Peter Chow: Why Drug Rehab Fails

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Could it be true that “Spirituality” is really where it’s at when it comes to recovery from a disease of the brain, such as Opioid Use Disorder?

Alcoholics Anonymous and Narcotics Anonymous  believe it is indeed Spirituality that is the answer, explicitly stating that recovery is achieved through a “Spiritual Awakening” from working through its 12-step program .

“The great fact is just this and nothing less:  That we have had deep and effective spiritual experiences which have revolutionized our whole attitude toward life……Having had a Spiritual Awakening as a result of these steps…”.

At least this was the belief when AA published its original text (the “Big Book”, Alcoholics Anonymous, in 1939, and despite the publication of this book in three further editions since then, this original text has remained unchanged.

 

12-step groups are based on the importance of creating supportive peer and mentoring relationships during recovery.

They are free of charge, use self-directed leadership, outline specific goals for change, focus on experiential learning, and encourage mutual helping.

The group dynamic itself is seen as fundamental to the recovery process, with giving and receiving help seen as critical components to promote change.

12-step groups draw on multiple ideas, including medical (i.e., the need to abstain completely in order to avoid triggering and kindling craving and compulsive use), behavioural psychology and group dynamics (i.e., through group meetings/helping others), and religious/spiritual concepts.The mechanisms of action underlying the effects of 12-step groups on substance use disorder include providing structure, teaching coping strategies, improving social networks, strengthening self-efficacy, encouraging a new identity and behavioural techniques such as stimulus control (e.g., avoiding persons and places with addiction problems), counterconditioning (e.g., calling your sponsor instead of using substances), and reinforcement (e.g., use of tokens to mark number of days sober/clean).

But the core belief of AA/NA is that individuals do not have the power within themselves to maintain sobriety.
Instead, they need to surrender to a “Higher Power,” which can be defined to fit a range of beliefs from a Deity, to Nature, to the support of group fellowship.

The dogma of AA has reigned supreme.
My favourite two sentences in the Alcoholics Anonymous literature are:
“Alcoholics Anonymous does not demand that you believe anything.”

“All of its twelve steps are but suggestions.”

When a drunk at the end of his rope, Bill Wilson, founded Alcoholics Anonymous in the late 1930’s  –  a spiritual program based on meeting with other addicts  –  there was a fundamental humility to his ideology:

“It might work for some.”

But these sentiments are largely forgotten in the rooms of AA/NA itself.
There, what are suggestions to some, are fundamentalist Scripture to others.

In the rooms of AA and NA, suggestions and traditions can sometimes feel more like ironclad commandments written in stone, and when those commandments are transgressed, there is humiliation and sharp rebuke.

The predominantly AA-based culture of drug rehab has become one of imposition.

If the program didn’t work for you, then you didn’t work the program.

If you succeed in staying sober/clean, then you did a good job working the program.

Ergo, the program works.

Almost all rehabs adhere to this intransigent dogma.
You check in, detox, and then go to addiction-education lectures, group therapy, and AA/NA twelve-step meetings.

A lot of meetings, meetings every day.

To the point where you can go 24 hours mouthing nothing but AA slogans (one website lists 252 AA slogans, each “with incredibly profound meaning”).

Patients attend these group gatherings for 28 to 90 days, and are then released back into the real world.

Problem is, the real world is teeming with temptations, and most people relapse.
So what do we do with them?

More rehab!!!

Because it isn’t the program that has failed.

It is you!!
Addiction has been stigmatized so fervently and for so long that for decades there was no body of science to help desperate addicts.

The basic science underlying psychiatry has always lagged far behind the rest of medical science and addiction medicine has always lagged far behind the rest of psychiatry.

In that vacuum, the field grew its own program.

Once you’ve seen one substance abuse program, you have seen the great majority of them.
The 12 steps of AA became the template treatment for just about every compulsive behaviour there is, from NA, Narcotics Anonymous to Sex Addicts Anonymous to Gamblers Anonymous to Overeaters Anonymous to Shoppers Anonymous..

But moral and spiritual principles are not medical treatment.
And using AA as the only rehabilitation treatment  –  rather than as an adjunct to treatment  –  defies the reality that there are many different effective treatment methods.

A deep schism between rehab science and twelve-step treatment programs developed.

