seems pretty compelling.

Another thing that adds to the issue is the utter contempt most medical people have for "pill seekers", despite the massive problems they have with addiction in their own community. I know a doc who is an alcoholic and so is her husband and she talks about people she ~suspects~ of being addicts like they are subhuman. I'm sure it puts people off asking for help.

Walled off from the rest of the American health care system, the rehab industry has failed to meet the same standards as other medical providers. Regulation, primarily by the states, is lax, letting facilities offer care that doesn’t meet rigorous scientific or clinical standards.

And thats different from regular American doctors how exactly?
posted by fshgrl at 9:14 PM on October 9 [10 favorites]


This Puritan bullshit that if you're addicted you don't *deserve* medication because it's like heaven forbid you get to "take the easy way out" if you already are guilty of the ultimate sin of having a normal human body that reacts to certain chemicals in a very predictable way. It's such stupid, harmful bullshit.

There were problems at home and school, and she was bullied. “Drinking and using just became the way to cope with things,” she told me. And, she added, it helped her find friends — letting her “hang out with people I didn’t feel like had standards that I didn’t meet.”

I guess in some way being so socially isolated that nobody told me that people took drugs to solve the very problems I had was actually a blessing. I would have been right in this boat.
posted by bleep at 10:31 PM on October 9 [33 favorites]


I’ve known far too many drug and alcohol addicts. Some have kicked the problem and have been sober for decades. Some have kicked the bucket thanks to their addictions. I know people who have gotten sober just on 12 step programs, and that’s great. There’s some very important things in there, especially confronting the fact that you have a problem and confronting the fact that you’ve hurt people. But kicking any habit is hard, especially a habit that re-wires your body in the ways addiction does. If you’re charging these kinds of sums, and not even trying to deliver clinically proven methods of treatment, you’re not only taking away a family’s money, but their hope as well.

(As a side note, I’ve told people before that society may talk about improving mental health care, but that it’s not ready to actually do what’s needed. Removing the stigma is only a small first step. There are not enough clinicians, and cost is a huge barrier to getting help. The opioid crisis only lays that even more bare. If you need addiction treatment, first you have to find where to turn and then you have to figure out how to pay for it. That’s a heavy burden for someone who is in this kind of trouble, and these types of facilities are a further drain on the system.)
posted by azpenguin at 10:37 PM on October 9 [8 favorites]


Whoo boy do I have feelings about this, as someone who’s seen at least a fifth of my friends die in the last ten years from self medication that led to addiction or suicide from untreated mental health problems - and probably another fifth of my friends are right now straddling the line between the two.

I think medication makes sense for those people who just have physical addiction problems. But you have to deliver real hope for people who are self medicating for other problems, or for societal problems. And that’s increasingly in short supply these days. It’s not moralizing to say it can’t always be fixed with a pill. Our society is deeply sick and its casualties are people like this.

Some people need mental health treatment 3-5 times a week. Name me a healthcare that pays for that. Some people need jobs, or to learn how to have relationships. Nobody is paying for life coaching. People need their worlds fixed too, to have something real to live for. Almost no one is offering it.

I don’t think these facilities are rip offs. I think they’re probably trying their best, especially if they’re staffed by ex addicts trying to share what worked for them. But the world is so much more terrible now.
posted by corb at 11:12 PM on October 9 [19 favorites]


Some of them are doing their best. I know people who work in ones like that. Some (many) are indeed ripoffs, and I know plenty of people who have gone through that particular pipeline. Some are medical, some are not.

However, I would wager that any studies purporting to demonstrate effective ways to help addicts stay clean are not longitudinal or rigorous enough to have merit, because that's true of most social interventions (fair warning: my expertise is in educational research, not addiction research). They're all barking in the dark, including those who believe in a medical approach.
posted by Peach at 11:27 PM on October 9 [3 favorites]


It’s not moralizing to say it can’t always be fixed with a pill.
That is true but people still are at least aware that there's therapy *and* medication for anxiety & depression. "The pills might work but we just don't do that here" is either moralizing or ignorance or worse.
posted by bleep at 11:28 PM on October 9 [14 favorites]


While we're mixing it up people with depression & anxiety should get to go to rehab too.
posted by bleep at 12:10 AM on October 10 [2 favorites]


Sober for Good, accounts from people who've solved their drinking problem.

Briefly, drugs work but there are a lot of non-drug, non-AA methods that work, too, and AA premises (you have to hit bottom, you need a group, one day at a time, a higher power) aren't true for a number of people who've succeeded.
posted by Nancy Lebovitz at 1:00 AM on October 10 [6 favorites]


We also need tools--pharmacological, therapeutic, whatever-- to help people who overcome addiction but later have legitimate need for painkillers and other potentially problematic medications. Some people suffer immensely because they (or their caregivers and loved ones) so fear the slippery slope to relapse. A family member of mine endured debilitating pain after a terrible accident trying to avoid risk of relapse, pain which other ex-addicts in his circle urged him to power through and ultimately contributed to his suicide. He didn't want to live in pain, nor did he wish to live as an addict. He was buried with his 12-step coins.
posted by carmicha at 1:23 AM on October 10 [18 favorites]


I don’t think these facilities are rip offs. I think they’re probably trying their best, especially if they’re staffed by ex addicts trying to share what worked for them.

Just like half of the people peddling snake oil through a pyramid scheme are just sharing what worked for them. I'm sorry, but the evidence of what constitutes effective treatment exists, and to ignore it while representing yourself as a treatment facility is, at the very least, the grossest medical negligence.

I don't give a fuck about their warm fuzzies. I care that their wilful ignorance is killing people.
posted by howfar at 1:44 AM on October 10 [24 favorites]


Not just America. NZ is having a political kerfuffle about pill testing at festivals right now. In favour is the Prime Minister, the Police Minister, Labour, Greens, the decent media, 75% of the population who answer polls, and fucking everybody who is evidence-based. (Disclosure: I'm deputy manager of the not-for-profit that's doing the testing.)

Against is the opposition party and the Law and Order spokesperson of NZ First, who make up the coalition government with Labour. NZ First are currently not fronting up to the media, so when the shitty media are looking for someone to argue against pill testing, who do they go to?

Well, today it's some random "drug rehabilitation expert" from Australia, who runs a faith-based rehab centre which apparently involves mostly shouting at people. Oh, and "tough love" and "praying the gay away". He's got a website that's long on stories and short on evidence or independent assessment.

