Dying to be free

I was sent a link to this fascinating piece on the Huffington Post http://projects.huffingtonpost.com/dying-to-be-free-heroin-treatment by Jon who blogs here https://jonsleeper.wordpress.com . The Huffington Post piece is written by Jason Cherkis and is a very strong argument to changing the way that addiction is treated in the USA. The piece contains some great video links that support the text. You can watch the whole video which is about 13 minutes long here.

Film produced by James Doolittle of Center City Film & Video, Philadelphia, Pa.

 

The Huffington Post piece, talks about the dreadful way, many are treated in the USA for heroin addiction, where there is a reluctance for treatment providers to use anything other than the 12 step method originated by “Alcoholics Anonymous” in the 1930’s, which is a faith based abstinence program. AA was designed as a support program not a treatment, but was adopted by people such as Hazelden, who used it as a core part of their rehab solution. Over the years the rehab industry has defended the 12 steps and has become quite anti medication. Harm reduction methods, which have been adopted in the rest of the developed world, where there is less of a 12 step tradition and less faith in religious solutions have been pushed aside. This actually is holding back addiction treatment and slowing progress, as other posts on my blog have talked about. In many places an abstinence only solution is all that is offered and people who do not respond to an AA style program, are treated as failures. Most people do not remain sober for ever as a result of going to a 12 step rehab and many suffer death after relapse as a result of a binge after being unable to cope with the outside world when they leave.

This piece has a look at how treatment has been managed over the years, and talks about Suboxone as a great method of beating heroin addiction and why it is not being used by many providers. It talks about the anti medication stance of quite a few people in AA/12 step groups, such as Narcotics anonymous, which was something that I saw, and which although AA has published a little pamphlet about members not playing doctor, is still something that can cause big problems, especially if a vulnerable person, is given advice by an over zealous “Big Book Thumper”. This is the bad side of AA, and almost certainly something that goes against the wishes of Bill Wilson the founder of AA, who even tried LSD as potential solution before abandoning this approach at one time.

Here is a section about AA from the piece:

The philosophy of AA co-founder Bill Wilson, also known as Bill W., a former Wall Street analyst and a recovering alcoholic, offered empathy and promised lasting sobriety. Wilson’s organization came out of evangelical Christian movements. His cure wasn’t a jail cell or a scheme to separate addicts from their money but a meeting space where people shared their problems and admitted their vulnerabilities. This was considerably less frightening and more affordable than electroshock therapy.

The Big Book, first published in 1939, was the size of a hymnal. With its passionate appeals to faith made in the rat-a-tat cadence of a door-to-door salesman, it helped spawn other 12-step-based institutions, including Hazelden, founded in 1949 in Minnesota. Hazelden, in turn, would become a model for facilities across the country.

“The history of 12-step came out of white, middle-class, Protestant people who want to be respectable,” said historian Nancy Campbell, a professor at Rensselaer Polytechnic Institute. “It offers a form of community and a form of belonging that is predicated upon you wanting to be normal, you wanting to be respectable, you wanting to have a stake in mainstream society.”

In the mid ’60s, the federal government decided that drug treatment should become more widely available. In ways that may be familiar to reformers today, government officials began to rethink incarceration policies toward addicts. Mandatory sentences fell out of favor, and a new federal law, the Narcotic Addict Rehabilitation Act, gave judges the discretion to divert a defendant into treatment.

The law also laid the groundwork for our current system by encouraging local communities to open their own treatment facilities. “There was a scramble away from centralized treatment at the Narcotic Farm and a scramble to get it in every city or small town,” Campbell said. “Who was best positioned to provide care at the time [the law] went into effect? Faith-based and 12-step programs, despite the fact that they had little experience with drug addicts in the late 1960s and early 1970s.”

The number of drug treatment facilities boomed with federal funding and the steady expansion of private insurance coverage for addiction, going from a mere handful in the 1950s to thousands a few decades later. The new facilities modeled themselves after the ones that had long been treating alcoholics, which were generally based on the 12-step methodology. Recovering addicts provided the cheap labor to staff them and the evangelism to shape curricula. Residential drug treatment co-opted the language of Alcoholics Anonymous, using the Big Book not as a spiritual guide but as a mandatory text — contradicting AA’s voluntary essence. AA’s meetings, with their folding chairs and donated coffee, were intended as a judgment-free space for addicts to talk about their problems. Treatment facilities were designed for discipline.

