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Commentary: Learning As We Go: Critical Assessment of Addiction Research and Practice

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A recent Join Together article, entitled “Half of Addiction Counselors Say It’s OK for Some Patients to Drink Occasionally,” drew attention to the fact that some substance abuse counselors believe moderate drinking is an option for individuals with substance use disorders. As a researcher and an advocate in our field, I reacted with mixed feelings to this news.

While I applaud new research by anyone into any area of our profession, I am also aware that not all research is created equal. Does a survey of professionals’ opinions reflect research or the content of counselor education for our professionals? Both? Neither? An approach that allows an individual to continue to drink is a risk about which many of us remain most skeptical.

For decades the belief in the United States has been that abstinence is the only real solution for such individuals. This was largely due to the influence of Alcoholics Anonymous and similar philosophies. Over the years, our profession has grown and the attention to evidence-based practice has come into clear focus. That said, we have tried to consider what seems to work in other parts of the world as well.

I have clear memories of the debate over the inclusion in our exams of harm-reduction strategies and Therapeutic Community model treatment programs. In the end, subject matter experts agreed that IC&RC exams should reflect all treatment modalities, not just our personal preferences, so the exams were infused with a broader range of treatment strategies and were weighted according to our research into what was being used the most and under what circumstances.

One place we looked for guidance was the United Kingdom, whose approach was heavily weighted toward harm reduction, seeing abstinence as a last resort. So what is harm reduction? It includes everything from “controlled” drinking to methadone maintenance programs and needle exchanges. I can make a case both for and against each of these under the right circumstances and so can most readers here, I suspect.

Interestingly, in the UK, there is currently a backlash building against methadone – with some professionals referring to it as “harm maintenance” programs. It seems that abstinence is starting to catch on as they debate the real definition of recovery and consider the vast numbers of clients who live for decades on methadone and claim “recovery.” Proponents of abstinence-based treatment in the UK commonly refer to “real” or “whole” or “true” recovery.

Another gray area concerns medication-assisted treatment. Again, there is a case to be made in either direction. If medication is involved in detox, the need is clear. If medication is involved in a transition period, it can be helpful, as well. But substituting medication for a holistic approach to the individual –that includes counseling and education– is a one-size-fits-all approach that opens the door to the exact same criticism some have directed at total abstinence for all.

In the case of medication-assisted treatment, we, as professionals, must consider the source of our education about this strategy. Many of the research and educational efforts around “MAT” are funded by the pharmaceutical companies that make the drugs. It makes sense that they want us to know about what they have developed. On the other hand, “research evaluation 101” tells us to always look at who funds a study and “follow the money” before we give too much weight to the research conclusions.

So my goal is to sound a note of caution against pushing too hard, too quickly for any new approach to treating a very fragile client population. We study. We learn. We jump the gun. Let’s be mindful of that last one.

Phyllis Abel Gardner, PhD
President of IC&RC

24 Responses to this article

  1. Phyllis Gardner / January 12, 2013 at 8:42 pm

    As always, happy to see animated discussion. This commentary was written to simply point out that we have a tendency to jump on the next big thing, sometimes too quickly. And I agree that there are different types of medication assisted treatment approaches that are appropriate for a variety of purposes. Some are invaluable. I am also conscious of the realities of misuse versus abuse, etc. In the end, I remain skeptical of medicines that are used as a complete substitute for a holistic approach to the person, which is what some have seemed to suggest. My comments about harm reduction are not intended to throw the baby out with the bath. Let’s just be cautious and learn from others about the benefits and limitations of any intervention. And if responsibly seeing multiple sides of an argument, gray areas and exceptions to the rule makes me wishy-washy, I will wear the badge with pride. Thanks again!