There is now a vast body of research on addiction treatment, including transformative medications like Suboxone, Methadone and Naltrexone that can quell urges, safely fulfill an addict’s need for dopamine, allowing them to work, go to school, take part in family and community life and prevent relapse.

And yet 80% of rehabs dispense no medication at all.

In fact, many rehabs consider the use of opiate-replacement drugs and other medications  –  like Naltrexone, Suboxone, and Methadone  –  as equivalent to drinking alcohol or using Heroin, despite the overwhelming scientific evidence of their positive effects.
In other words, you’re not truly sober if you’re “on” something.

To that end, many rehabs kick addicts out for secretly using  Medication Assisted Treatment  –  that is, for being addicts.

 

The idea of changing the life course for people with a severe, recurrent form of brain illness through a time-limited intensive, transformative 12-step rehab is a fatally flawed relic of ancient times.
What other chronic medical disorder do we treat that way?

Ask someone in Alcoholics Anonymous if there are alternative treatment options for addiction other than the 12 steps, and you’re likely to hear:

“Sure, you can end up in jail, be institutionalized, or die.”

 

But the science tells a different story.

The vast majority of people who get and remain sober do so without AA or NA.

AA does confer benefit through multiple mechanisms simultaneously, but in particular, through facilitating adaptive social network changes.

It’s not that the traditional AA model is bad or wrong;  it just isn’t the only way.

Suboxone is a combination of Buprenorphine and Naloxone.

Buprenorphine is what’s known as a “partial opioid agonist” meaning it stimulates some of the same brain receptors as drugs like Heroin and Oxycontin.
In proper doses it eliminates craving for opiates.

Naloxone is an opioid antagonist that competes with and blocks the effect of Buprenorphine if given by injection.

Naloxone is poorly absorbed when taken by mouth and it is added to decrease the risk that people will misuse Suboxone by injecting it.

 

Together with Methadone, Suboxone is one of the two most effective treatments for opioid dependency.

But you wouldn’t know that from how little those two drugs have actually been used to treat opioid dependence.

The vast majority of addicts who enter treatment rehab programs fail multiple times  –  not because they are incapable of recovery, but largely because they’ve been denied the therapeutic interventions most likely to produce success.

 

12-step programs have had a virtual monopoly on the provision of addiction treatment.

The prevailing 12-step treatment system generally claims success rates of 30%  –  a figure most experts view as grossly inflated.
But even if we take it at face value, by the industry’s own admission, 70% of people who go into drug rehab come out no better than they went in.

And some cases even worse.

 

One 2015 study found opioid dependent patients receiving only 12-step treatment were twice as likely to suffer a fatal overdose than those being treated with opioid replacement medications, Medication Assisted Treatment (MAT).

People who die of drug overdoses, if you look at their history, were often recently in rehab or jail or prison.
Having been in rehab or prison , they lost their tolerance for the opioid.

If that person relapses and mistakenly believes they can use the same amount of the drug as before detox, there is a risk of overdose and death.

 

By contrast, dozens of studies show improved outcomes for opiate addicts who use medication in recovery.

Yet three quarters of all opioid-dependent patients are still treated without the use of medication.

In light of their ideological position, abstinence-based treatment programs are reluctant to educate unsuccessful patients about alternatives like Medication-Assisted Treatment.
Instead, the standard 12-steps response to relapse is encapsulated in a deflating motto that is repeated daily in drug rehabs across the country: “Keep coming back, it works if you work it.”

 

Thomas McLellan, founder and chairman of the Treatment Research Institute, calls this “unethical.”
“In any other area of medicine, to not mention medication at all, that is a breach of ethics.”

“They’re obligated to act in the patient’s interest and they don’t, always.”

 

But there are big profits to be made in treating drug addicts; and since rehabs aren’t required to counsel patients on alternative therapies, many of them don’t.

The US National Institutes for Health (NIH) estimates that by the end of the decade, annual expenditures for drug and alcohol rehab treatment will exceed $42 billion, almost as big as the entire medical diagnostic and laboratories industry.
The small number of effective programs based on scientific principles of opioid dependence are dwarfed by an ideologically driven system that is uninformed by medical best practices and continues to operate largely without any oversight.

