Posts in category: News

The Cochrane Collaboration is the gold standard in medicine if you want to know whether a particular intervention works. Its methods are rigorous and its reputation unquestioned. It works by meta-analysis where the combined outcomes of multiple published trials are evaluated. People involved in the addiction treatment and recovery world might be interested to know that a Cochrane review, published in March this year has shown that Alcoholics Anonymous is significantly more effective than psychotherapy and other interventions, including no intervention, in achieving abstinence in people with alcohol use disorders. In studies where the outcome other than complete abstinence was measured, AA was found to be as effective and when costs were considered, AA showed significant savings, which is not surprising because AA is free to anyone who chooses the intervention. It should be noted that the outcomes of the measured studies were consistent, irrespective of age, gender, occupation or location as the studies reviewed covered five different countries.

What is the secret behind AA’s success in helping alcoholics achieve a sustainable sobriety? There are a number of elements that give AA a headstart over the competition.

Firstly, no other agency addresses the shame associated with alcoholism as effectively as AA. Membership of AA amounts to an anonymous but public disclosure that one is alcoholic and not just a heavy drinker or party animal. AA defines an alcohol use disorder in an unstigmatised way, which allows the alcoholic to accept the condition more readily. This is hugely important because unless you accept the problem, you won’t be able to start with a solution. AA makes it ok to be an alcoholic. It is the only club in the world where the entrance requirement is that you have to be an alcoholic. Everyone else tries to exclude alcoholics from their midst.

Secondly, it is not by chance that AA is described as a fellowship. It is not an organization, association or society. Fellowship creates an egalitarian sense of community, everyone is important, everyone belongs and there is no discrimination based on past exploits or behaviours. While everyone is accountable for their choices and behaviours, AA understands that alcoholics do anti social things as part and parcel of their illness. The shared commonality of negative experiences helps ameliorate the guilt arising from the behaviours that haunt the alcoholic and allows for a new found personal freedom.

The mainstay of AA is the actual 12 Step programme. This attracts most of the criticism but is AA’s secret weapon. Irrespective of how you might interpret the theology behind the programme, embedded in the steps is a pathway to a transcendent experience. The 12^th step calls it “a spiritual awakening” but the preamble is gratitude, humility and an unconditional surrender. If these are the values that 12 step recovery embraces, then these are surely values that account for AA’s superior outcomes.

Finally, the real power behind AA’s success, despite it being a non professional group without an organizational hierarchy or formal structures (2 million members in 180 nations with 118 000 active groups), is its empirical but accurate explanation of the actual problem of alcoholism for every alcoholic – an inability to safely or accurately predict the outcome of alcohol use, once consumption commences despite external control measures, constraints or accountabilities. This resonates with everyone who has the problem and strongly informs abstinence as the most sensible route out of the mess.

So this Cochrane Review, the world’s most independent and reputable scientific review mechanism only confirms what every member of AA has already known for a long time– “it works if you work it”.

[Cochrane reference: https://doi.org/10.1002/14651858.CD012880.pub2]

Are all addicts the same?
I recently attended an addictions conference in London. One of the presentations that caught my attention focused on the problems presented in treating high net worth individuals, or more often, their children. We are talking about Saudi princes, political kleptocrats, Kazakhstani royalty, popstars and real-estate billionaires. People whose money supply is literally endless. The talk was hosted by an outfit that caters to the treatment needs of these souls and therefore biased in favour of making out a strong case as to why the treatment challenges of these clients are fundamentally different.

Some of the claims made in favour of differentiating this treatment cohort is that they often suffer from affluent neglect, their parents are too busy flitting around the world to devote sufficient attention. They are brought up by au pairs and nannies. Many are victims of “affluenza” in that they have never had to deal with the consequence of any misdemeanor, as the family lawyer has always been around to make good. They suffer from a lack of purpose and boredom because there is no need or incentive to do anything creative and they often live isolated lonely lives because they never know whom they can trust. An excessive financial dependence on their families makes true independence difficult and ongoing public scrutiny makes their lives the fodder for the tabloid press, often coupled to generous doses of schadenfreude arising from an envious audience. This discourages disclosure, no matter how hard they are hurting. And finally, the classic rock bottom is somewhere in “never-never land”, for these addicts can buy their way out of any gridlock.

