October 7th, 2016
A piece on The Influence last week by Patrick Hilsman, a member of this publication’s editorial team, strikingly recounted his experiences—both pleasurable and harrowing—with heroin, to which he was once addicted.
He contrasted these personal experiences with some received wisdoms about heroin—though in doing so, he inserted some important disclaimers about different people experiencing phenomena like withdrawal in different ways.
Personal experiences like these have value: They can illustrate some of the cultures around heroin and other drugs (and that word, “culture,” is critical).
But when forming both policy and informed broader views, it’s good to periodically remind ourselves that data and research are always king.
AA and Addiction Treatment
And how do we know? Because someone, many someones, have told us that they could never overcome their alcoholism—but then they went to AA, and voilà!
Now let’s do some research. Two types in particular.
In one, which we can only do occasionally, and perhaps is no longer possible, since it is inhumane-seeming, is to assign people with alcoholism to AA or to no treatment, and to see what the outcomes are.
No such research has ever found AA to be effective (although such research has only been conducted a handful of times). That is why University of New Mexico professor and Motivational Interviewing founder William R. Miller and his colleagues rate both AA and 12-step-based treatments so low in their comprehensive Handbook of Alcoholism Treatment Approaches.
Here is their summary of the cumulative results of all comparative research of this type, as conducted with 48 different kinds of alcoholism treatment:
|Efficacy of Alcohol Treatments|
|Treatment||Cumulative Evidence Score|
|Community reinforcement approach||110|
|General alcoholism counseling||-284|
|Education (tapes, etc.)||-443|
|Source: Data from Miller et al. (2003).|
The second type of investigation I discuss here in my summary of this and other research on disease explanations for alcoholism and addiction and disease treatments.* These are large epidemiological surveys, such as NESARC, in which approximately 4,500 alcohol-dependent people (discovered among 43,000-plus randomly selected Americans) are questioned about the course of their relationship with alcohol over their lifetimes.
In NESARC, although only about 12 percent went to AA or received specific alcoholism treatment, and only 25 percent received any sort of treatment around their alcoholism problems, the same approximate 25 percent have remained alcohol-dependent at the time they were questioned, whether they have been in treatment or not.
|NESARC Past-Year Drinking Among Ever Alcohol-Dependent Respondents (%)|
(n = 1,205)
(n = 3,217)
|Remission, risk drinking||6||14|
|Remission, drinking without risk||10||20|
|Source: Dawson et al. (2005).|
Based on these two types of research, our conclusion should be that both people who go to AA and get better—and people who don’t go to AA and get better—all do so by going through the same natural curative life process.
But the people who go through AA attribute their recovery to AA and the 12 Steps, and can never be persuaded otherwise.
And are you really going to bring this up to someone you meet at a party, who swears to God that AA has saved their life? You are not. (Well, I might. And I can tell you that it’s the surest way never to get invited to a party again!)
Aided and Unaided Smoking Cessation
Let’s turn to smoking. I knew a man who went to Smokenders, a group that supports people in quitting smoking. He succeeded in quitting smoking via the method. Admirably, he formed a support group along with three fellow quitters, with whom he went through the program.
The result? The other three relapsed.
Nothing daunted, my acquaintance would practically scream at people, “Anyone who tries to quit smoking on their own is crazy!”
Flash forward to the 2015 film The Business of Recovery (in which I appeared). I attended a screening in Manhattan, and after the film, I did my thing. I asked the audience to declare what the hardest substance addiction to quit was. As usual, they shouted out, “Smoking!”
I then asked how may in the auditorium had quit smoking. Half or more in the room raised their hands.
Then I asked how many of these hundreds had used nicotine replacement, group support, or any other types of treatment, medical or otherwise, to quit. As always, fewer than a handful raised their hands.
Lest I be accused of relying on mere anecdote, this study by Harvard’s Center for Global Tobacco Control researchers, who want to rid the world of smoking, found NRT added no advantage to quitting on one’s own when tracked for many years (as opposed to initially quitting). Even more remarkably, the most dependent smokers were several times more likely to relapse if they used NRT than if they quit solo. Gregory Connolly, director of the Center, decried their own results: “We were hoping for a very different story. I ran a treatment program for years, and we invested millions in treatment services.”
And what did Greg Horvath, the producer of that excellent film calling out the anti-scientific basis of most US addiction treatment, say following my exercise at the screening? From the front of the auditorium, he told us he was only able to quit smoking after years, decades, with a medication—and so that was the way that it had to be done.