  2. Avatar of Lorraine Hill
    Lorraine Hill / January 12, 2013 at 5:13 am

    A thoughtful article and thoughtful responses. In 32 years of working in this field I have learned and held many conflicting biases which have directed me to search, to read and to work in order to understand the ebb and flow of addiction disease and addition science through contrary models. Most importantly I seek to be honest and insightful with the people I work for and with to be a simple, direct messenger of what I see from my knowledge base and to clarify what the choices they have might be at the moments of decision making in their lives. I seek to impact all or nothing thinking with challenges of reality in their experience. I prefer abstinence based therapy, I know there are other methods that are helping people manage their lives with pain and I support the medical use of those therapies. I also know that often these are shams for street sale and livelihood of those not seeking recovery at its best. Further research, additional knowledge and development of best practice models has challenged my early beliefs. I will continue to be open to anything that works to clear a path to individual health and peace. Heard years ago: “I don’t care if you have to stick carrots up your nose to get well, I support it.” That has been stuck in my head and I share it again, thinking what is my purpose and responding that it is to facilitate the process, not be the end of it, that is the world of the recovering soul.

  3. miastella / January 11, 2013 at 4:32 pm

    I’ve been a methadone counselor for 3 years after about 25 years of mental health counseling. Given the high rate of co-occurring problems for clients, I’ve come to believe that a drug is a drug is a drug. Addicts have too many issues to judge well on moderation.The issue is not just one trigger or one treatment. Our job would be easy if there was a cookie cutter response or a valid research supported treatment. Recovery really is a multifaceted process and the best recovery is aided by patient, consistent, high rapport counseling that focuses on all facets of a persons’ life. I have a high success rate with “graduates” from my case load after one or more years of treatment. Granted, I am one person with a yearly case load of about 60 people. But, we explore all facets of life – - – career, family, spirituality, the past, goals, life skills, healthy living and self-care etc. If a person really is in the ready stage of change, then it takes shortly about 2 years of persistent work. If they are using pot or benzodiazepines or sipping, they are not “getting” that their life is in jeopardy of going off track. They are still playing on the “wrong side of the tracks”. I can’t argue with theory; I am a totally applied professional. But, I personally believe that no good counselor should be telling people that playing on the railroad tracks is safe enough just because the trains run ten minutes apart.

  4. Carolyn Moore / January 11, 2013 at 2:10 pm

    Dr. Gardner:
    Thank you for writing this article; it presents some very thought provoking information. Apparently, I didn’t have the same opinion as many of the others that commented. I felt you were presenting information than anything. Also, the only commenter that I saw that had any real ” recovery” from addiction was Debra Mullen, the first responder. I began my recovery on March 15, 1987 and my drug of choice was amphetamines or anything else that was available. If meth wasn’t available, I would dig through a trash can to find part of a half smoked joint. Although at the end of my active years, I didn’t drink as much when I had I drank as much as I could and I could outdrink most people I knew. I honestly can say that I have thought about having a glass of champagne at Christmas or some other alcoholic beverage or even marijuana for pain relief but I also have thought that I know how my addict mind works. I might have just one tonight but then I will remember that in two months and tell myself that its okay to do that again and then I will have two and off I go. One is never enough for an addict, period. After all these twenty plus years, I have spoken with and listened to thousands of fellow addicts both that are new to recovery and have been in recovery a long time. I have also heard hundreds that have quit and started again over and over and I have seen many, many people die. Maybe someone can safely drink again or drink in moderation but who knows who that person safely might be? We are talking about peoples lives here and a very serious “disease”, addiction that kills. Personally, I am not willing to take that chance to tell anyone that they can drink or use drugs in moderation ever again. It is as someone else stated, who knows if that next drink or drug isn’t the one that puts them overboard and they are on the road to no return. Even if they do not die, it will not only destroy their life but the lives of all those around them. It just isn’t worth the experiemental chance to me. That is my personal opinion and I certainly respect the right for all of the rest of you helping addicts to have your own. Their lives are in your hands, not mine.