Something else has been lost with the institutionalization of the 12 steps over the years: Bill Wilson’s openness to medical intervention. From the start, Wilson intended AA to work with, not against or instead of, the latest and best medical science to treat addiction. In 1965, he recruited Dr. Vincent Dole to become a member of AA’s board of trustees. Along with Dr. Marie Nyswander and Dr. Kreek, Dole pioneered methadone treatment for heroin addicts.

In one of their mid-’60s papers, the three scientists wrote of the limits of non-medical intervention. They described the addict as being “functionally disabled” and the life of the addict as a cycle of relapsing and repenting. But they found that methadone treatment worked. “The present state of these patients is so dramatically improved over their previous condition, and the improvement began so soon after entry into the program, that there can be no doubt that these patients have made a significant response to treatment,” they wrote.

Kreek recalled Wilson’s pleading for a similar treatment for alcoholism. “Bill would say, ‘Vince, please develop a methadone maintenance treatment for alcoholism. AA is very helpful, but as you know most relapse…And that’s the bottom line,” Kreek said.

Dole wrote about this episode in a 1991 article: “[Wilson] suggested that in my future research, I should look for an analogue of methadone, a medication that would relieve the alcoholic’s sometimes irresistible craving and enable him to progress in AA toward social and emotional recovery.”

The Twelfth Step calls on addicts to carry the program’s message to other addicts, which is considered central to one’s own recovery. But many rank-and-file 12-steppers took a hardline message from some of Wilson’s written philosophy. Those who can’t stick with the program are “constitutionally incapable of being honest with themselves,” reads the Big Book. “They seem to have been born that way.

Resistance even to Hazleden by some NA 12 step groups.

It is a great shame that AA and other 12 step groups have failed to evolve and have instead decided to cling on to old-fashioned ideas that they consider to be divinely inspired! I used the 12 step groups for some support in my early days, and having social contact with others, helped motivate me, but I certainly never considered the 12 steps to be the ultimate solution for addiction and certainly do not credit any God or “Higher power”, with having anything to do with my current alcohol and drug free life. Here is another section from the piece:

The Hazelden Clinic in Minnesota is perhaps the most influential treatment center in the country, noted not just for its rehabilitation facilities but for its academic publishing arm. Founded in the late 1940s on a farm, the clinic brought order and professionalism to the 12-step method. Hazelden’s recent merger with the Betty Ford Center has made it an even more powerful force. Administrators made headlines in early 2013 when they integrated buprenorphine into their treatment of opioid addicts.

A few years ago, Dr. Marvin Seppala, 58, the clinic’s chief medical officer, began noticing that not only were more and more opioid addicts coming into his care, but they were rebelling against Hazelden’s message and conspiring to smuggle narcotics onto campus. Former residents were also dying a few weeks to a few months after leaving the clinic.

Given Hazelden’s long history of treating addicts, Seppala could have stubbornly stuck to the brand. But he was willing to consider alternatives. He’d come to Hazelden in the mid-’70s, as its first adolescent resident, for an addiction to drugs and alcohol. “I blamed myself so much,” he recalled. “I really hated myself. I can’t put that strongly enough. I didn’t understand why I did all these things.” His experience at Hazelden was powerful. He met people just like him who felt the same bottomless craving and the shame that went with it. Still, he relapsed five days after graduating from the clinic. It would take him another year and a half, along with a platoon of understanding adults, before he found sobriety through another 12-step program. Now, as a physician, he knew he had to track down the clinic’s dropouts and their families, and ask them what Hazelden was doing wrong.

The dropouts told Seppala and his team that they had felt neglected at the clinic and that the program, which covered all types of addictions, didn’t speak to them. “The degree to which we ignored opioid dependence was significant,” Seppala said. “The fact that people were dying from relapse was not being fully addressed either.” Heroin addicts who relapse are more likely to fatally overdose than other drug users, but Hazelden hadn’t integrated that fact into its curriculum.