 

Suboxone, which has a low overdose risk, has quickly become the first-line evidence-based treatment of choice for opiate addiction.

But the dominant 12-Step definition of “recovery” has excluded anyone who uses medication to address their addiction.

This has created a trickle-down stigma against MAT that for years has made addicts reluctant to embrace it.

 

The abstinence-based 12-step treatment industry responded early to the push toward evidence-based MAT practices, convening a special meeting in 2012 to develop a response to what they rightly perceive as a market threat.

The vast majority of rehabs still adhere to a drug-free treatment regimen for opiate addiction, or else only incorporate Suboxone into “transitional” detox protocols but reject long-term maintenance therapy.

Many more halfway houses refuse to admit recovering addicts on maintenance drugs.

 

For the majority of opioid-dependent patients, the evidence overwhelmingly supports MAT.

 

Short-term tapering strategies using Methadone or Suboxone have a very low probability of resulting in long-term abstinence for opioid-dependent patients.
Most patients who attempt to taper off Suboxone or Methadone after a short course of treatment relapse within 12 months.

The neurology of opioid-dependence is similar between Heroin and prescription opioids, and it is not comparable to other substance use disorders due to the profound neural re-wiring which occurs following prolonged opioid use.

The literature strongly supports longer-term MAT for opioid-dependence treatment of Heroin and/or prescription opioid-dependence

 

MAT remains the clinical strategy with the best evidence for long term patient safety, social stabilization, and long-term health benefit  –  it is for this reason that both Methadone and Suboxone are recognized by the World Health Organization as essential medicines.

For the majority of patients seeking treatment with the hope of stabilizing the impact dependence has had on their quality of life, MAT is the best option.

Alternative approaches including tapering, counselling and psychosocial interventions may also have benefit; but again the evidence suggests that on their own, these treatment strategies are not nearly as effective as MAT.

With respect to programs which offer a combination of medication and counselling, evidence suggests that outcomes are not much better than MAT alone.

The conversation on recovery has been driven for so long by the 12-step philosophy of total abstinence that the default metric for success in recovery has become how long a person maintains sobriety from all mood-altering substances rather than quality of life metrics such as job stability and strong family connections.

With more and more middle-class Canadians seeking access to treatment, and officials expecting addiction treatment to model other forms of healthcare, pressure will be on providers to ensure treatment outcomes reflect medical goals, not ideological ones.

On September 8, Ontario’s science table said a wide variety of strategies must be implemented to help tackle the opioid crisis, including addressing the increasingly volatile illegal drug supply, increasingly tainted with Fentanyl and Carfentanil.

Dr. Bonnie Henry, B.C.’s  chief medical officer, has issued an order to mandate health professionals in British Columbia to help people at risk for overdose access safer alternatives to the toxic street drug supply.

British Columbia will require all health authorities to develop programs that provide pharmaceutical-grade opioids, stimulants and other addictive substances to street-drug users, under a policy directive on safe supply aimed at curbing overdose deaths.

The B.C. government recognizes that providing drug users with regulated versions of street drugs such as Morphine, Cocaine, and Methamphetamine can reduce deaths and other drug-related harms.

Prescribed safe supply drugs such as long-acting Morphine tablets and injectable Hydromorphone will be covered under PharmaCare, the province’s drug plan.

Stimulants, Cocaine and Crystal Meth, are expected to be added at a later date.

 

For people with severe Heroin Use Disorder who have not responded well to more traditional forms of treatment like Methadone or Suboxone, injected Hydromorphone or Diacetylmorphine (Heroin) assisted treatment (HAT) resulted in greater treatment retention and reductions in illicit drug use compared to Methadone or Suboxone treatment
Heroin-assisted treatment (HAT) would be considered only for individuals for whom other treatment options have not been successful, and with careful medical supervision.
Studies have shown that Heroin-assisted treatment (HAT) provided in dedicated clinics is feasible, safe, and effective when treating long-term, chronic injecting opioid users for whom the available treatments have not been effective.

Heroin users weren’t always “the scum of the earth.”
In the late 19th century, Heroin was a trademark name for a popular over-the-counter drug made by Bayer.

Today, there are politics behind which drugs are demonized and which aren’t, and much of that is rooted in racism

Wealthy White socialites snorting cocaine in an Aspen ski lodge are forgiven, while inner-city blacks smoking crack –  just another form of cocaine –  are vilified and locked away.