  5. Carlos / January 11, 2013 at 2:03 pm

    I like this *too, and I am a nature born skeptic. I think it is that too few clinicians (only 28% according to Butler, William & Wakefield,(1993)”Obstacle to disseminating Applied Psychological Science”, Journal of Applied & Prevention Psychology2) do not read science article. We get our information from others than scientific journals like Newsweek, etc and books who mentions a research without citing them. Seems like clincians have yet to know how to implement Evidence Based Treatment, and little know much about science as a whole and the reasons that we use research as foundation to backup clinical work. Regarding research, we most understand, that in science, we work toward refining our knowledge,not drawing conclusions from just a few studies. I think we still do not know, how would do well with moderation and who will not, or are not ready. It does appear however that most people who go to treatment, whether they say abstinence or not, they do slow down their drinking or using from where they were operating before.

    My moderation is so moderate, I forgot the last time I had a beer. It surely was not last New Years Eve, and most likely neither the last one either. Moderation became true to me when I stop thinking about it, and people offer me alcohol numerous time and I had lost the taste for it.

    We also need to define, what do we really mean by recovery? are we strictly talking about abstinence, or are patients able to gain their lives back, economically and socially just as recovered as abstinence based in an inflexible fashion.

    I agree, we still have more to learn before we can agree conclusively in lot of different areas of substance use disorder. I think that we are reaching consensus that the War on Drugs have been causing a lot more harm than fix problems for users.

  6. Jamie Matter / January 11, 2013 at 12:47 pm

    Anne fletcher’s comment makes a key point. People are going to try the moderation route so you might as well keep them engaged in treatment while they try it. If it works, there’s nothing to fix. If it doesn’t, they’re still in treatment to work on abstinence.

  7. Anne Fletcher / January 11, 2013 at 11:54 am

    I meant to say that the wise therapist trusted me to figure out “for myself” that abstinence suited me best. Anne Fletcher

  8. Anne Fletcher / January 10, 2013 at 7:39 pm

    After interviewing more than 200 people with at least 5 years of sobriety for a book on recovery (Sober for Good), I was about to eliminate the chapter on moderate drinking – thinking it was too controversial – when the late Dr. Alan Marlatt convinced me to include it. Why? Not only because a good number of people with alcohol use disorders are able to resume drinking without problems, but because, he reminded me, “Moderation is often the pathway to abstinence.” Indeed, years earlier, I had chosen to quit drinking because of a wise therapist who trusted me to figure out on my own that abstinence was best for me. Had he told me to quit cold turkey when I first walked through his door, I would have walked out. And so I left the chapter in the book.
    Anne Fletcher, MS, Author, Inside Rehab

  9. Ben House / January 8, 2013 at 9:37 pm

    Thank you. My thoughts about this confusing field where we do not agree on what addiction is or what recovery is have evolved since my 1971 heroin detox work in RVN. I have watched numbers of cottage industries develop over the years each with their own ideas and in my own small way I am sure I am just one more of those. That we remember how our bias impacts our work is an appropriate ethical challenge. Thank you.

  10. Avatar of Anne Fletcher
    Anne Fletcher / January 8, 2013 at 8:28 pm

    First, moderate drinking for alcohol use disorders (AUD) is not the same as MAT for opioid use disorders – it’s like comparing apples and oranges. When it comes to AUD, research suggests that although abstinence is the most stable form of recovery for most individuals who were once alcohol-dependent, many are able to drink again without problems. For those with less severe AUD, moderate drinking is not a controversial consideration. I would argue that a hard-line on abstinence is likely to dissuade help seekers. As for MAT, there is no “gray area.” After spending nearly five years writing a book on addiction treatment, it’s clear to me from leading experts in the field and a large body of scientific research that MAT is the most effective approach for treating opioid use disorders and also lowers the death rate. Because they recognize the value of MAT, even conservative treatment programs are implementing Suboxone maintenance treatment – not just using Suboxone for detox or “transition.” It’s wrong to infer that a client on long-term MAT is not in true recovery.