What's frustrating is that NZ has solid, evidence-based treatment and rehabilitation for alcohol and other drug disorders, yet the people making the noise and getting all the attention are very much the shallow end of the swimming pool.
posted by happyinmotion at 2:15 AM on October 10 [16 favorites]


I think what's incredibly incredibly harmful is that we know what works. And it's not just medication, and it's not just therapy it is both and has always been both. We know that trauma informed approaches are critical. We know that social determinants of need to be addressed, and yet co pays are still common, medication coverage spotty, transportation not covered and housing needs addressed in a very random way. We know that relationships with therapists are incredibly important, but use interns and approve therapy on 2 to 6 week increments. We know that there are plenty of behaviors that are due to mental illness or addiction and user those behaviors to bar people from treatment. We know that mental illness and chronic medical conditions exist with substance abuse all the time, and yet create barriers for individuals seeking care. Our mental health system wants to ignore substance use, and our substance use system wants to ignore mental illness. Both are wrong.

The differences between a medicaid run treatment program and a program aimed towards private pay or private insurance is huge not just in the diversity of programs (and many programs still rely soly on 12 step for most of their programming) and the quality of the lighting in the building, but how staff interact with their patients, the freedoms they are afforded and how they transition from one level of care to another. It's important to look at what we are denying our poorest and most vulnerable substance users in addition to improving care across the board.

Treatment for addiction isn't overnight. It is recovery from a chronic condition and requires rehabilitation . Just like, for example, people don't just recover from strokes we cannot expect that someone can learn how to live sober in a short amount of time or do it without assistance. The brain is changed. We know that.

In IL becoming a substance abuse counselor requires 18 credits of community college classes, a GED, a 500 hour internship, and passing a multiple choice lisensure exam. It's not enough . It really really isn't. And every substance abuser needs the professionals (all of them!) To be incredibly well educated on the effects of addiction and the practices that work. Everyone needs individualized treatment plans that holistically address the patient.
posted by AlexiaSky at 4:14 AM on October 10 [17 favorites]


It's honestly kind of shocking how many of the rehab places around where I live are literally engineered to provide false hope for lots and lots of money. There is a story in the newspaper pretty much every week about someone "sneaking out" of a supposedly secure rehab facility and being found dead of an overdose on a street corner.

I have no doubt there are inpatient rehabs that mean well, but they aren't the nice looking ones with slick websites that charge princely sums to the families of the addicted.

Also, while it is true that medication and therapy in combination has the best long term outcomes, it is also true that the availability of medication like buprenorphine alone is enough to significantly reduce the death rate. Even if we can't help people fully recover due to a lack of therapy providers, there is nothing except puritanical moralizing that is stopping us from allowing more doctors to prescribe medication to help people survive until they can get the therapy needed to solve/cope with the underlying issues rather than just shrugging our shoulders and letting people die.
posted by wierdo at 4:28 AM on October 10 [4 favorites]


Treatment, when evidence-focused and accessible, can help.

The key to the effectiveness of all medical care! Lots of reform has focused on increasing access to care and we have made some strides forward there (battled by insurers and large provider systems at every turn). I would like to see in the future an effort to bring all these types of care now considered different from or lesser than medical care (mental health, dental, substance abuse, even veterinary medicine) under the same rigorous processes and standards as traditional medicine. Perhaps that would help us combat the sweeping tide of people ceasing to believe in medicine and science.
posted by sallybrown at 4:30 AM on October 10 [1 favorite]


Been moderately perplexed seeing TV ads for clinics with 24hr 800 numbers, seemed like a it needs a major profit center to afford national ads. Did not seem that they are evil or such but more another symptom the entire med system is way out of balance.
posted by sammyo at 5:36 AM on October 10 [1 favorite]


The pattern of ex-addicts working as "treatment counselors" is complex: as a starting point, it can be appropriate and helpful in a number of ways. In residential programs there's a legitimate need for "counselors" in the summer camp sense of the term, and it can make sense for those people to have personal experience with the program.

But when a program is run primarily by ex-addicts with counseling certificates there's typically a lot of reliance on personal experiences and adherence to a preferred program that may be all or mostly some flavor of woo; and lack of real clinical expertise and supervision, not to mention a lack of capital, compliance and insurance. The results can range from dishonestly wasteful through directly harmful to predictably tragic.

Lay against those problems the reality that if you have a checkered enough past after addiction (including alcoholism) then society demands you embrace a public identity around recovery to become "respectable" again (to the point of mandating it judicially in some cases); and you will still have employment problems. (And mix in background patterns of demographic inequality regarding employment and substance abuse.) Getting into "substance abuse counseling" is natural solution to those pressures, if you legitimately feel that re-organizing your life around your program has worked for you and will work for others and you are blocked from most other professional or pseudo-professional opportunities.

Not to mention that affordably treating addiction, with all the prevailing misery, is a growth sector.

And as a society we are largely content with this, because we don't want to devote more "real" resources to a stigmatized group. Leaving it to former addicts whose treatment programs tend to have a strong whiff of religion, or a substitute for religion, comports with the prevailing subtext that we still regard addiction as mostly a moral failing.
posted by snuffleupagus at 6:03 AM on October 10 [8 favorites]


Here's a link from today's paper in my hometown: https://www.syracuse.com/news/2019/10/how-a-rogue-aa-group-puts-syracuse-alcoholics-in-danger-drunk-with-power-episode-1.html

I've been in AA for my entire adult life, and this behavior is self-righteous bullshit. (and it's not just in Syracuse.) These fuckers are killing people. We are not doctors, and even if we are, we're not that person's doctor. I jump right on that whenever I see it, and I talk about it in meetings. This does nothing for my popularity, but I'd rather people rolled their eyes at me than see another addict die from terrible advice.
posted by corvikate at 6:04 AM on October 10 [14 favorites]


Also, everything AlexiaSky said.

Here's some anecdata for you: my youngest cousin Ben was a heroin addict. He got clean, went to NA, and endured three years of abstinence before he went back to using and overdosed in his childhood bed, where his mother found him. He was 30. In NC, about 15 people PER DAY die of overdoses.

