Are Centers That Avoid Drug Treatments for Addiction “Shunning Science and Ethics”?

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This is a question that’s certainly generating a lot of discussion in our industry these days. In fact, a recent article in Addiction Professional took square aim at the issue by implying that “it’s unethical not to use medications.” Well, it’s just not that simple whereby anyone should be making a blanket statement to that effect.

We’ve all seen, read or heard about successful addiction treatment, ranging from abstinence-only to medication-friendly and somewhere in between where medication is used only in the facility. It’s worth repeating here: Addiction treatment is not a simple process. So, perhaps, it’s worth delving a little deeper into some of the complexities that keep us from taking a one-size-fits-all, medicate-everyone approach to addiction treatment.

A good place to start is co-occurring disorders. There are varying opinions in our field about the existence and treatment of co-occurring disorders. Does a person who has both an alcohol or drug problem and an emotional/psychiatric problem warrant a dual diagnosis? At times, the symptoms of both problems can overlap and even mask each other, making diagnosis and treatment more difficult. There is discrepancy over diagnosis. Is it truly a dual diagnosis? And which is primary in the diagnosis—the substance abuse or the psychiatric disorder? Further, how is it treated?

So, taking this into consideration, are centers that avoid drug treatments for addiction really shunning science and ethics?

There are reasons to be skeptical of current research in the addiction/psychiatric arena. There have been increasing allegations of “sham” science funded by pharmaceutical companies with researchers on payrolls of drug companies.  Hopefully this is a true minority, but these studies tend to have small numbers and short follow-up. In addition, there is inconsistency in reproducing findings.  With billions of dollars at stake, there needs to be a true clinical “real-life” verification when it comes to these new drugs. Abstinence-based treatment has a long, successful record in treating addictions and there needs to be ongoing support for this approach regardless of developments in the medication-assisted arena.

Medical practitioners have tried to adhere to their oath of “First, Do No Harm.” There is an ongoing debate between medication-assisted and abstinence-oriented treatment philosophies as to what constitutes harm. Successful treatment of addiction has traditionally been an all-or-nothing undertaking, involving complete abstinence rather than a regimen of moderation. For many, that definition includes abstinence even from drugs that may help fight cravings.

This trend toward “harm reduction” follows European moves in a similar direction.  In fact, the United States is the last country advocating for abstinence in addiction. This is a scary trend and this path should be trod carefully because once there, there is no going back. So the total abandonment of a philosophy that has led to millions of recovered lives deserves careful scrutiny. These new medicines are not magic bullets. They may have a place but we do not yet know enough for them to be the only option. The experience of a true abstinence-based program is beyond valuable, as there will always be a need for someone to start from a “clean slate. Although many providers have recently become open to new options, the majority of American addiction treatment continues to use the abstinence model.

Since many symptoms of substance abuse mimic other psychiatric conditions, the person must go through a withdrawal from alcohol and/or drugs before the physician can accurately assess whether there is also an underlying psychiatric problem. Making a dual diagnosis in substance abusers is difficult as drug abuse itself often induces psychiatric symptoms, thus making it necessary to differentiate between substance-induced and pre-existing mental illness. More often than not, psychiatric disorders among drug or alcohol abusers disappear with prolonged abstinence.

While everyone is screaming for evidence-based practice, what we really need is practice-based evidence. The data and rationale for what ‘should’ work are far different from what happens in real life. What we hear from patients coming into the program and what we see happening in treatment centers like Willingway shows us what is working.

Wet Houses Are Not a One-Size-Fits-All Solution for Alcoholics

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Wet house programs, for the chronically alcoholic and homeless, have been covered quite extensively in the media the past several months. And it’s causing controversy.  Wet houses provide homes for homeless alcoholics while allowing them to continue drinking. No treatment programs or counseling are available. It’s a place for alcoholics to drink themselves to death.

The wet house concept, very similar to a heroin safe house, is a harm-reduction model designed to reduce the public costs and inconvenience, while allowing the disease to go along to its conclusion in a safer way. Safer for the public, that is. Some would say it is analogous to hospice for those with other end-stage diseases. But the difference is an addict or alcoholic can get clean and sober, at any point prior to death.

It seems clear to the proponents that it saves tax dollars and provides homeless alcoholics who have failed treatments a safe place to live and eventually die. 2009 research published in the Journal of the American Medical Association on a program in Seattle showed significant savings in public spending. The year prior to the opening of the wet house, its 95 participants had cost the government nearly $8.2 million in policing, jail, detox and other medical spending, an average of $4,066 per person per month. But after moving into the wet house, costs were reduced to $1,492 per person monthly after six months, and to $958 after 12 months. Additionally, a University of Washington study found that “housing first” facilities in Seattle cost taxpayers remarkably less than leaving alcoholic homeless people on the streets, where they depend on hospital emergency rooms as well as social and legal services.

Obviously, the primary “pro” for this approach is the money saved by keeping homeless, chronic alcoholics off the street and out of ERs and “drunk tanks.” It seems the data supports this. Wet houses offer an easier alternative than continuing to work with the alcoholic to actually get better. The alcoholic sees this as more appealing and is more apt to accept this option.

The “con” to all this means we are giving up on a segment of our population.  We should never give up on alcoholics.  Alcoholics can get sober and do, often after repeated attempts. This approach removes the possibility that the next attempt may be the one that succeeds.

So what are the alternatives? There are homeless shelters that incorporate alcohol and drug treatment into the facility itself. The Healing Place in Louisville, Ky. comes to mind. There are actually a series of centers modeled on The Healing Place across Kentucky now. They are a joint effort of state and private funding. Some people do enter and fail, but many get sober and become employed, tax payers again. I’ve met them.

Many times, we often take a solution designed for a fairly specific population, then try and extend it to others later. An example is opiate replacement treatment. It was developed for use with urban heroin addicts. Now, there are Methadone- and Suboxone-based clinics in strip malls in small to medium communities all over the country. They advertise themselves as an alternative treatment for all alcohol and prescription drug addictions. As a result the incidence of deaths due to unintentional opiate overdose is up well over 100 percent during the last decade.

Wet houses are ostensibly designed for homeless, chronic alcoholics who have failed several prior treatments. If cost savings is the driving force behind this movement, it won’t take long for there to be a trend toward using this model for those not yet homeless or who have yet to fail multiple treatments. If it saves money and keeps alcoholics off the streets, then the general consensus will be: Why wait till they have cost us more money, get them into the wet houses sooner, than later. That should be a major concern for us all.