I AM AT THE gym, staring at a television to break the monotony of the treadmill. A man, whose name I have since learned is Chris Prantiss, looks at me from the screen, slim and good-looking with his gray hair, suntan, and dark suit. He is standing next to his son, Pax, just as elegant himself. The older man has his hand affectionately placed on the younger man’s shoulder. I hear him talk about the book he has written.
I wrote
The Alcoholism and Addiction Cure to give you hope and to share with you what works. Within the covers of my book, I will show you how to cure your addiction to alcohol, prescription drugs, street drugs, smoking, food addictions, sex addictions, gambling, and all other addictions. Notice that I do not say “however,” “maybe,” “although,” “perhaps,” or use other qualifying terms or conditions. By reading my book you will learn exactly how to cure your dependency.
The Alcoholism and Addiction Cure contains the process that we use at the Passages Addiction Cure Center in Malibu, California. Passages currently has a very high success rate for curing all forms of addiction.
1
Really. I guess I can close down my lab and start trying to figure out what to do. Which may be hard, because I really don’t like to play golf.
Or maybe not. There are indeed a number of treatments for addictive disorders that have shown some degree of efficacy
2 in randomized controlled trials, the staple of evidence-based medicine. Famously invented by the Royal British Navy physician James Lind in the eighteenth century,
3 this is ultimately the only way to know if a treatment really does what it is claimed to do, in any field of medicine. It is therefore encouraging that the number of studies evaluating the efficacy of addiction treatments with this stringent methodology has steadily risen over the past three decades; all the while their scientific quality has also improved. A vast majority of this research in the world, probably more than 90 percent, is funded by American taxpayers, through the National Institutes of Health (NIH).
4 Based on this science, there is support for efficacy of both behavioral and pharmacological treatments.
It is also important at this stage to point out that treatment studies face many challenges. Even when carried out with the best possible methodology, there is ultimately a certain element of chance, which can skew the results of any single trial, one way or the other. That is why multiple studies at different sites are needed to properly evaluate a treatment. It is only once evidence from these multiple studies accumulates that one can start to feel really confident about having a reliable assessment of a treatment. Another staple of evidence-based medicine, the meta-analysis, is the technique for boiling down the results from these multiple studies to a unified picture. By that sophisticated approach, several behavioral treatments as well as addiction medications—methadone and buprenorphine for opioid addiction, the nicotine patch and varenicline for smoking cessation, naltrexone and acamprosate for alcoholism—are clearly effective.
Just
how effective these treatments are is a separate issue. The conclusion that a treatment has a statistically significant effect means only that the difference in outcomes between treated patients and some appropriate comparison group is unlikely to have been caused by chance. It does not say anything about the magnitude of the clinical benefit produced. A treatment that has “significant” effects could therefore still be providing only a small, perhaps not really meaningful amount of improvement on average. An intuitively informative measure to express the amount of benefit is the “number needed to treat,” or NNT:
5 how many patients will I need to treat, on average, to prevent an adverse outcome in a single individual? Methadone maintenance for preventing relapse to heroin addiction has one of the best NNTs in clinical medicine, below 2 in many of the better studies. For the most part, the effect sizes of other addiction treatments are modest but not necessarily all that inferior to widely accepted treatments in other areas of medicine. For instance, the NNT for the medication naltrexone to prevent relapse to heavy drinking is around 7, compared with an NNT of 3 for a widely prescribed beta-blocker to prevent exercise-induced chest pain, a treatment considered to be a major success story. On balance it would then seem that what we have is useful, while at the same time it is clear that we would like to do much better. The latter is of course what current research, including my own, tries to achieve.
Meanwhile, however, you would think there would be widespread use of the tools already available to us. After all, if a chemotherapy for some cancer form modestly improved five-year survival, say, from 12 to 25 percent, surely you would not shrug it off and do nothing, while waiting for the miracle drug that will save 90 percent of the patients?
And here is something else you would certainly not do, at least not in the case of cancer: you would not, instead, have patients sit in a circle and talk, drink carrot juice, take cleansing baths, be subject to herbal treatments, or receive other interventions based on nothing but a claim that in your experience, you have found these things to be helpful. Or at least you would not do this if you were a licensed physician, because if you did, the state medical board would quickly make sure that you would not remain one for long.
6 Yet the equivalent of exactly these things is going on day after day when it comes to the treatment of addictive disorders.
I started having my eyes opened to the discrepancy between what we should be offering patients and what is actually being done more than two decades ago, and I still recall the feeling of shock and disbelief. In 1989 Ried Hester and Bill Miller, legendary behavioral researchers at the University of New Mexico, published a book, the
Handbook of Alcoholism Treatment Approaches, that attempted to bring together all the available evidence on the efficacy of alcoholism therapies and combined this with some deeply disturbing real-world observations.
7 The book was very useful as a whole, with the later chapters providing concise descriptions of important behavioral treatment approaches. But the first two chapters were what converted me from the all too common practice of “opinion-based medicine” to trying to make treatment choices informed by data. The book has subsequently been updated twice, the latest in 2003, but little has changed between the editions or since then.
