Sunday, June 12, 2011

Why are Treatment Centers Afraid of Anti-Craving Medications?

Using What Works

Why do so many drug treatment centers continue to shun science by ignoring medications that ease the burden of withdrawal for many addicts? That’s the question posed in an article by Alison Knopf in the May-June issue of Addiction Professional, titled “The Medication Holdouts.”

“Nowhere else in medicine,” Knopf writes, “are the people who treat a condition so suspicious of the very medications designed to help the condition in which they specialize.”

Acamprosate, a drug used to treat alcoholism, is a good case in point. A dozen European studies examining thousands of alcohol test subjects found that the drug increased the number of days that most subjects were able to remain abstinent. But when a German drug maker decided to market the drug in the U.S., fierce advocates for drug-free addiction therapy came out in force, even though the drug was ultimately approved for use.

Disulfiram, naltrexone, acamprosate, methadone, buprenorphine—the evidence for all of them is solid. Knopf cites the case of buprenorphine:

“‘There are scores of peer-reviewed journal articles that evaluate the success of buprenorphine,’ says Nicholas Reuter, MPH, senior public health adviser in the Division of Pharmacologic Therapies at the federal Center for Substance Abuse Treatment (CSAT). ‘It's well established that the data and the evidence are there. Not treating patients with a medication consigns most of them to relapse, adds Reuter. While some opioid-addicted patients, as many as 20 percent, do respond to abstinence-based therapy, ‘That still leaves us with the 80 percent who don't,’ he says.”

Dr. Charles O'Brien, one the nation’s most respected addiction professionals and a Professor of Psychiatry at the University of Pennsylvania, is incensed that anti-craving medications are not more widely used. “It's unethical not to use medications,” he says. “This is a subject that I feel very strongly about.” O’Brien told Addiction Professional he no longer cares who he offends on the subject. “If you're discouraging people from taking medications, you are behaving in an unethical way; you are depriving your patients of a way to turn themselves around. Just because you don't like it doesn't mean you have to keep your patients away from it.”

And at the Association for Addiction Professionals, “the prevailing philosophy is pro-medication,” Knopf writes. Misti Storie, education and training consultant for the group, told Knopf that the “disconnect” at treatment centers is due to a “lack of education about the connection between biology and addiction.” Counselors working in centers that do not allow anti-craving medications are in a tough spot, Storie acknowledged.

It is continually astonishing that treatment centers--where the primary goal is supposed to be the prevention of relapse, even though the success rate remains abysmal--would spurn medications that often help to accomplish precisely that goal. Relapse rates hover around 80%, by an amalgam of estimates, so it’s not like rehabs are wildly successful at what they do. What’s really behind the resistance?

What stands between many addicts and the new forms of treatment is “pharmacological Calvinism.” I would love to claim this term as my own, but it was coined by Cornell University researcher Gerald Klerman. Pharmacological Calvinism may be defined as the belief that treating any psychological symptoms with a pill is tantamount to ethical surrender, or, at the very least, a serious failure of will. As Peter Kramer quoted Klerman in Listening to Prozac: If a drug makes you feel better, then by definition “somehow it is morally wrong and the user is likely to suffer retribution with either dependence, liver damage, or chromosomal change, or some other form of medical-theological damnation.”

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PeaPod said...

We will certainly use anti-craving medication when required in our clients. Acamprosate's been around for many years in Europe. My feeling is that when it works for an individual it works well. The problem is that it doesn't work for everyone. Don't understand why it wouldn't be tried in someone who was craving.

Naltrexone? Not so sure of that solid evidence. See:

Those outcomes from treatment seem way too low. Look at NTORS, DORIS and DARP. If treatment is too short or doesn't employ evidenced interventions (most importantly good empathic therapeutic relationships) then outcomes will be poorer.

Many in long term stable recovery will have had more than one treatment episode and it may have been a few years from asking for help to achieving stable recovery, so short term outcomes do not necessarily predict long term outcomes.

Assertive linkage to recovery communities has a significant impact too. Mark Litt and colleagues found that the addition of one sober person to a recovering alcoholic's social network reduced relapse rates by 29% in the following year.

Dirk Hanson said...

Thanks for the reminder about short term vs. long term outcomes. I think the ideas about "assertive linkage" are fascinating and I plan to look into those stats more comprehensively.

damarisfish said...


Thanks for the reminder how important it is for a recovering addict/alcoholic to have a paradigm shift by having [a] sober role model[s]. It is difficult all the way around, and it is heartening to know that makes a signifcant difference.

It may be a sober friend who reads this blog and passes along the encouragement for their friend to ask for that medication help.

Edward Lebron said...

Why people are dragged towards the prescription drugs more than ever before? The reason is obvious, easy availability of the prescription drugs. You can hardly find other drugs as easily as you can get hold of the prescription drugs. This is in fact that main reason people become addicted to prescription drugs beyond their control. In the blog of Findrxonline indicate that Addiction to any substance requires constant supply of the same product. This becomes little bit difficult when the drug is raw and not available openly in the market like the prescription drugs. Most of the times, no one will even doubt you when you buy the prescription drugs over and over again without presenting any particular prescription.

Quit Marijuana said...

I'm always amazed that people who have gone to school and studied medicine and addiction still whole emotional prejudices against certain drugs.

acid & alkaline foods said...

Pharmacological Calvinism may sound logical at one point but if you look closely to the flight of those suffering from possible relapse because of the difficulty they undergo in the process of getting over their addiction, it is more ethical to try it to those who are suffering certain cravings with the use of medication. PeaPod is right, these meds don't always work for everyone but since it works for some, why not check it out first if it'll benefit the person in the end.

Anonymous said...

It's the anti scientific AA shadow over the treatment community that explains most of this attitude....Focus on each of the twelve steps: is this really the way to cure a brain chemistry disorder? AA/NA was developed in a pre scientific era.

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