Heroin was romanticized when musicians (Chet Baker, Charlie Parker, James Taylor, Keith Richards, Ray Charles), used it, but after black kids in inner cities got hold of it, the perception changed and stuck.

 

Many functioning Heroin addicts are not slumped over in alleyways with used needles by their sides.

Their dignity, from outside appearances, remains intact.

They haven’t lost everything while chasing an insatiable high.

They are functioning Heroin addicts –  people who hold down jobs, pay the bills and fool their families.

The United Kingdom has provided prescription Diacetylmorphine (Heroin) for severe treatment-refractory Opioid Use Disorder for over 100 years.

Prescription Diacetylmorphine treatment has been available in Switzerland as a standard drug treatment since 1999.

In 2008, as part of a national referendum, 68% of Swiss voters supported the permanent institution of a legalized prescription Diacetylmorphine program funded by national health insurance.

More recently, Germany, Denmark and the Netherlands also adopted supervised prescription Diacetylmorphine treatment for those with severe, treatment-refractory OUD

Heroin-assisted treatment (HAT) is available in 6 European countries  –  Germany, Luxembourg, the Netherlands, Denmark, Switzerland, the United Kingdom  –  and now in Vancouver.

 

In the 1970s and 1980s, numerous physicians in the UK, many well-respected and distinguished, upon their retirement revealed that they had been injecting themselves with Heroin for most of their professional lives, totally unbeknownst to their patients, their colleagues or even their own families

The idea for Heroin-assisted treatment (HAT) is that if people have a legal source of Heroin, they’ll be less likely to overdose on tainted street drugs, spend less time and energy trying to get their next fix, and instead be able to focus on the underlying drivers of their addiction.

Contrary to popular belief, individuals on maintenance Heroin-assisted treatment are able to function normally at work, go to school and participate normally in family and community life.

Heroin-assisted treatment (HAT) is just another treatment that could help stabilize lives.

When there are these other tools shown to be effective in other countries and in British Columbia, why not use them in Ontario??

The following are the recommendations and guidelines from Guidance for the Clinical Management of Opioid Use Disorder published by British Columbia Center on Substance (BCCSU) and the Canadian Research Initiative on Substance Misuse (CRISM).

 

1)  Harm reduction rather than total abstinence should be the initial primary goal in treatment of Opioid Use Disorder

2) 12-step programs like Narcotics Anonymous, based on AA, that demand total abstinence are ineffective in early withdrawal management and treatment.

3) The central pillar of Harm Reduction is Medication Assisted Treatment with opioid agonist drugs such as Suboxone and Methadone.

4) Psychosocial treatment interventions and supports should be routinely offered in conjunction with pharmacological treatment.

5) This guideline strongly recommends against a strategy involving withdrawal management alone, since this approach is associated with elevated risk of HIV and Hepatitis C transmission, elevated rates of overdose deaths in comparison to providing no treatment, and nearly universal relapse when implemented without plans for transition to long-term evidence-based addiction treatment such as maintenance opioid agonist treatment with Suboxone.

This includes rapid (< 1 week) inpatient tapers with Methadone or Suboxone, which invariably leads to relapse and an increased likelihood of death.
6) Withdrawal management, for most patients, can be provided safely in an outpatient rather than inpatient residential setting.

7) It is the consensus of the committee that most individuals with opioid use disorder should be offered community-based, outpatient withdrawal management as opposed to rapid inpatient withdrawal management.
Outpatient withdrawal management programs permit a slower, more flexible and individualized approach to tapered agonist reduction, and allow for dose readjustment and stabilization in the event that withdrawal symptoms, cravings or lapses to illicit opioid use occur.
Outpatient withdrawal management is also less disruptive to the patient and their family, and offers the opportunity to continue with their normal routine of daily living, providing a more realistic environment for the development of coping strategies and support systems on reduction or cessation of opioid use.

This guideline supports using a stepped and integrated care approach, where treatment intensity is continually adjusted to match individual patient needs and circumstances over time.