The moralizing about "don't use any medications" and "don't replace a drug with a drug" is killing people. People with opioid addictions have changed their brains, just as a person with diabetes has a different pancreatic response, and having a medicine that short-circuits the addiction response is medically sound.
posted by corvikate at 7:00 AM on October 10 [11 favorites]


This whole concept that the way to treat drug addiction is with more drugs, and all the conspiracy theory voodoo associated its promotion, strikes me as something being pushed by the drug companies and rehabs that stand to benefit financially from the drugs. Follow the money, and in this area there is a lot of money flowing. The current rehab industry is a mess, with many unscrupulous or incompetent operators chasing insurance money. Treating opiate addiction with more opiates might be reasonable in the short term, but you are never escaping the dragon until you are opiate free. There is more profit, however, in a lifelong prescription than in a short term one.

This modern world loves a simple solution in the form of a drug for many problems which really scream for lifestyle changes. How many diabetics convince themselves that pancakes are a fine breakfast because their drugs have their blood sugar number in a range higher than a normal person, but good enough for a diabetic? How many people at risk for or even suffering from heart disease believe they can ignore their diet because statins lower their cholesterol? The list goes on. Modern medicine loves a pharmaceutical cure because it seems quick and concrete, whereas lifestyle changes are hard to sell, hard to measure, hard to enforce, just plain hard.

There are some drugs like the aforementioned Baclofen which show promise to reduce craving and are not themselves just more of the same kind of drug which is the problem. It has helped many people.

Drug use is a real medical issue all on its own, but it is also a symptom of an underlying mental or spiritual issue. If that is not addressed long term recovery is very hard to achieve. A 12 step program is one way, but their are other ways. Some people find the help in religion, others in therapy.
posted by caddis at 7:25 AM on October 10 [1 favorite]


There is more profit, however, in a lifelong prescription than in a short term one.

Would you say this to any other person with a chronic illness requiring lifelong medication?
posted by OverlappingElvis at 7:41 AM on October 10 [27 favorites]


This modern world loves a simple solution in the form of a drug for many problems which really scream for lifestyle changes. How many diabetics convince themselves that pancakes are a fine breakfast because their drugs have their blood sugar number in a range higher than a normal person, but good enough for a diabetic?

This is... not how diabetes works.
posted by vibratory manner of working at 7:46 AM on October 10 [34 favorites]


"In IL becoming a substance abuse counselor requires 18 credits of community college classes, a GED, a 500 hour internship, and passing a multiple choice lisensure exam. It's not enough."

That's about middle-of-the-road as far as variation in the US. State requirements are in some cases even much more minimal than those, and in some other cases at the other extreme requiring post-graduate work. That extreme divergence is a measure of the incoherence of our social notion of addiction and its treatment.

One of the perspectives I have into these matters is via an ex who was an LCDC in Texas, which has requirements higher than those you describe for Illinois, thought not so high as to require an undergraduate degree. And what I find interesting is that she eventually left the field because it was nothing but 12-step as far as the eye could see, and the vast majority of people in treatment were there involuntarily via the criminal justice system -- people for whom, in her opinion, 12-step is not well-suited. She'd be exactly the type invested in that status quo, yet she felt the whole system was broken.

I live with a congenital, incurable illness involving disability and constant pain. I have had effective treatment involving opioids and I have never suffered an addiction. Yet I do not currently take opioids, and am more incapacitated than I need be, because I've found the hassle and stigma associated with opioids to be more onerous than the incapacitation and pain. I'm somewhat angry about this state of affairs.

At the same time, I have a lot of secondhand experience with addiction via friends and family. Mostly alcohol, but in some of those cases terminal-illness levels of alcohol addiction, such as with my late stepsister. Two of her three children -- one with a young child of her own -- are on the same path. If there ever was a time in my life when I couldn't differentiate "addiction" from, say, "alcohol abuse" (whatever that is, but let's just say it's somewhat problematic but not clinically pathological), that's no longer the case because the cluster of interrelated seriously pathological behaviors associated with a dependency that can be loosely called "addiction" is definitely a thing. Is it absolutely, qualitatively distinct from mere substance abuse, or a pharmaceutical dependency, or a mental illness? No, not quite. There's some intersections and continua, yes -- but I think we can clearly see the shape of something there. It's a serious health condition of some sort, requiring treatment. An evidence-based medical approach makes sense.

But I think implicit in what I'm saying and not saying and within all my elaborations and qualifications is that at almost every step, at every level, of our social concept of "addiction" there are serious problems. Inconsistentencies, incoherence, rigid ideology. Our understanding of mental health is likewise confused and treatment scattetshot; indeed, the notions of health and disability themselves are often problematic.

Addiction and its treatment inherits and involves all these problems and, worse, it's notably mired in ideology and stigmatized.

When I look across this landscape I've described, I just want to burn everything to the ground and start over. There's so much broken, it's hard to know what to fix first.

In my view, the tragedy here is that the 12-step understanding of addiction is deeply flawed, but is dominant because in its historical social context it got some things right. We can talk about evidence-based treatment within the medical model -- productively -- but keep in mind that this model is so simplistic it hardly differentiates between dependency and addiction. Medicine, in general, is confused and divided with regard to pain and palliative care; but I think it's clear that addiction involves a pathological, self-medicating palliative response. So the same perspective that currently is suspicious of purely palliative pharmaceutical treatment in general, and which currently has culturally re-embraced, in practice, a moralizing view of addiction, is our superior alternative to 12-step?

I guess what I'm trying to say is that there's no avoiding this problem of moralizing. 12-step is actually, in historical context, an attempt to move beyond the simplistic view of addiction as nothing more than a moral failing, a choice. In its own, clumsy, rudimentary way, it sees addiction as pathological behavior involving both internal and external factors. It can't avoid moralizing because it correctly sees addiction as involving (but not limited to) personal choice regarding behavior within the context of what society sees as "normal". The medical model of health simply elides the matter of social convention. Broadly speaking, it does not recognize that it relies upon that fundamental premise; and so in matters where social convention is especially predominant, as in mental health, its failures are particularly catastrophic. This is why medicine so often fumbles palliative care -- in some deep sense it willfully avoids the problem of pain because pain is both subjective and intimately involved in issues of moral philosophy.

If addiction were nothing other than a dependency treated or managed clinically, then it would be seen neutrally, such as insulin is with regard to diabetes. But it's not because it's not: addiction involves behavioral maladjustment, by defintion within some social context. Therefore, while evidence-based medical treatment is a big improvement over the ad hoc response which is 12-step, it is nevertheless in some respects equally problematic because medicine is deeply ambivalent about mental illness -- and addiction surely has a strong mental health component.