As therapists, we are often awe struck by their wealth or celebrity status. We are often flattered by their attention and generosity and so strict supervision is the key, lest our counter-transference leads us astray. And of course, their money and prestige often buys our goodwill.

The clinical focus needs to remain on the client’s true needs and I suspect many of these clients actually want to be treated like any other patient, with respect and dignity. Perhaps behind it all, they crave normality. The same problem in a different guise arises with patients at the other end of the socio economic spectrum – the down and outs, where the same sense of hopelessness about their odds for recovery often clouds our clinical judgements, albeit for different reasons.

So, are all clients the same? Obviously not, but the triangulation between the client, the counsellor and the disorder remains the same. Cutting through the defenses, whether they are solid gold or rusty tin remains the therapeutic challenge. For an addict, sleeping in a palace can be as lonely as sleeping in homeless shelter.

Researchers studied the brain scans of more than 1,000 individuals to determine which substance was more damaging to the brain. When it comes to long-term effects on the brain, researchers have found that alcohol may be more damaging than marijuana, according to a new study in the journal Addiction.

More specifically, researchers at University of Colorado Boulder and the CU Change Lab found that alcohol consumption was linked to long-term changes in the brain, while marijuana was not linked to any long-term changes.

Researchers studied the brain scans of 853 individuals between the ages of 18 and 55, as well as 439 people between the ages of 14 and 18. Alcohol and cannabis use varied by individual. According to Science Alert, study authors wrote that alcohol use was associated with reducing the volume of grey matter in the brain. Grey matter is a substance in the brain that contains most of the brain’s neuronal cell bodies. White matter in the brain, which has to do with communication between grey matter, was also affected.

When either is damaged, the brain’s normal function can be disrupted. This was especially true for people with a long history of alcohol use, researchers found. “Alcohol use severity is associated with widespread lower gray matter volume and white matter integrity in adults, and with lower gray matter volume in adolescents,” study authors wrote. Additionally, the study found that the effects of alcohol use were worse for those over age 18. But the grey matter levels in those younger than 18 were still affected.

Still, more research is necessary in order to determine how marijuana truly affects the brain.  “With alcohol, we’ve known it’s bad for the brain for decades,” study co-author Kent Hutchison told the Colorado Arts and Sciences Magazine. “But for cannabis, we know so little.”

Because of the immediate effects of the cannabinoid, THC, in marijuana, it’s been thought that cannabis would be more damaging to the brain in the long-term. But Hutchison tells the magazine that this isn’t necessarily the case.

“When you look at the research much more closely, you see that a lot of it is probably not accurate,” Hutchison said. “When you look at these studies going back years, you see that one study will report that marijuana use is related to a reduction in the volume of the hippocampus. The next study then comes around, and they say that marijuana use is related to changes in the cerebellum or the whatever. The point is that there’s no consistency across all of these studies in terms of the actual brain structures.” Although the research showed no specific damages due to marijuana use, that does not mean it’s beneficial for the brain either.

“Considering how much is happening in the real world with the legalization movement, we still have a lot of work to do,” Hutchison said.

By Beth Leipholtz 02/20/18

Acknowledgement: The fix.com

The Constitutional Court recently declared that the prohibition of cannabis cultivation and use within the privacy of one’s own home impinged on the constitutional rights of the individual and has instructed Parliament to change the legislation accordingly. This progressive thinking on the part of the Constitutional Court reflects the principle of respect for the rights of the individual in a liberal democracy and overrides the notion of a “nanny” state, which manages all aspects of the lives of its citizens.

Irrespective of any constitutional considerations, the real reason why cannabis use should be legalised is because prohibition policies have failed dismally to achieve what they are intended to do.

With the introduction of the impending legislation, the following will happen with respect to people who use cannabis: those who use cannabis in a non-problematic way will continue to do so. Those who have a cannabis use disorder will no longer get arrested.

The illegality of cannabis has never deterred anyone from using the substance. Prohibition has just created an underground drug economy that is impossible to regulate or tax, given rise to powerful supply chain monopolies who rule communities and filled the prisons with people convicted of victimless crime. It corrupts the criminal justice system and provides easy income to the legal fraternity dedicated towards defending users caught in the legal net. A whole industry is dedicated towards maintaining the status quo with vested interests, including politicians on the right bereft of any other social causes.