    Anne M. Fletcher, M.S., Author of Inside Rehab: The Surprising Truth About Addiction Treatment – And How to Get Help that Works (Viking, 2013)

  11. Avatar of Dottie Saxon Greene
    Dottie Saxon Greene / January 8, 2013 at 4:21 pm

    Thanks for speaking out Dr. Gardner. This article has been thought provoking for me as well. As research advances, it is important to use our newfound knowledge responsibly. Treatment goals that include moderation of use do not mean that it is the “safest” or best approach, and we must be clear with our clients (informed consent)regarding the risks of such goals. It is also important to clarify “harm reduction” defnitively – any reduction in harmful behaviors is defined as “harm reduction,” which inlcudes abstinence. Abstinence and harm-reduction are not dichotomous or binary concepts and are not necesserily contradictory terms. Harm reduction is an umbrella term under which exists a continuum of behaviors from total abstinence to reducing harm by using clean needles. Additionally, many clients are not willing to accept total abstinence, so trying to force this goal onto a client who is not ready may push them right out of our office door. In order to help them remain in treatment it might be necessery to START with reduced intake as the goal. If one has the the disease of addiction, this will be a difficult behavior to maintain, thus the client finds out on his or own the value of complete abstience. Another point I’d like to make is an ethical one. Given what we know about addiction (chronic, progressive, and if untreated potentially fatal) it is important to make treatment recommendations that include moderation of substance consumption thoughtfully, particulalry if a client has a dependence diagnosis. We must remember to practice ethically, forever keeping the principle of non-malfeasance at the forefront of our practice. With addiction, any use is like playing Russion Roulette – one never knows if the next round will contain the bullet.

  12. Avatar of Mark Willenbring, MD
    Mark Willenbring, MD / January 8, 2013 at 4:10 pm

    It is highly unfortunate that a leader in the addiction field spouts such utter nonsense, none of which is supported by scientific studies. First, the goal of treatment depends on the severity of the addiction. Many if not most people who develop substance use disorders have relatively mild, self-limiting cases. In one very large NIH funded and conducted study, 40% of people who had had alcohol dependence were drinking at low risk levels and had no consequences, 20 years after onset. It’s true that people in AA and rehab almost always require abstinence (except for opioids), because they are the sickest 10% of all people with addiction, and the likelihood of achieving non-abstinent recovery is inversely related to addiction severity. As for opioid agonist therapy such as methadone or buprenorphine maintenance, there is not one single study documenting success with an abstinence-based approach. In yet another study published this month in the American Journal of Medicine, David Feillin and colleagues found that counseling offered no benefit over the provision of buprenorphine alone. In another recent study, the relapse rate after tapering off buprenorphine was 93% within 8 weeks in spite of intensive counseling. It is intellectually dishonest to state that there is a ‘grey area’ when it comes to the effectiveness of opioid agonist therapy, since the research is very clear that it’s the only proven effective treatment. Ms. Gardner’s argument is similar to that made by the climate change and evolution doubters: claiming that a question hasn’t been answered when, indeed, it has. I hope she doesn’t also believe the earth was formed in 6 days, 4,000 years ago, but it wouldn’t surprise me.

  13. Floyd Frantz / January 8, 2013 at 2:05 pm

    There are many people pressured into treatment these days that are not ready for recovery. I have no problem in telling them that if they can drink successfully, then great, go for it, but that I cannot work with them while they are drinking or using. When they are ready to consider an abstinence model then to come back and see me. I really do feel that honesty in the counseling relationship is important, and it works both ways. I do recommend some meetings, a few readings, and discuss stages of change with them. By the way, I have been counseling for more than 20 years, and I try to never tell someone that they are an alcoholic. It doesn’t mean anything to them, it must come from themselves. I can tell them what alcoholism is, and is not, and then they can decide for themselves, it is their nickel.