The large cross-cultural variance with regard to mental illness, and with regard to substance abuse, unavoidably implies that the medical model with regard to these matters won't address many of the fundamental issues that are problematic with 12-step. The facts that we have an opioid crisis and we inadequately manage pain and we inadequately treat mental illness and we can't agree on the definition of addiction and ableism decides who is "worthy" of participating in society and who is not -- these are all expressions of some severe, fundamental issues.

The particular problems we have in understanding and treating addiction arise from the unfortunate fact that addiction sits right at the nexus of several related essential conceptual and institutional failures. Evidence-based treatment in the medical model would be an improvement, yes, but far from the improvement many would like to see. The shift to the medical model in mental health in the last century demonstrates both its great benefits and its great failures, and those failures are still profound.

On preview: see the recent comments from corvikate and caddis. On balance, I strongly prefer the first and dislike the second -- but what is both right and wrong with the second is what the first ignores entirely. What we wish for, in vain, is for medicine to provide us with an absolute, objective definition of "health". But it can't. That certainly doesn't mean we should retreat to pious moralizing or defeatist relativism, but that willfully ignoring the complexity increases suffering.
posted by Ivan Fyodorovich at 7:49 AM on October 10 [9 favorites]


Caddis...you're just...not informed on the science behind the treatment of drug addiction, to put it kindly.
posted by agregoli at 7:52 AM on October 10 [18 favorites]


The fact that medical treatment with drugs is risky if treated as alternative to social and economic change is true of every major medical condition. No illness or disability exists in isolation from its behavioural and social consequences. The medical model is inadequate for all illnesses. Criticism of its specific applicability to drug misuse always comes down to moralistic myths about free will.
posted by howfar at 8:01 AM on October 10 [4 favorites]


The 24-hour hotlines are very often actually for "brokers" who will pawn you off on whoever pays them the most for referrals.

Treating opiate addiction with more opiates might be reasonable in the short term, but you are never escaping the dragon until you are opiate free.

I know I've told this story before recently, but I know a lifelong opioid addict who, because of his relatively high social standing in his environment, managed to get and keep access to prescription narcotics his whole life. He died as a senior citizen, and it was the cigarettes (which he'd actually given up many years before) that killed him. His was not a desirable life, but he was both a person with a very bad character independent of his addiction and a survivor of abuse himself. Even under automated gay luxury space communism, he was not going to have a good life. But he didn't die in a McDonald's bathroom at 37, either.
posted by praemunire at 8:11 AM on October 10 [7 favorites]


you have to hit bottom

My personal axe to grind. As if it is LITERALLY IMPOSSIBLE for someone to say "oh shit, I gotta get sober" and do so before they lose their job, marriage, health, freedom, etc. And sloganizing that "your rock bottom is wherever you stop digging" is just admitting that the whole concept is useless.
posted by thelonius at 8:23 AM on October 10 [12 favorites]


Yeah, no, it's not useless; it sure wasn't to me.
posted by Halloween Jack at 8:34 AM on October 10 [2 favorites]


Well, I didn't want to belittle yours, or anyone's, experience. I'm sorry. What I should have said is that it is not helpful, in my view, to insist that someone for who it is not meaningful recast their experience in those terms.
posted by thelonius at 8:46 AM on October 10 [7 favorites]


Even under automated gay luxury space communism

What does this mean?
posted by 41swans at 8:52 AM on October 10 [1 favorite]


I'd like to thank everybody in this thread who has never had an addiction problem for setting me straight and letting me know that I'm a moralizing puritan for working the 12 steps to recover from addiction. And all this time I thought I was someone with a substance abuse problem and I was working toward a solution.
Yes, I think everyone will agree there is a problem with rehabs, how they're licensed, who works in them, et fucking cetera. I suppose there are people in the programs who will tell you that you're completely wrong and it's all good. If we were talking politics, we'd call those people republicans (or capitalists, but I digress).
I'd also like to point out the hypocrisy, of stating that this system was broken, and then making it sound like the rest of the medical community somehow had it's act together.
Really.
Come on now.
I'm for whatever will get the most people help for their serious problems. Medication works, jolly, let's do that. Let's not however decide that those of us getting help for a problem in a manner that works for some of us, are scheming bastards out to make bank and destroy the moral fiber of our defenseless! I get that some of you have gone to meeting s and didn't like them. I've gone to meetings and didn't like them, however, I've gone to others and gotten what I needed. I'm not asking anyone who dislikes the 12 step programs to keep trying, you do you. I'm asking for room to do what appears to work for me, without you telling me it makes me Satan. I'll extend the same courtesy to you.
posted by evilDoug at 9:05 AM on October 10 [8 favorites]


No one is telling you it or you is satan. But studies have shown the success rate for AA is only about 11%. I'm truly glad you were one of those 11%. But courts force addicts into AA as part of their sentences, forced into a program with a low success rate only funnels them back into jail when they more than likely fail. We have evidence based ways to fight addiction, but the AA model is so powerful most people only know it as the only way forward. That has to change.
posted by Homo neanderthalensis at 9:16 AM on October 10 [31 favorites]


I find it hard to believe it's only been a little more than a month since the last let's all shit on 12-step programs comment thread, but I guess Vox is slow-rolling their addiction treatment series.
posted by hanov3r at 9:17 AM on October 10 [6 favorites]


I'm not asking anyone who dislikes the 12 step programs to keep trying, you do you.

If you've been to more than two meetings, you know you've met people who were literally there by force--that is, because of a court order. When that happens, it's no longer a question of what individuals may try to see what's best for them. The standard of efficacy goes way up.
posted by praemunire at 9:29 AM on October 10 [8 favorites]


it's only been a little more than a month since the last let's all shit on 12-step programs comment thread

That's a mischaracterization of the discussion in this thread, frankly. I started out by saying that they do work well for some, but that they could be BETTER and work well for more. That's not shitting, that's trying to think of how things could be better for more people. This isn't a zero sum game.
posted by allkindsoftime at 9:31 AM on October 10 [13 favorites]


There is more profit, however, in a lifelong prescription than in a short term one.