Seppala thought that if he was going to reach these addicts and keep them from relapsing, Hazelden needed to revamp its curriculum and start prescribing buprenorphine and other medications. The biggest challenge, he knew, would be his own staff’s resistance. “It’s a real 12-step culture throughout our whole organization around the country,” he said.

He spent all of 2012 planning to integrate maintenance medications into the program and working to win over staff, some of whom he found avoided treating heroin addicts at all. A small group of employees still thought that heroin addicts seldom got better and therefore Hazelden shouldn’t put in the effort to treat them.

In one of the first staff meetings on the subject, a colleague of Seppala’s who was running the session asked the room a simple question: Who here has had a former resident die from an opioid overdose? Three-quarters of the staff members raised their hands. “We said, ‘This is why we’re doing this,” Seppala recalled. “We are trying to save lives. This is a crisis. It’s essential that we do everything we can, so we cannot base our decision on philosophy or preference. We have to base it on science. We have to base it on research.”

“This is a crisis. It’s essential that we do everything we can, so we cannot base our decision on philosophy or preference.”

DR. MARVIN SEPPALA, THE HAZELDEN CLINIC’S CHIEF MEDICAL OFFICER

Seppala was well aware of the latest research on treating heroin addicts with buprenorphine. He had worked at an outpatient clinic in Portland, Oregon, that gave addicts both the medication and the 12-step philosophy. He saw how the addicts stuck with that program. The success in Portland was no anomaly. In November 2004, Stanley Street Treatment and Resources, a nonprofit in Fall River, Massachusetts, introduced Suboxone into its mix of detox, short residential and outpatient therapies. In 2014, more than 300 addicts were enrolled in the program. Nancy Paull, the facility’s CEO, reports a relapse rate of about 10 percent.

Seppala and his staff consulted with a clinic in Washington, D.C.; a former drug czar; and William White, a respected drug treatment historian and researcher who has written about the value of AA. White explained in an email that his reaction to Hazelden’s plan was “one of pleasant surprise that a leading addiction treatment program would so value the emerging addiction science and be so committed to improving recovery outcomes that it would be willing to weather potential controversy that could affect its business interests.”

Seppala also sent a team to study other clinics around the country. His staff went to facilities in Oregon and Missouri that were offering a mix of medically assisted treatments and 12-step. The team came back optimistic. “They saw in action how this could actually work,” Seppala said.

After introducing medically assisted treatment in 2013, Seppala saw Hazelden’s dropout rate for opiate addicts in the new revamped program drop dramatically. Current data, which covers between January 1, 2013 and July 1, 2014, shows a dropout rate of 7.5 percent compared with the rate of 22 percent for the opioid addicts not in the program. In the first year, no addict in the new model curriculum died from an overdose.

My Thoughts:

I really do think that relying on a 12 step solution in this day and age, as the core part of a treatment program is doing a great disservice to those who really need help. The disease theory is a popular one in USA (but not elsewhere!), yet this is a disease that is being treated by faith, rather than medication in the majority of institutions. The piece contains other stories about treatment in Kentucky and other areas where there is little on offer except the 12 step solution. People have different reasons behind their addiction and a solution that simply makes addiction a moral issue such as AA will not motivate many to change. I think that care over a couple of years as an outpatient while using a support group (which is pretty much what I did) can have better results that taking people out of their natural environment on and simply locking them up until their insurance runs out. I think AA and other 12 step groups, could be much more effective and respected, if they acknowledged modern solutions and the role of medicine. Unfortunately those that remain in AA long-term, are often fans of the religious side of the program and see no reason to change, what they feel helped them. They think that it should help everyone and have bought into the faith-based solution. I do hope things change in the future and the key to this will be different recovery groups working together and modifying ideas, but unfortunately that will take a long time. The Huffington Post piece is really great and well worth a read, and the accompanying video is well balanced and shows the different points of view that illustrate why progress in the addicton treatment field is so slow.

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Commenting area

  1. That article was incredible.

  2. Good post! We are linking to this particularly great article on our website.
    Keep up the great writing.

  3. Incredible points. Outstanding arguments. Keep up the amazing spirit.

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