What was so disturbing about this reading that it brought me out of my intellectual slumber? Three things stand out: First, as I have already said, there are treatments that do a modest but significant and useful amount of good in addictive disorders. As you will see, these treatments interact with the addiction mechanisms we have already covered. Conversely, there are treatments that have been evaluated by the same stringent methods and have consistently been shown to be ineffective. Second, in the analysis there was a significant inverse correlation between how well supported the efficacy of a treatment was and how much it cost. Overall the effective treatments were cheap, and the expensive ones were ineffective. This was rather provocative. The third observation was, however, the most disturbing. The treatments with documented efficacy and low cost were rarely provided to patients. The treatments with documented lack of efficacy and high cost were the ones most commonly offered.
I read and reread those chapters and vowed to rethink my ways. It was tough going because it forced me to reevaluate much that I thought I already knew and to learn many new things. I promised myself in those days that I would always come to work ready to change the way I practiced medicine if solid data suggested that was called for. One might think that would be a given in any field of medicine, but along the way I discovered that these insights were frequently met with indifference at best, and on many occasions with outright hostility. A few years later I became the director of a large addiction medicine service and was confronted with both the opportunity and the challenge of delivering care to large numbers of real patients who needed it. Together with a dedicated leadership team, we decided to revamp the whole service based on the available evidence. I had expected a lot of resistance from treatment staff, and there was certainly some of that. Less than a year into that work, however, most nurses and other treatment providers had in fact been bitten by the evidence bug and were helping drive the change themselves, curious about the best way to help patients they truly cared about. To my surprise and dismay, the hardest part instead turned out to be dealing with policy makers who just “knew” how addiction was to be treated, no matter what the data said. After all, we all have a cousin who drinks too much, don’t we?
But neither when I was busy managing the treatment service nor when I ultimately retreated into a more academic existence did I pay enough attention to the megabuck industry that is based on provision of “treatment” that costs much and achieves little. These are businesses that promise a “cure” and charge astronomical amounts of money in ways that simply prey on people made vulnerable by their addictions. The industry obviously has a disincentive to provide inexpensive treatments that work. After all, these may ultimately prevent patients from coming back, and put the industry out of business.
Like most people who realize they have been taken for a ride, I was upset not only because of what was going on but also because I felt like a fool. Once I had a chance to think about it for a while, I decided to convert the energy of my frustration into something that could hopefully be more useful. So many lives are devastated by addictive disorders. So many of my colleagues work passionately to better understand and treat these conditions. Yet despite the advances this hard work has brought, very little has changed in the practice of addiction medicine outside academic settings. I am convinced that in order to bring much-needed change, patients, their loved ones, policy makers, and the public need to share the scientific advances the field has made. The individual news story that highlights an occasional new research finding may be great. But even when it is, it rarely provides the greater context in which every scientific advance happens or avoids the oversimplifications required by a short format. And too often the message becomes one of the sensation du jour—finding yet another “addiction gene,” “addiction transmitter,” or “cure.” These stories rarely if ever fundamentally alter the way people view or handle the problems of addiction.
We need to do better. Only a better-informed public will become a more tolerant and caring public. Only better-informed patients will become less vulnerable patients.
In developed countries we tend to take advances of modern medicine for granted. It is easy to forget that until fairly recently the history of treating medical conditions isn’t all that glorious. I don’t know when exactly the scales tipped in favor of doing good over causing harm, but it is definitely less than a hundred years ago. Trepanation, the time-tested practice of drilling a hole in the skull as a treatment for brain disorders, continued to the Middle Ages, as documented in the famous Hieronymus Bosch painting Extracting the Stone of Madness. And bloodletting remained in practice as a treatment for fevers and infections throughout the nineteenth century. It most likely claimed the life of George Washington, who might have been able to deal with the throat infection he contracted in 1799 but definitively got in trouble after he was bled almost 4 liters.
With the benefit of hindsight, it is easy to find these methods absurd. My point is that, absent an understanding of disease mechanisms or data from randomized controlled trials, many approaches that at the time seem to make sense later turn out not to be very helpful. If you don’t understand that social stress is a major relapse trigger in addiction, it may seem like a good idea to stage dramatic surprise confrontations between patients with addictive disorders and people affected by their behavior. If you fail to appreciate that patients with addictions apply steep temporal discounting to outcomes that are distant in time compared to those that are immediate, then you may want to spend a lot of time and money on educational movies that extol the dangers of alcohol use to the liver. I could go on, but you get the idea. And, by the way, in controlled trials, both the methods I just mentioned are of course entirely ineffective, as are standard addiction counseling, psychodynamic psychotherapy, and a host of other approaches that continue to be widely practiced, sometimes at great cost. In contrast, a number of behavioral as well as pharmacological methods that do produce measurable improvements still have not been implemented to the extent the data justify. A common theme is that these treatments all make sense in the context of the addiction mechanisms we have begun to uncover.