This is so, so ugly and dismissive of people like me who are able to self regulate and enjoy something like a stable life where I can show up for the people who are important to me with a course of pills that yeah, might be lifelong. You are literally telling me that I should forsake the medical technology that lets me live much closer to embodying my values and morals than anything I did previously in favor of, I guess, going off and thinking harder about those values and morals and how I fail to embody them. It is profoundly unfair that most other people have not had the quality of access to the care I have had. The attitude that I am somehow cheating by putting myself into a position to be what I and those around me would consider to be a better version of myself by using pharmaceutical means is part of the reason for that unfairness.

I'll extend the same courtesy to you.

You literally are not because the discussion you are so violently objecting to is not "ban 12 steps," it's "people need options besides 12 steps."
posted by PMdixon at 9:33 AM on October 10 [24 favorites]


"My personal axe to grind."

Yeah. But I think it's a naive attempt to address the fact that elaborate rationalization and self-delusion is (in my opinion) a fairly reliable sign of clinical addiction. That being so, it's often (but not necessarily) the case that people will only commit to treatment when they are in very dire straits.

I should add that my lifelong experience with a chronic illness and healthcare has led me to believe that effective medical treatment for many conditions, but certainly for chronic conditions, rely upon the patient being an active, informed participant in the process. If this is true with regard to my collagenopathy, or with regard to diabetes or depression or cancer, it's most certainly true with regard to addiction. I mean, really, a certain amount of delusory rationalization plays a role in my accepting a lower quality of life than I ought to because a variety of maladaptive responses work for me in the short term but not in the long term. If I find it very difficult to be as active as I need to be because I can't be active without considerable pain, and so I procrastinate and rationalize and avoid it to my long-term serious detriment, then it's hard for me to see why we would expect someone to easily give up their short-term maladaptive coping mechanisms and confront an addiction. In my observation, addiction is very often co-morbid with some very serious, intractable problems. My late stepsister had severe generalized anxiety disorder and agoraphobia -- her addictions seemed to be a lifeline that were actually just slow-motion falling anchors. She was hospitalized and near death on several occasions but that was not enough to drive her to be sober.

It's a continuum. The rock-bottom thing is much truer for people like her (though in her case it wasn't enough) but increasingly inaccurate on the other side of the spectrum. Even so, a signal trait of addiction is to cling to those maladaptive short-term solutions notably far beyond what other people would see as reasonable. There surely are a number of things that 12-step gets right and perhaps that's one of them. I think it's probably the case that they're excessive and dogmatic about it to the point that it is likely in some cases counterproductive and a self-fulfilling prophecy -- but I do think that it's very important to acknowledge just how surprisingly difficult it is to abandon behaviors that, from the inside, feel like coping but, in the long term, are very much the opposite.
posted by Ivan Fyodorovich at 9:36 AM on October 10 [3 favorites]


Automated gay luxury space communism is a somewhat expanded reference to Iain M. Banks's Culture novels, a post-scarcity sci fi universe in which mind-altering substances are accepted enough that people have engineered organs to produce them endogenously.
posted by snuffleupagus at 9:43 AM on October 10 [6 favorites]


Even so, a signal trait of addiction is to cling to those maladaptive short-term solutions notably far beyond what other people would see as reasonable

Oh, sure. Absolutely. I remember when I took an online test about alcohol problems. One of the questions was something like "have you ever injured yourself or anyone else while under the influence of alcohol" and I said, of course I have. What kind of question is that? Turns out that's not normal! But I had accepted it as a cost of doing business.

I actually got curious as to how much that affected my score, and retook the test with a "no" there. It lowered it some, but the sheer quantity I was drinking dominated everything else, and still landed me in FOR THE LOVE OF GOD GET HELP territory on the quiz.

So I could have, I suppose, said "this is rock bottom!" the time I cut my scalp banging into a door and came to the next day, gradually realizing that there was blood all over the apartment and that I had hurt myself in a blackout. But I didn't. I drank for years after that, and learned how to be more careful. What finally worked for me was, I got scared, really scared that I was on the threshold of late-stage alcoholism and that I was out of time and that I needed to take what might be my last chance to not have to live through that horror. But I was still basically holding myself together when that happened.
posted by thelonius at 9:48 AM on October 10 [4 favorites]


Additionally, it's common Mefi shorthand for "the ideal leftist future."
posted by praemunire at 9:48 AM on October 10 [12 favorites]


PMdixon,
I literally am, and if you read with more than an eye to argue my point you would not find much that I would consider violent. Also you would see that I am not opposed to a medical rehabilitation for addiction, my objection was to the use of the phrase moralizing puritans to describe folks in the 12 steps.
Also, praemunire, yes, people are court stipulated.However, I'm not getting your point. Are you saying that the 12 steps are bad because the courts force people to go? If your point is that court stipulation is a bad idea, I agree. I think most folks in a 12 step program would.
posted by evilDoug at 10:01 AM on October 10 [1 favorite]


my objection was to the use of the phrase moralizing puritans to describe folks in the 12 steps.

In fairness, I read that as a response to people who think medical treatment is cheating and addicts should just straighten up and fly right. I dont think anyone is calling AA participants moralizing puritans, just those that insist its the only way and are faith based too and really pushy about it.

I've never been to AA but I know people who have and the extreme right wing facist Christian brainwashing is a thing. At least around here. Its like they traded alcohol for Trump or something.
posted by fshgrl at 10:26 AM on October 10 [10 favorites]


The problem is many treatment centers use 12 step alone, all day every day as a model of treatment has a success rate of 11 percent(that's from above, I did not actually look that up). 12 steps is a free peer led program. It has no business being used in a facility charging more than 1000 dollars a day advertized as top of the line care. It isn't. Top of the line care uses multiple modalities in a trauma informed framework, where 12 steps may play a small role . It is a resource, it is free. But it isn't backed by science. It isn't therapy, or treatment for mental illness . It isn't Medication assisted treatment. It isn't cognative behavioral therapy or dialectical behavioral therapy or smart recovery or hundreds of other approaches that could be offered by trained clinicians.

It is a club of people with a goal not to drink, or use drugs, which is fine . It is a useful place for some. But it isn't treatment.
posted by AlexiaSky at 10:36 AM on October 10 [15 favorites]


Reply All had an interesting piece on the lucrative rehab industry, for anyone interested.
posted by FakeFreyja at 10:39 AM on October 10 [3 favorites]


So I'm going to try and explain Suboxone (a common medication assisted treatment) in layman's terms, please correct me if I'm awfully wrong here, and this is not intended to be a perfect explination but a rough and dirty why give an opioid addict opioids primer. Please note Methadone is a different drug and MAT approach I won't get into here.