Cannabis remains the most widely used illicit substance worldwide. This change in thinking is long overdue. A regulated, taxed industry, while not without its challenges, makes much more sense and reduces collateral damage much than the idiotic prohibitionist policies of the last century.

However, cannabis use should not be regarded as without consequence. Cannabis has always retained the image of a “soft” drug. The problem is that “soft” is often confused with “safe”, whereas “soft” actually means that cannabis does its damage softly and insidiously. The damage from hard drugs is usually clear and apparent. It is easy to connect cause and effect with hard drugs. A dysfunctional lifestyle that, if left unabated, ends as a nightmare and is often fatal. No one has been recorded as deing from a cannabis overdose.

The intrinsic damage arising from a soft drugs like cannabis is much more difficult to identify or quantify because the dependence producing quality and the intrinsic toxicity of the drug is low.

My experiences in addiction treatment over the past 25 years identify the adverse consequences of cannabis use in five broad, all dose related (quantity and duration) and possibly reversible with abstinence although some studies have questioned this. I have excluded the non conclusive suggestion of the relationship between cannabis use and psychosis.

1. Intellectual function is impaired. The ability to process and recall information is impaired
2. Executive function is restricted. The ability to be pro active, organise and co ordinate activity is limited.
3. Cannabis use induces a depression. Although it is a mild euphoriant, chronic use depresses mood. It is rare to find a daily user who is inspired with life.
4. Procrastination is endemic amongst regular users. Their year book is filled with a litany of failed good ideas
5. Chronic users often become a shadow of their former glory.

The cannabis war cry “don’t panic, it’s organic” needs to be regarded with caution. Recreational cannabis use is probably less dangerous than alcohol use. Cannabis addiction, on the other hand, is often a very sad story.

Addiction is often affectionately or ominously described as a chronic, relapsing condition – something like a peptic ulcer or arthritis except a bit more dangerous. The problem with this description is that it is both inaccurate and irresponsible and in the hands of any self-serving addict, it simply invites a relapse. “I have a relapsing condition and that is why I have relapsed, in case anyone is looking for an explanation of my relapse.” With this descriptor, relapse just becomes a self-fulfilling prophecy driven by circular logic.

Addiction certainly appears to have the features of a chronic condition in the sense that when activated by a return to substance use, it often returns from its dormant state of remission with the previous ferocity.

It is a question that I have pondered for many years – why someone who has suffered through the nightmare of active addiction , who then may have had the insights and partial resolution of the problem afforded by some intervention like a treatment programme or the 12 step fellowship, followed then by a period enjoying some of the benefits of sobriety and recovery, when this person decides to return to substance use, even just to test the waters – why this person, who is both forewarned and forearmed more than most people, often ends up back in treatment or worse. One would think that such a person, more so than your average mortal, is tuned in to the potential dangers of substance use and therefore any return to substance use would be with caution and vigilance. Yet, the underlying chronicity of impaired control or “powerlessness’ often kicks right back in with vengeance. Unlike a broken leg or flu, which is an acute problem – once it is treated, it is over, the underlying vulnerability of addiction seems to stay with the addict long after the active phase of the condition has passed. That is it’s chronicity.

What is a misnomer is the idea that addiction is a relapsing condition. This moniker needs to be abandoned forever. Relapse is always a choice, never an inevitability or a mistake or a chance event. If our patients are to recover and find sustainable recovery, then a relapse has to be framed as a conscious choice and usually followed by adverse consequences driven by the underlying powerlessness. Any other understanding of a relapse does the addict a therapeutic disservice. Responsible addiction treatment always refers to the condition as a chronic problem and some people choose to relapse.

Spiritual programs like AA have long served as the mainstay of addiction treatment. So have people who are recovery successes. That’s the problem.

A friend recently asked what I’ve got against spirituality in addiction treatment, citing my opposition to the inclusion of 12-step work in rehab and my insistence that medical experts—not people in recovery—be in charge of addiction care that gets insurance or government reimbursement. He asked: do I think that the existential need for meaning and purpose plays no part in addictions? And why do I deny the importance of recovering people to the field?

My answer is complicated. I certainly believe that recovery for many people is a spiritual experience and that treatment often fails because people cannot find a way to have a meaningful or even bearable life without drugs. My own recovery certainly felt like a spiritual rebirth: I was in awe of how close I’d come to death and my physical turnaround alone seemed like a miracle.