  14. doogiem / January 8, 2013 at 12:30 pm

    Dear Phyllis,
    I’m surprised at how many times behavioral health providers “jump the gun” by writing articles before clarifying terms, before considering the full spectrum of disorders treated, and before acknowledging “the person in the patient” who is in our office! In your article you refer to “addictions counselors” without indicating if those counselors also see clients/patients who do not meet the criteria for addiction, patients who might moreso meet the criteria for substance abuse (a classification soon to become obsolete in the new DSM-V, unfortunately). You also refer to “such individuals” without clarifying if you are referring to the 12% of adults who actually develop addictions (vs. the 35 – 60 % who don’t meet criteria for addiction, but who meet criteria for “mis-use” or “abuse”). And if you are referring to (the 12% who are) addicts, you don’t clarify if they belong to the substantial portion that “mature out” of their addiction, many of whom are able to successfully practice moderation (per the NESARC study). So, we should all rightly have mixed feelings; nothing wrong with that at all! They (mixed feelings) might indicate a spectrum of conditions that are objectively involved in the situation at hand, and an associated range of modalities to be discussed with the specific person/client/patient in our office. The criteria of/for “real…true” health and recovery are to be applied to and – to a delicate but crucial degree — determined by the specific client in front of us. (Also – ANYTHING can become a “one size fits all” approach; that has less to do with the client or the particular modality, and much more to do with the provider/program/agency offering the treatment).

  15. Philip Appel / January 8, 2013 at 12:20 pm

    A case can be made for…a case can be made against. On the one hand.. on the other hand. One of the most wishy-washy, fence-straddling pieces I’ve read in a long time. It would be fine if Dr. Gardner were just being cautious, but it’s worse than that. Among other equivocations, her piece insidiously reprises the knock on methadone maintenance because the Brits have problems with it, because some patients stay on methadone a long time (SO WHAT!).How did this piece get a hearing?

  16. Avatar of Patrick Connealy
    Patrick Connealy / January 8, 2013 at 12:04 pm

    Good article Phyllis!

  17. Avatar of Debra H Mullen
    Debra H Mullen / January 8, 2013 at 11:50 am

    I am a recovering addict of 26 years. My drug of choice was Heroin,methadone clinics, narcotics if the Heroin wasn’t available. I drank very little. I have been in the rooms of recovery with people who stopped using their drug of choice and eventually started drinking. It is my opinion that a drug is a drug is a drug. ALcohol is a drug! I believe if I were to start drinking, I would get a high only to want my real drug of choice. This information could be so harmful to the recovering person. It could be for me, I just believe throughout the years I have witnessed this “alcohol” use, and once an addict is always an addict. I will die being an addict as that monkey is always on my back. Why give permission to harm myself, or someone who is NOT grounded in their recovery, and think they have one more use?

  18. Reid K Hester, Ph.D. / January 11, 2013 at 1:48 pm

    I heartily agree with Mark’s comments. What Dr. Gardner failed to mention was that this change in counselors’ acceptance of moderation as a goal for less dependent drinkers follows over 40 years of successful randomized clinical trials of moderate drinking protocols. Moderation, as a goal of change, is feasible and a common outcome in people with alcohol problems, especially those at the less severe end of the spectrum. Both the moderate drinking studies over the years and the whole field of natural recovery supports this perspective.

  19. Avatar of sunny
    sunny / January 22, 2013 at 12:27 pm

    Is that simple “unkindness” or arrogance?

  20. Avatar of Susan C.
    Susan C. / January 12, 2013 at 8:42 pm

    I am appalled by the notion that there is even such a thing as CONTROLLED or MODIFIED substance use of any kind- at least with alcohol. Sometimes medical doctors prescribe meds for conditions that if not treated simultaneously will sabatoge their sobriety- but the recovering person

  21. Susan C. / January 12, 2013 at 9:11 pm

    Thank you for the clarification. I have been a recovering alcoholic 21 years plus and trying to control it didn’t work for me- I fit the criteria for Alcohol Dependence- or as those of us in AA say, a REAL ALCOHOLIC.
    Opiod Replacement Therapy is a different thing entirely. So are comorbid DXs which require medical monitoring. I have ADHD and know it can & will sabotage recovery from addictions if I don’t work with a mental health Dr.-who I informed of my addiction HX.