First off, suboxone is actually two medications, buprenorphine and naloxone. One is an opioid (buprenorphine) and the other is an opiod antagonist(naloxone), which means it makes opiods not work. You hear about naloxone in the shot or nasal spray to reverse overdoses, because that's what it does. This is key, because if you use suboxone and then go use another opioid, it will decrease the effect (the high). Now dosage matters and people can still manage to overdose (but way less risk than people using). The point is in general, it stops opioids from doing their thing. Honestly I'm not quite sure how the opioid part of suboxone plays into it, other than opioid dependance really messes with the body and pain receptors and it's incredibly uncomfortable (intolerable for many) to just come off of them. Ultimately from my understanding the combination kind of creates a threshold of a "high" so that someone can feel some effects of it but not nodding out/respitory distress level effects and avoid withdrawal. (High is the best word I have, as I said imperfect explanation here). That's why it works. That's why it's safer. Because impulse control is hard and many people really are well intentioned when they wake up not to use, but something happens. If they are well intentioned enough to take a pill, then MAT can be right for them, and decrease the consequences of that use, and also decrease the cravings to use in the first place because of the included opioid part. But it is important to understand that the antiagonist is a part of MAT treatment.
posted by AlexiaSky at 11:06 AM on October 10 [4 favorites]


I'd like to thank everybody in this thread who has never had an addiction problem

Trust me, that's not the angle some people here are coming from.

I actually kind of like traditional 12-step people, even though it's Not For Me. I mean, it can be kinda culty, but there are real communities out there. I am deeply skeptical of most inpatient rehabs, though. I should say I'm mostly talking opiates, here (because that's what I know) but basically:

If you're "functional" (i.e. you have a job and relationships but you have to quit dope because you're out of money or people are finding out or you got in some trouble) what's going to work better for most people - to suspend all that for a month to talk about getting your shit together, or to get on maintenance and get on with your life and with actually getting your shit together? And then the other category, if you're, you know, a true fuck-up, chances are pretty good that you are getting sent off somewhere you don't really want to go and I don't think that does anything. So for the standard 28-day sort of programs to be worthwhile I think you have to be in really bad shape and also to genuinely want to go? And in that case they should probably be longer, really.
posted by atoxyl at 11:12 AM on October 10 [6 favorites]


First off, suboxone is actually two medications, buprenorphine and naloxone. One is an opioid (buprenorphine) and the other is an opiod antagonist(naloxone), which means it makes opiods not work.

This is a little nitpicky but in reality it's the buprenorphine that is responsible for both the opioid effects and the opioid blocker effects. It's a partial agonist of the "main" (mu) opioid receptor - which means it only activates the receptor up to a certain plateau, which also makes it generally safer than most opioids - while also binding to it tightly enough that it locks out other drugs. It's also a full-on antagonist (blocker) of some of the other opioid receptors, the implications of which are less well understood. It's a pretty interesting drug.

I don't think naloxone even lasts long enough in the body to have the long-term blocking effect buprenorphine does. I believe it was added to prevent IV use of suboxone... which it doesn't, because buprenorphine binds to receptors so effectively, but it's not that amazing a drug to inject anyway according to most people I've talked to.

I should say there definitely are people who maintain opiate use while also taking suboxone to stave off withdrawal - taking a low dose or going on and off of it. But I don't think that puts anyone in a worse position than not having it, and with a modest level of commitment I think burpenorphine tends to work pretty well.
posted by atoxyl at 11:32 AM on October 10 [4 favorites]


Some people need mental health treatment 3-5 times a week. Name me a healthcare that pays for that.

Medicaid. This is the goal of the parity rule finalized in 2016.

When I was on Medicaid, I self-referred to a private social worker, went whenever I wanted or needed, and got lots of practical help and emotional support. Depending on the state, Medicaid can also offer job coaching, job transportation, and other community-based services. Medicaid coverage like this might be especially useful to people with a dual diagnosis, so I want everyone to know about them.
posted by Snarl Furillo at 11:33 AM on October 10 [11 favorites]


The other important thing about buprenorphine is that (like methadone) it has a 24+ hour half-life. So it's a once-a-day thing.
posted by atoxyl at 11:35 AM on October 10 [2 favorites]


However, I'm not getting your point. Are you saying that the 12 steps are bad because the courts force people to go? If your point is that court stipulation is a bad idea, I agree. I think most folks in a 12 step program would.

I'm really not trying to be all that complex here. If people are being forced to participate in a particular form of treatment, then the evidence for that treatment's effectiveness should be pretty damn strong.

I would also go so far as to say that if you're charging desperate people lots of money for such a treatment, the same applies. Especially in a situation where a predictable and not uncommon failure mode for the treatment is death.
posted by praemunire at 11:37 AM on October 10 [10 favorites]


atoxyl thank you for that addition, I'd forgotten how burpenorphine worked and that's really really important information!
posted by AlexiaSky at 11:54 AM on October 10


Yes, the entire point of MAT is to convert addiction into manageable dependence. With luck, those on MAT can eventually stop using even that, but who really cares if they don't? There are worse things in life than taking a daily pill, especially when inpatient treatment or intensive therapy is likely to cause one to become unemployed.
posted by wierdo at 11:57 AM on October 10 [4 favorites]


High is the best word I have, as I said imperfect explanation here

I'd say basically it prevents withdrawal and keeps the receptors activated enough to subdue the drive to take more opioids. If you take it without an opioid tolerance - or, say, take twice your usual dose - you will get for-real high, but because of the plateau effect it only takes a short period on a stable dose to reach the point where you barely feel it.

atoxyl thank you for that addition, I'd forgotten how burpenorphine worked and that's really really important information!