Of course, treatments need to be tailored to those being treated. A socially anxious, alcohol-dependent man who is medically healthy, is employed, and lives together with a loving family in a house in the suburbs will require different ingredients in his “treatment soup” than an impulsive, homeless heroin addict who has to steal for a living, has advanced hepatitis C, and is losing teeth. This is not a textbook to actually teach addiction treatment, but extensive research shows that we can’t effectively treat patients with addictive disorders without carefully assessing their needs in the many areas of life where those needs exist. To properly tailor treatment, we need to take in account not only the nature and severity of the addictive disorder but also psychiatric and medical problems, housing, occupation, and crime, to mention those that are most important. This can clearly be done in many different ways, but research shows that systematic, structured approaches are the ones that work best. In their absence, even experienced treatment providers frequently find that they have failed to cover important areas of assessment. Believe me—been there, done that. More than three decades ago Tom McLellan, whom we met earlier in this book, developed the Addiction Severity Index (ASI).
8 This is an interview that typically takes less than an hour and covers what is important. The materials are free and have been translated into some thirty languages. I frankly cannot imagine running a treatment program without it.
A systematic assessment like the ASI or something along the same lines identifies areas in need of services and helps direct treatment efforts to those areas. But it does more than that. It serves a purpose just as important as any of the hardnosed science in this book. That purpose is to build a relationship with the patient, viewed as a fellow human being. That relationship in turn allows an alliance to be established. To paraphrase Kirkegaard, you can rarely help people arrive at a new place in life unless, for a while at least, you walk beside them. There is a terrible tradition of talking about addicts who relapse as showing “resistance to treatment,” or not showing “motivation” for change. In fact, research shows that motivation is more a function of the interaction between the treatment provider and the patient. Walk into an office and say, “I have a solution for your problems, and it requires you to change,” and you will experience resistance. Walk into the same office and ask, “What pains you?” and you will share an inner world and begin building a relationship with a person. Then the progression to asking more and more specifics will feel like—and be—a reflection of this intricate relationship web being woven. Once that is done, the work toward change can start, as a joint effort.
So we could say, “You are powerless under your addiction, and you should never again touch alcohol.” Or, instead, we could listen for a while and then say, “You told me that even when you plan to take just one or two drinks, your drinking often spirals out of control. You told me that when that happens, you do things to your kids that make you feel terrible afterward. You know, many people I’ve worked with have told me that in the end, they found it easier to just avoid alcohol, rather than trying to control the amount they drink. Is that something you would consider trying for a while?” Although we are in both cases trying to work toward the same goal, research shows that the former approach will often meet resistance and lack of motivation. In contrast, the latter method will help the patient evolve toward a greater readiness for change, perhaps through intermediary goals that we can set up together, work toward, and evaluate. While all that happens, we are building something that is central to all treatment that requires behavioral change. To get to their goals, people need to feel that they have an ability to influence the course of their lives. Patients with addictions are no different. The feeling of this ability is the essence of the Stanford psychologist Albert Bandura’s concept of “self-efficacy.”
9 People who develop addictions frequently don’t have much of that feeling to begin with. Addiction effectively degrades it further. Tragically, confrontational or coercive addiction treatments then add insult to injury.
This is the place where science and humanism come together in this book. There is a widespread perception that people who take an interest in neurotransmitters and their receptors, or who offer to treat ailments of the mind with medications, are cold cynics who don’t care about their patient’s feelings and “objectify” patients into some kind of guinea pigs. The clinical and human realities are instead that the two perspectives of science and humanism are inseparable in any area of medicine, but perhaps most so in psychiatry and addiction medicine. In a good addiction treatment program, humanism and science aid each other, as do empathy and anticraving medications. As I stated in a prior chapter, I don’t know how to theoretically reconcile an understanding of the brain as a machinery that produces behavior based on the laws of nature, on one hand, with a view of the brain’s owner as an agent endowed with a free will to choose one behavior over another, on the other. It does not seem that anyone else knows the answer to this dilemma either, so I have decided not to worry too much about it for now. But I do know this: patients with addictions strive toward and long for the same things that the rest of us do—love, work, a reasonable amount of material goods. And none of them wants to get sick or die from drugs. Those who say they do, as sometimes does happen, are really only saying, “To be alive like this is too painful.” The problem addicts have is not that they strive toward taking drugs and all the bad things that leads to. The problem is that brain machinery that allows the rest of us to guide behavior toward better goals somehow is broken or overpowered in people with addictions, so that they end up taking drugs instead of achieving what they dream of.
I am saying all this to explain that any effective treatment has to reflect a marriage of two perspectives. One is more of a general framework than a specific method, although it is not without its own techniques. This is the perspective that is focused on building a relationship that allows the treatment provider to walk beside the patient. This perspective boils down to caring about and respecting the fellow human who also happens to be a patient. Clearly this is the domain of words spoken, but even more, of words listened to. The other perspective is about the specific, scientifically based methods for helping guide the course of this walk in a desired direction and actually getting there. That is the domain of science that provides specific tools and techniques to put at the disposal of our patients. Among useful tools, there are both those that are behavioral and those that are pharmacological. But in the end, it all has to come together. After all, what matters is behavior, and helping patients gain control over it so that it can take them where they want to be. And all that behavior is produced by brains.