The Recovery Stool
A reasonable question to ask is this: Why aren’t we having better outcomes with many patients who are being treated for addictive disorders in spite of many years of treatment experience (Miller, Wilbourne, & Hettema, 2003)? To answer this question, I would like to propose that a three-pronged approach to the treatment of substance use disorders (SUDs) is necessary to achieve enhanced outcome. Not all patients will require all three approaches (e.g., some patients with alcohol use disorders attend AA and stay sober without any additional services), but while these are not the type of patients that are the focus of this column, all patients should be screened for the need for all three efforts.
A partial answer to why we aren’t having more treatment success may be that even though addiction is considered a chronic, relapsing brain disease, we are not providing sufficiently comprehensive treatment. As an example, the most common treatment is psychosocial treatment and of that approach, the most common model is Twelve Step, disease model approach (Nowinski, Baker, & Carroll, 1999).
At least for alcohol addiction, success fifty years ago seems to have been better (much better) than today. Examining the differences between then and now, the single greatest one are the characteristics of the patients treated. Patients back then often found themselves in a gradual decline into alcoholism over many years in contrast to today’s patients who started using alcohol and other drugs at earlier ages and progressed more rapidly into addiction. Fifty years ago alcohol addiction was more common with fewer heroin addicts and no prescription opioid addicts in treatment. Those early patients had jobs or possibly careers, unless they lost them due to their substance use; if not employed, they had at least job skills; lived in intact families, unless they lost their families due to their substance use; had high school diplomas if not graduate and postgraduate degrees. They had learned to function successfully, but their ability to cope was compromised by their substance use. They were “rehabilitatable” (i.e., able to go back to an earlier level of successful functioning) in contrast to many of today’s patients who are only “habilitatable,” never having achieved an earlier level of successful functioning to which to return because of the earlier onset of substance use and addiction.
There were far fewer patients with co-occurring mental health disorders in treatment because if they were found to have both a substance use and a mental health disorder, they were more likely referred for psychiatric rather than addiction services. People who committed substance-related crimes were simply sent to prison or jail, but not to addiction treatment services as this predated drug courts. Simply stated, today’s patients are more complex with a wide range of co-occurring mental health, criminal justice, and social issues. There is also increasing awareness of the role of trauma is the development and maintenance of substance use and mental health disorders, both then and now.
Currently complicating this situation is the increasing abuse of prescription and illicit drugs (opioids). Addiction to opioids drives illegal behavior to acquire the substances and sometimes violent or other antisocial behaviors. When I began my career, alcoholics and drug addicts were not treated together, not even in the same facility; they were regarded as two separate and distinct populations, and those who were addicted to illicit drugs were considered less “upstanding,” primarily based on the perception of antisocial behavior.
The Twelve Step disease model has great value and should not be abandoned. Rather, it is insufficient in and of itself to address all of the needs of today’s patients and has to be augmented. The significantly increased numbers of patients with co-occurring mental health disorders will need additional help beyond recovery support groups. The Twelve Step recovery groups for substance use were never meant to be treatment for mental health disorders.
In the introductory paragraph, I described addiction as a chronic, relapsing brain disease. However, psychosocial treatment alone only treats part of the brain: the cerebral cortex, which is responsible for thought, reason, and decision making. These are all necessary, but insufficient to bring about recovery. Such treatment addresses that part of the brain with individual and group counseling, family therapy, reading and writing assignments, and videos, among other things. In this scenario, there is part of the brain that is not addressed, namely the limbic system, from which hunger, thirst, sex, and drug craving drives emanate. There are now drugs, both agonists such as methadone and buprenorphine (approved by the FDA for opioid disorders), and antagonists such as naltrexone both in in oral and long acting injectable forms approved approved for both alcohol and opioid disorders, and acamprosate, approved for alcohol use disorders. These drugs reduce craving, nullify the effect of the drug of choice if used, and enable better functioning in major life areas. Given the high relapse rates, and the extensive research findings on their efficacy, there cannot be a rational argument against their use in selected patients (Pettinati et al., 2004). Should all patients be on these drugs? The answer is “no.” How then do we decide who are appropriate patients for anti-addiction drugs? Criteria for selection of patients for pharmacotherapy include:
- Alcohol and/or opioid dependence (required)
- High addiction severity
- High levels of craving
- History of relapse after treatment
- History of AMA discharge or drop-outs from treatment
- Potential for serious consequences or imminent danger if use again
- Willingness to use pharmacotherapy
- Absence of medical contraindications (required)
It is important to recognize that these drugs, as effective as they are, are not magic bullets and should always be used in conjunction with psychosocial and behavioral treatments for optimal outcomes.
I am proposing a three-pronged approach in which the third component is recovery support services (RSS)/case management. If we look at many of today’s patients, these needs become clear: housing; transportation; childcare; employment preparation services such as resume writing and education about how to dress for and function during a job interview; employment or job skills training; education including acquisition of a GED or high school diploma or literacy training when required; college preparation where warranted; and a sober, supportive milieu in which to recover such as recovery residences (Jason, Light, Stevens, & Beers, 2014).
Putting this all together, recovery can be pictorially represented by a three-legged stool. The seat represents recovery; one of the legs represents trauma-informed, recovery-oriented psychosocial and behavioral treatment which responds to co-occurring mental health problems; the second leg which represents pharmacotherapy; and the third leg which represents recovery support services and case management.
[INSERT ILLUSTRATED IMAGE OF STOOL AROUND HERE]
I firmly believe that by utilizing this approach we can enhance treatment outcomes in general and for a good segment of the population to make a life-changing, if not life and death difference.
Jason, L. A., Light, J. M., Stevens, E. B., & Beers, K. (2014). Dynamic social networks in recovery homes. American Journal of Community Psychology, 53(3–4), 324–34.
Miller W. R., Wilbourne, P. L., & Hettema, J. E. (2003). What works? A summary of alcohol treatment outcome research. In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (3rd ed.), (pp. 13–63). Upper Saddle River, NJ: Pearson.
Nowinski, J., Baker, S., & Carroll, K. (1999). Twelve step facilitation therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Retrieved from http://pubs.niaaa.nih.gov/publications/ProjectMatch/match01.pdf
Pettinati, H. M., Weiss, R. D., Miller, W. R., Donovan, D., Ernst, D. B., & Rounsaville, B. J. (2004). Medical management treatment manual: A clinical research guide for medically trained clinicians providing pharmacotherapy as part of the treatment for alcohol dependence. Retrieved from http://pubs.niaaa.nih.gov/publications/combine/Combine_2.pdf