Don't get me wrong, your comments are on the right track here. I think some of the information initially put out by the manufacturer of suboxone was a little misleading or based on ideas that weren't really fully tested (like the idea behind including naloxone in the formulation) so there are just a few details one might get a more realistic picture of looking at online drug fora, say. I know I'm sitting on this topic a little bit but it's something I have subjective experience with in addition to having spent some time reading the literature so I figure I might as well contribute what I've got.
posted by atoxyl at 12:08 PM on October 10 [2 favorites]


my objection was to the use of the phrase moralizing puritans to describe folks in the 12 steps.
I used these words in my comments but I never & *would never* use them to describe the folks who are *doing* 12 step programs themselves. I was talking about the people running programs who don't make available all the tools that are in our toolbox for solving this problem because they don't think you deserve to be healthy unless you've struggled hard enough.
posted by bleep at 1:04 PM on October 10 [4 favorites]


The problem is many treatment centers use 12 step alone, all day every day as a model of treatment has a success rate of 11 percent(that's from above, I did not actually look that up). 12 steps is a free peer led program. It has no business being used in a facility charging more than 1000 dollars a day advertized as top of the line care. It isn't. Top of the line care uses multiple modalities in a trauma informed framework, where 12 steps may play a small role . It is a resource, it is free. But it isn't backed by science. It isn't therapy, or treatment for mental illness . It isn't Medication assisted treatment. It isn't cognative behavioral therapy or dialectical behavioral therapy or smart recovery or hundreds of other approaches that could be offered by trained clinicians.

My big issue with 12 step within the context of an inpatient rehab is that 12 step programs excel at psychosocially integrating people into their community in a functional way. When you take those lessons into an inpatient facility, you end up with folks who find a way to be happy and healthy people... in an inpatient facility. This is useless for the wider world.

I can't blame people for looking at that phenomenon from either the inside or the outside and concluding that 12 step programs are useless, or worse. What other conclusion can you draw? So the overuse/abuse of 12 step work within inpatient communities poses a serious threat to the credibility of 12 step programs in general.
posted by billjings at 1:18 PM on October 10 [10 favorites]


More on the disastrous version of this in Australia: "Tough love rehab’s poor success rates revealed"

What do people who are recovering need? According to the muppets at Shalom House, a 12% success rate is "definitely" what they need.
posted by happyinmotion at 2:45 PM on October 10 [2 favorites]


To go back to the original topic I also think thay any treatment facility or provider that pays hundreds or thousands per patient referred as many/most rehab facilites reportedly do, is by definition not operating in the patients best interest. Or their families best interest. Or the larger insurance pool members best interest, be that public or private insurance. I think it should be totally illegal, tbh.

Re read the article and compare rhe cost of the successful and unsuccessful facilities this family used. I think that tells you all you need to know about the philosophy behind them.
posted by fshgrl at 3:19 PM on October 10 [6 favorites]


Something I've always wondered: what would happen if you just gave opiate addicts as much free heroin as they wanted? Assuming no surprise contamination by fentanyl or other, more dangerous substances, would most people just reach an equilibrium point of use, or does the addiction naturally escalate to the point of overdose or more-or-less constant inebriation?
posted by yersinia at 8:32 PM on October 10 [1 favorite]


At a certain point, you're just shooting up to get well, not even to feel all that high for particularly long (though you certainly won't be "sober"). Most overdoses result from (a) contamination; (b) miscalculated dosage; (c) combination with some other CNS depressant or similar; or (d) quitting, relapsing, and not realizing your tolerance has diminished. I believe there would be very few deaths resulting directly from use if all people only took premeasured doses of legitimately-manufactured drugs using clean works at a supervised injection site. (Although if you're in that world, they might as well go all the way and give you the tablets.) It is not a life that you'd wish on anybody--you couldn't hold a meaningful job, for instance--but it wouldn't be death, and while there's life, there's hope.
posted by praemunire at 9:23 PM on October 10


That's literally what Switzerland does. It's called heroin-assisted treatment.

It works extremely well, with substantial reductions in deaths and HIV infections. People tend to stabilise their dosage about a few months. It's also very affordable, ~20k Euro per year.
posted by happyinmotion at 10:38 PM on October 10 [4 favorites]


Adding to the above that buprenorphine has recently been approved for a once a month injectable version, which might make it easier to stay on.
posted by quercus23 at 11:23 PM on October 10


On a different tack I was shocked by Russell Brands' 60 minute video: From Addiction to Recovery. (2012)
In the video Brand had a sexual relationship with a vulnerable drug addict he was managing and berated medical experts for prescribing medicines instead of "healing souls".
Brand came across as both pompous and predatory.
posted by Narrative_Historian at 2:11 AM on October 11 [1 favorite]


Sounds like Brand was on brand.
posted by snuffleupagus at 8:02 AM on October 11


you couldn't hold a meaningful job, for instance

Because you have to get back to the injection site four times a day? I'm not completely sure if that's what you meant but that's the first thing that comes to mind for me. Programs that require attendance at the one clinic around are indeed a hassle for employed people - including methadone because they won't let you take it home until you've been going (and in compliance with their rules) for some time. It's another huge advantage of buprenorphine (for patients) that it's available more or less as a regular prescription.

If you could take home your heroin it would be somewhat less safe, but more attractive beyond the most marginalized users.
posted by atoxyl at 8:20 AM on October 11


Attendance at the injection site would be a challenge for employed people (trying to imagine being a lawyer in Vancouver and having to go to the Downtown Eastside three-four times a day...). Most people have co-morbidities, and, unless you magically address them as well, they will continue to be problems. Inability to pass a drug test will bar you from a lot of employment. And, realistically, even after the introduction period some people still experience some impairment at the peak that will interfere with work. I spent more childhood hours at a VA methadone clinic than anyone would ever believe. Patients' reactions were...varied.
posted by praemunire at 11:42 AM on October 11 [1 favorite]


I have always felt kinda weird about talk of the 12 step program, which began as a way to deal with Alcohol addiction, being used as the ONLY treatment offered at some 'treatment centers' for every and all kinds of addiction. When we know that Alcohol, Cocaine, Opiates etc. affect the brain differently. I am not even getting into the other things like pills(non opiates like benzos), sex, gambling, eating etc etc. It looks like there is as 12 step program for everything. WHY? What started as a way to help people with Alcohol related issues; has been stretched way beyond its efficacy or usefulness.

Let me say, right now, that I have been sober for a little over 6 years using the AA program. I can safely say, I would not be alive today if I did not find the program. So I am always kinda pissed off whenever these articles come out. Because; all these hucksters and profiteers who need to be exposed; get bundled in with AA. Talk about the profit motive, making money of desperate people etc. which are horrifying to read; are not what I have experienced. I go to 3 meetings a week. I put in a buck or 2 when the hat is passed around. If I don't do it; no one harangues me for it. So in the 6+ years I have been going to meetings; I have put in a little more than 1000 bucks. If that is considered taking advantage of my need; so be it. When discussing this, I would prefer that they concentrate on the treatment centers themselves without dragging AA into it all the time.
posted by indianbadger1 at 12:36 PM on October 11 [5 favorites]


Patients' reactions were...varied.