The support I got from other recovering people in 12-step groups truly felt like God’s grace. Going from being an 40kg wreck dotted with tracks to a healthy young woman whom no one would believe had once been very ill was as extreme a change as reliving puberty, far stranger and more mystifying than any psychedelic trip I’d ever taken.

However, I am extremely uncomfortable with attempts by treatment providers to force particular visions of spirituality—often explicitly religious ones—on patients, especially those who are coerced into the treatment system. While 12 step–based treatment programs aren’t explicitly religious, the word God remains in the steps, complete with His male pronouns and implicit Christianity, which is often made explicit in sharing by patients and even discussions by counselors of their own paths. The idea that spirituality is the only way to meaning is also troubling.

The problem is this: if you allow people to use treatment to teach the 12 Steps, why not Christianity, Islam, Judaism, Buddhism, Scientology or the Great Spaghetti Monster? And if addiction really is a disease, why is it the only one where having it makes you qualified to treat it?

For no other medical disorder is meeting and praying considered reimbursable treatment: if a doctor recommended these religious or spiritual practices for the primary treatment of cancer or depression, you would be able to sue successfully for malpractice. Similarly, people who have those medical conditions and recover from them may have valuable experience and information to share. But they have not graduated from medical school and would never escape legal scrutiny if they decided to set up a medical practice.

Given that, I think that professional treatment that is covered by medical aid or any other insurance system should be exactly that: professional. The historical isolation of addiction from the rest of mental health care, and from the health care system in general, results from stigma—and reinforces it. Integrated treatment requires practitioners who know about far more than addiction and addiction counseling.

All of this said, I do think that recovering people have a critical role to play in the field and that being in a community of people who have overcome addictions offers a powerful source of hope and support. Referral to 12-step or other support groups, encouragement of such attendance, providing information about what to expect and even having such meetings available on-site for those who wish to attend is helpful, not problematic. I certainly found inspiration in hearing people who’d successfully climbed Mt. Recovery before me.

However, I don’t think people should get paid to essentially act as sponsors who indoctrinate people in the 12-step belief system: not only does this violate AA’s traditions, it also winds up making patients pay for self-help knowledge they could get for free. Neither treatment nor the 12-step community is improved by this conflict of interest.

Nonetheless, because recovering people can serve as such powerful role models, I do think they should be given special help to overcome educational barriers that might otherwise prevent them from getting properly qualified to work in the field. I also think that recovering people who get those qualifications should be given preference in hiring over those without such experience: we want the enthusiasm and passion that comes with good recovery. If their only knowledge is of getting better through one self-help path, however, it’s unfair to patients or insurers to pay such people as counselors, except perhaps in well-defined situations where it is made clear that this is their only source of authority.

Nor do I think discussions of spirituality have any more place in professional addiction treatment than they do in psychological counseling for depression or other disorders. If someone wants to explore their relationship with a higher power, there are plenty of places outside the medical system that can help with that, again, for free and without constitutional issues of separation of church and state. As in cancer care or in hospices, pastoral care should be an adjunct to treatment for those who want it, not a substitute or requirement.

Of course, with data increasingly showing that meditation and exercise can be effective in dealing with multiple psychological problems, I see nothing wrong with programs that incorporate these powerful tools into treatment: indeed, I think they should be encouraged. Still, I don’t think that addiction should be seen as a “special case” where spirituality is any more essential to recovery than it is for other conditions. We need to recognize that not all healing is medical: some of the most potent spurs to health are social. But when friends are the best medicine, we shouldn’t have to pay for them.

Like depression, addiction can be a response to an existential crisis, and treatment providers need to empower addicted people to find ways to make a meaningful life for themselves. To recover from either problem, finding a purpose—whether through relationships, work, altruism or, yes, spirituality and religion—is often critical. That, however, can only come from within each individual, often through a network of social ties. Attempts to impose it via a treatment system are too often counterproductive, intrusive, offensive or all three.

Finally, when we emphasize addiction as a uniquely spiritual problem, I think we not only subtly reinforce the idea that it’s not a medical issue, but, in fact, suggest that it is a sin. The health care system is no place to enforce morality: to protect both spirituality and addiction care, I think we need to keep God or whatever higher power we choose (or don’t choose) outside of formalized treatment and within our own personal belief and support systems.

Acknowledgement: Thefix.com

By Maia Szalavitz