NESARC was able to compare the rapidity of recovery among cigarettes, alcohol, marijuana and cocaine users. (Note: Heroin is a difficult drug to study in terms of addiction and recovery, because there are relatively so few people addicted to it in America: fewer than a 10th of 1 percent.)
The half-lives of people who achieve recovery with each substance—i.e., the number of years it took for 50 percent of addicted users to emerge from dependence on each—were as follows:
Smoking: 26 years
Alcohol: 14 years
Marijuana: 6 years
Cocaine: 5 years
Cultural and Individual Expectations in Addiction and Recovery
Returning to Hilsman’s piece, one area he discussed was heroin withdrawal, and how his own experience of it was far worse than the “three days of ‘flu-like symptoms” often portrayed:
“Again, I add the disclaimers that different people experience different things, and it’s sometimes hard to distinguish the physical symptoms of withdrawal from the emotional ones—but that shouldn’t be used to downplay their power. I can’t ever remember a flu that made me feel like I was ready to die, or like I had lost a lover.”
His disclaimers are crucial here. But how are we going to compare experiences of heroin withdrawal in our own culture to those of people who, well, don’t know about heroin withdrawal, or who are treated with placebo? Where will we find them?
In the early years of the last century, when the Harrison Act made narcotics use illegal, two physicians at Jefferson Medical College were able to study substantial numbers of people who used very pure doses of heroin, and who reported being unable to quit (research I review in The Meaning of Addiction).
Light and Torrance did observe a withdrawal syndrome comprising restlessness, vomiting, diarrhea, perspiration and enervation. However, the reactions that supposedly defined narcotic withdrawal could not be related to any of a host of careful physiologic measures, and thus could not be said to constitute a medical syndrome.
The skeptical investigators reported observing a similar syndrome among “a university football team just prior to the playing of a so-called important game… yet, when the whistle starting the game is blown, all fatigue quickly disappears” (pp. 14-15). In particular, they focused on one man who constantly asked for more drugs, whom they injected with saline solution: He “promptly went to sleep for a period of eight hours” and “never became aware of the fact that he was given nothing but sterile water” (p. 12).
(Note: This would now be considered a cruel hoax and wouldn’t, and shouldn’t, be done. We don’t toy with human beings that way. But we can’t discard what we have learned from such research.)
Does this mean that his withdrawal wasn’t real? Of course not.
But it does demonstrate—along with other important research—that personal and cultural expectations are the most crucial determinant of the manifestations of drug use, drug addiction and recovery, even including withdrawal and tolerance, as Ilse Thompson and I detailed in our book Recover!
Here is what, for instance, an international team of WHO investigators discovered on applying DSM criteria cross-culturally, contrary to their own “expert” prediction:
“While descriptions of dependence symptoms were quite similar among key informants from sites that share norms around drinking and drunkenness, they varied significantly in comparisons between sites with markedly different drinking cultures.’’
There is not space here to discuss my fellow columnist Maia Szalavitz’s brilliant recent treatment of expectation and disappointment in this publication, but only to say this: Expectation overcomes dopamine et al. every time, as I have shown in The Influence. I will discuss Maia’s landmark work more in my next column.
*Titled “Addiction as Disease: Policy, Epidemiology, and Treatment Consequences of a Bad Idea,” as a chapter in Henningfield et al.’s, Addiction Treatment in the 21st Century: Science and Policy Issues. (Baltimore: Johns Hopkins, 2007; pp. 153-163).
Dawson, D.A., Grant, B.F., Stinson, F.S., Chou, P.S., Huang, B., and Ruan, W. J. 2005. Recovery from DSM-IV alcohol dependence, United States, 2001–2002. Addiction 100:281–92.
Light, A.B., and Torrance, E.G. 1929. Opiate addiction VI: The effects of abrupt withdrawal followed by readministration of morphine in human addicts, with special reference to the composition of the blood, the circulation and the metabolism. Archives of Internal Medicine 44:1-16.
Miller, W.R., Wilbourne, P.L., and Hettema, J.E. 2003. What works? A summary of alcohol treatment outcome research. In R. K. Hester and W. R. Miller, eds., Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 3rd ed. Boston: Allyn and Bacon.
Stanton Peele is a columnist for The Influence. His latest book, with Ilse Thompson, is Recover!: An Empowering Program to Help You Stop Thinking Like an Addict and Reclaim Your Life. He has been at the cutting-edge of addiction theory and practice since writing, with Archie Brodsky, Love and Addiction in 1975. He has since written numerous other books and developed the online Life Process Program. His website is Peele.net. Dr. Peele has won career achievement awards from the Rutgers Center of Alcohol Studies and the Drug Policy Alliance. He is currently working on his memoir. You can follow him on Twitter: @speele5.