Yeah I just mean, I promise it's possible to have a middle-class job as a heroin user. That the clinic model doesn't primarily cater to that group is probably sort of okay, because outpatient buprenorphine does pretty effectively. But there are definitely ways in which the regimented structure of the model limits what patients can do more than just using drugs does.
posted by atoxyl at 12:39 PM on October 11 [2 favorites]


Why does AA say people need to hit rock bottom before treating their alcoholism?

They don't. The first chapter on Step One in their Twelve and Twelve book, read frequently at meetings, and which anyone at a meeting can request be read at any time, is almost entirely about how people who are just beginning to have problems with alcohol can identify and address their alcoholism by recognizing their behavior is similar to other alcoholics. It's practically the mission of the organization to help people identify and address their alcoholism in the early stages of their disease.
posted by xammerboy at 7:31 AM on October 12 [4 favorites]


Many people on prison release programs are forced to go to AA.

Often as the only alternative to keeping them in prison, because they cannot be released unless there is a way to establish they are at least working on their drug problem. Many of these prisoners would not be released at all if there wasn't a nearly free, easily accessible treatment program available.
posted by xammerboy at 7:52 AM on October 12 [3 favorites]


AA forces spiritualism on its participants.

Belief in a higher power is a suggestion, not a requirement. The alternative suggestion is to believe in the greater wisdom of the group of alcoholics (i.e. Group Of Drunks) at the meeting, but the higher power can be anything: a personal code, society, physics, etc. This is necessary, because prolonged exposure to alcohol makes it difficult for alcoholics, put in the bluntest non-scientific terms, to recognize, relate, and connect to a worldview larger than their own needs.

Personally, I wish AA would drop its spiritualism. In the thirties, it was non-controversial, and many aspects of spiritualism do provide a psychological shortcut to a greater emotional connection with one's community, adherence to behavioral rules, and a sense of one being a part of a larger whole (ego-deflation/inflation), but too many alcoholics today use the "requirement" as a ready-made, easy excuse to avoid treatment altogether.
posted by xammerboy at 9:43 AM on October 12 [4 favorites]


AA is not an evidence-based treatment regimen and is therefore likely inferior.

I am all for evidence-based medicine, but be aware that this is also a sales tactic. A decade ago, evidence-based research proved there was a pain epidemic in the United States that could be solved by greatly increasing prescriptions of opiates. The evidence consisted of asking people whether or not they experienced pain in their daily life. Similarly a lot of the evidence for these alternative treatments' success consists of asking alcoholics, prone to denial and highly resistant to authority, whether or not their treatment was successful. Words fail to express how problematic this "evidence" is.

But it's not necessary to debate the value of treatment regimens if one understands alcoholism as an ongoing effort to re-size, re-connect, and re-commit the individual in relation to their community and society at large. Seen in this context many alternative treatments only address symptoms without their underlying causes. A program that addresses narrative distortions is not addressing the causes of those distortions. A program of trigger avoidance is not addressing underlying needs.
posted by xammerboy at 10:44 AM on October 12 [2 favorites]


"I am all for evidence-based medicine, but be aware that this is also a sales tactic. A decade ago, evidence-based research proved there was a pain epidemic in the United States that could be solved by greatly increasing prescriptions of opiates. The evidence consisted of asking people whether or not they experienced pain in their daily life."

We could talk about Purdue Pharma's false claims that Oxycontin could not be easily abused or all the money they spent to encourage physicians to prescribe it. We could talk about the FDA's failure to disprove that claim during the approval process and how approval was fast-tracked and the money-trails associated with that. We could talk about unscrupulous physicians making large amounts of money with pill mills or about the vast diversion of prescription opioids into the illegal drug trade. We could talk about the money involved in why a variety of regulatory institutions looked the other way as all this was happening. All of that is true, though it's pretty much irrelevant to the argument you're making, with the big exception of the dubious Purdue Pharma-funded studies they relied upon to argue Oxycontin wouldn't be abused. (For those not aware, it includes a slow-acting buffer which reduces its appeal as an oral recreational drug -- an obstacle easily circumvented by crushing and snorting.)

And, even given all of this background about this specific heavily-marketed then-new drug that in various ways was a Trojan horse encouraging mass abuse as an introduction to clinical populations not previously prescribed opioids, we could rightly criticize all the various interested parties who turned a blind eye to these problems and relied upon the questionable research that Oxycontin was particularly difficult to abuse. This last bit does support your argument that "evidence-based research" can also be unreliable.

Instead, however, you choose to attack all the research that said then, and still says now, that pain is generally poorly managed and often unaddressed in medical treatment and that this is particularly true with regard to chronic pain. You might have argued, wrongly, that opioids are not the most effective pain relief currently available by a large margin, because that argument is made now and then and most of us would like that to be true. But, no, you just thought, hey, why don't I just deny that there wasn't and isn't insufficient pain management because pain isn't actually a serious problem.

That's ... wow. Aside from the fact that it's deeply offensive to very large number of us who suffer from serious chronic pain, it's also just not true. Medical and research consensus is that pain was and is insufficiently treated and is a debilitating intractable problem for a large number of patients and which frequently results in a variety of comorbid conditions exacerbated by constant pain. This isn't really disputed -- what's long been in dispute is what to do about it and whether the most effective available pain treatment, opioids, are safe enough to widely prescribe.

In some ways, this is tangential to the discussion about 12-step, institutionalized rehab, and evidence-based research regarding addiction treatment. But of course there is an epedimic of opioid abuse and addiction and it looms behind both the general discussion and this particular example.

I just find it astonishing and infuriating that someone would claim that pain isn't poorly managed and, in fact, is exaggerated by self-identified sufferers. As a means to argue that one should be wary of "evidence-based treatment methods" because of hidden ulterior motives and flimsy argument it is unnecessary, provocative, hurtful but also egregiously hypocritical, given that it's built around a blatant falsehood.
posted by Ivan Fyodorovich at 1:06 PM on October 12 [11 favorites]


I did not mean to attack evidence-based medicine generally. I meant only that just because a treatment regimen claims to be evidence-based does not mean we should not ask questions or be critical of it.
posted by xammerboy at 5:40 PM on October 12 [2 favorites]


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