  22. Avatar of Claire Saenz
    Claire Saenz / January 15, 2013 at 6:03 pm

    I had a similar experience. A few years before I decided to quit drinking completely, I tried using the Moderation Management program to address my drinking problem. It didn’t work for me as I was unable to stick to the drinking limits for more than a day or two, and from this I learned that for me, abstinence was going to be the best approach. Sometimes I wonder why some folks are so horrified by the idea of moderation based approaches. They do help some, and others of us learn from them. What’s the problem?

  23. Carlos / October 5, 2013 at 3:17 pm

    Anna Fletcher: Damn, I just finish reading Inside Rehab. I think you were too nice about some of practitioners. But then I guess you are a polite writer and not one like me where 20 years of recovery whose life was devastated by misinformation, forceful domineering confrontational intimidating, coercive and retaliatory treatment staff. While alcoholics and addicts are treated like the lowest of the low if I may say NIGGER <blacks do not have a monopoly on the word, and I assure you it is in American Dictionaries. Still a pejorative word, but has little if any to do with race). By inadequate personalities that became counselors, psychologist and people in mental health so they can avoid being diagnosed. And while treatment is about the patient, their main purpose to work in a treatment facility is to practice the last 12ths Step and "Cannot keep what they have unless they give it away". Except that they do not give it away, they forcefully expect you to be indoctrinated, become a true believer so that they and not necessarily the patient "get better". I do not know how many time I have heard so call professionals claim "I am here for me and not for you" or something similar to this. They seem to forget there is such a thing as a Behavioral Code of Ethics for the health and helping profession. They probably have not read it since they left college, and I have heard it more than once that some of the principles of the code of ethical behavior actually get in their way of their practice.
    Nevertheless, thanky for writing Inside Rehab. What you said needed and most be said. Thanky you so much, but you might concider writing Inside Rehab Two. When treatment do not work and the patients get blame for the outcome,eventhought in treatment nothing belongs to them. The facilties is theirs, the food, the treatment plan, the modality, their regulations and policies. Ect, etc, etc. I have never ever been asked what I want to get out of treatment.NEVER. Yet when treatment becomes an pitiful outcome. Somehow it becomes the patients foult. I like Nora Volkow statements she made to Ira Flatow "Present at the Future'page 50+ If this is a disease why are treatment facilities avoiding medications that patients can curve their craving for alcohol and drugs… This claim that their medications is going to AA and NA meeting maybe a useful metaphor, but it is definitely Junk Medical Science.
    Thank you Ms. Fletcher my hat goes off for you. I still taking notes on you book, because although you are not a professional in the field you are a journalist. You did ask the top of the line researcher and practitioners. You need to consider interviewing Dr. Hester Miller and William Miller <developer of Motivational Interview) Authors of a team of researchers and scientific practitioners of The Handbook of Alcoholism 3rd Version. Who have being doing review of the literature since early 1970s before AA ever became the undeserving dominant modality. And allow for facilities to violate the 6th, 8th and 11th Tradition which are supposed to be nonnegotiable. Of course unless there is big money coming for a chunk of the money that goes in the basket and the sales of books, and other materials. They are violating the 6th tradition whether we like it or not. And it is diverting their attention to money rather than their mission to carry the message to alcoholic and their only requirement for membership is a desire to stop drinking
    Thank you again.

  24. Avatar of Joyce
    Joyce / April 3, 2013 at 1:00 pm

    I just read some of the comments so if someone has posted the following comment ….sorry.
    Abstinence can be a goal of Harm Reduction..

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