A SUMMARY OF THE CONTINUUM OF TREATMENT OF OPIATE USE DISORDER:

LOW INTENSITY TREATMENT  –  WITHDRAWAL MANAGEMENT
Tapered Methadone or Suboxone
+/- psychosocial treatment
+/- oral naltrexone

MODERATE INTENSITY TREATMENT  –  OPIOID AGONIST MAINTENANCE THERAPIES
Suboxone
Methadone
Slow-release oral morphine

HIGH INTENSITY TREATMENT  –  SUPPLYING SAFE INJECTABLE OPIOIDS
Diacetylmorphine
Hydromorphone

CONTINUUM OF EVIDENCE-BASED ACTIONS

Treating drug addiction as a disease, instead of a crime
Harm reduction vs abstinence as the primary goal in treatment of opioid addiction
Medication Assisted Treatment of drug addiction with Suboxone and Methadone and Naltrexone
Safe Injection Sites
Anonymous Drug Testing to screen for Fentanyl
Injectable opioid agonist treatment (MAT) for intractable Opioid Use Disorder
Providing safe drugs to mitigate drug-overdose deaths
Decriminalising all drugs

British Columbia is the cutting-edge of addiction treatment in Canada.
Ontario is slowly inching to catch up.

There are over 20 Supervised Consumption Sites in operation or being planned in Ontario, including in Sudbury and the Lakehead.

Faced with figures showing that, per capita, Timmins has the worst opioid death rate in Canada, city council there has voted to invest more than $1 million in establishing a safe injection site in hopes of reducing the number of deaths associated with the ongoing opioid crisis gripping the community.
In addition, Timmins will dedicate funding for a position to provide support and leadership in the development and implementation of collaborative community programs and services that address substance use.

 

In stark contrast, here in the Sault, a frustrated and disappointed Dr. Paul Hergott has resigned as president of Citizens Helping Addicts and Alcoholics Get Treatment (CHATT), a grass-roots organization he created.

Dr. Hergott wrote in his resignation letter:

“I still feel as strongly about the needs and deficiencies that exist in our community related to the treatment of addiction as I did a year ago.
The providers on the ground are doing the best they can with what resources they have.
Agencies and providers remain grossly underfunded for what the needs of the community are.

Our providers continue to work in silos each competing for their own funding with no overall plan for a continuum of care, never mind any thought to early prevention and treatment of childhood trauma.”
“The three levels of government appear to not take any responsibility for our current crisis.”

Months of hard work rewarded by empty platitudes.

 

In May, the Ontario government announced $343,000 in ongoing operational funding for a new withdrawal management centre in Sault Ste. Marie.

 

This is the Level 3 withdrawal management facility Sault Area Hospital submitted as its proposal back in 2017, about 100 drug overdose deaths ago.

“It’s just a different title now,” Sault Ste. Marie MPP Ross Romano said plainly during the funding announcement.

An inpatient withdrawal unit, when the best medical evidence favours outpatient withdrawal management programs.

Reflecting the general attitude of the community, local elected leaders have shown little enthusiasm for applying for a Supervised Consumption Site or for pushing to make Suboxone more readily accessible or for setting up an anonymous drug testing.

The last 2 measures alone would make the most immediate and biggest impacts on opioid overdoses and deaths.

In a clear statement of priorities, city council is going ahead with spending $8.4 million on a downtown plaza.

Sudbury, the Lakehead and Timmins are embracing the most current evidence-based approaches to treatment of Opioid Use Disorder.

Sault Ste Marie lags behind again.

 

5 COMMENTS

  1. This article offers a lot of excellent stuff!!

    Good for the Timmins City Council for spending their taxpayers’ money to get the ball rolling in the right direction on this MOST IMPORTANT municipal issue… citizens are dying!!

    The one thing in this article that I might change is instead of “Decriminalising all drugs” I would Decriminalise all supervised drug use. In that way all unsupervised use of illegal drugs would still be illegal, and would, therefore, offer police an opportunity to get unsupervised illegal drug users into a mandatory supervised drug use program.

    Thanks for this article.

    Sincerely,
    Mark Brown

  2. NA, AA, and any other group like it, was never meant for people with addictions. It is a program that was specifically designed for people who have been driven insane by others. Terms like alcoholism, addiction, diseases, allergies, OUD, they were born that way, or genetics are all scapegoat labels, usually told to people by people who drive people insane.

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