A medical student examines three approaches to treatment and envisions better referral from primary care
Imagine the following scenario: A 32-year-old man makes an appointment with his doctor because he has been having trouble sleeping. When the physician takes the patient’s history, the patient mentions that he drinks 4-6 glasses of wine 3-4 times per week.
While the patient’s difficulty sleeping may be unrelated to his alcohol use, this visit created an opportunity for the physician to address the patient’s risky drinking habits. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines risky drinking for men as drinking more than four drinks in one day or greater than 14 drinks within one week. For women, this number reduces to three drinks in one day or greater than seven drinks in a week.
If the patient was amenable, many physicians would recommend that he seek help at a local Alcoholics Anonymous (AA) meeting. Although it is not treatment, AA is widely available in communities, and candidly, may be the only “treatment” that most physicians are exposed to in their medical school education. So, what else should we as aspiring, or (eventually) practicing physicians know about treatment approaches to substance use problems?
Although drug and alcohol treatment based on the principles of AA and its sister organization, Narcotics Anonymous (NA), are typically viewed as the “most successful” recovery method, they were developed in the 1930s and other options have emerged.
In addition to AA and NA, I’m going to take a look at two schools of thought on opposite ends of the spectrum: Passages Malibu (where you can recover in paradise) and Pavel Somov’s book Recovery Equation, which takes a more cognitive approach to staying sober.
Alcoholics Anonymous: 12 steps to achieve sobriety
AA (and later, NA) has been a key component of addiction treatment and recovery for over 70 years. Founded in the late 1930s by Bill Wilson and Dr. Bob Smith, AA is a peer support system based on the idea that a recovering alcoholic can help other alcoholics stay sober.
The concept of alcoholism as a disease was a revolutionary idea in the 1930s, but soon the pair had gathered over 100 men that they had helped achieve sobriety. The Big Book forms the basis of AA’s teachings, which describes how to recover from alcoholism using personal stories and anecdotes. About 20 years later, Narcotics Anonymous was founded in Sun Valley, California.
Integral to the philosophy of both AA and NA programs is “working the steps,” or following a set of 12 guidelines designed to bring about a life change and assist the alcoholic in moving into recovery. Step 1, for example, states, “We admitted we were powerless over alcohol – that our lives had become unmanageable.”
Passages Malibu: recover in luxury?
Named “one of the most luxurious places to dry out” by Forbes Magazine in 2004, Passages Malibu was established in 2001 by Chris Prentiss. Passages is clearly marketed to addicts with substantially greater material resources than most: at $88,500 per month and a typical stay of three months, recovery certainly does not come cheap.
Prentiss credits a reported 84.4% success rate to the customized approach to each client combined with the rich surroundings of the $15 million Passages mansion. Upon arrival, each client is assigned a personal team of nine clinicians. Additionally, Passages offers 22 unique modalities for addiction treatment, including adventure therapy, ocean therapy, and equine therapy, as well as the more typical rehab fare like psychotherapy and relaxation techniques.
Pavel Somov’s simple formula for recovery
Recovery Equation is Pittsburgh psychologist Pavel Somov’s novel approach to drug and alcohol treatment. His theory draws from a variety of teachings such as cognitive behavioral therapy, cognitive dissonance, stress inoculation, and motivational enhancement therapy. Somov views recovery as the sum of three components: the development of motivation for change, choice awareness, and use prevention skills.
Dr. Somov’s model has been implemented in the Allegheny County Jail and it has been well received by patients because it stresses useful skills that patients can put into practice almost immediately. For example, clinicians first discuss the neurobiology and experience of cravings and how to disarm them. The group leader may induce a craving by taking out a plastic bag filled with sugar and lining up the loose sugar with a credit card to simulate cocaine or heroin. Clients then have the opportunity to practice their skills in a safe environment.
Somov’s model uses one particular exercise to demonstrates that addicts retain control over their drug use. Facilitators tell clients to imagine that someone is putting a gun to their head. If they use, they will die. Most people will admit that they would be able to refrain from using that one time.
This situation illustrates that the gun, an inanimate object, did not introduce the choice not to use; the choice was there all along. The presence of the gun helped the client become aware of the choice. Because many addicts have felt as though they were under the control of a substance for many years, this exercise can be very powerful.
Evaluating the Malibu “treatment” model
Besides the fact that the colorful pictures of the Passages mansion make me want to go there for vacation, Passages Malibu is probably the easiest treatment modality (if you can call it that) to critique.
Because other facilities have nowhere near an 80% success rate, a reporter at LA Weekly took a look at the numbers. The stats include those who have been clean for only 30 days and the quoted number never changes. This particular reporter dubbed the Prentiss duo the “Holocaust deniers of the addiction recovery industry” because they deny the existence of addiction, deny the existence of alcoholism, and deny that it is incurable.
Prentiss scoffs at the idea that patients are put to work at some facilities saying, “Why should we punish someone for being an alcoholic by turning them into a cleaning person?” This viewpoint unfortunately encourages the sense of entitlement many addicts struggle with already and is extremely offensive to a “cleaning person” who works an honest job.
This same “entitled” mentality is reflected in the lack of group therapy at Passages Malibu. The idea that you can’t gain any insight from any other group members during any part of group therapy is isolating and only further perpetuates the lack of connectedness that many addicts already feel.
Proponents of 12-step models and Somov’s Recovery Equation identify a sense of entitlement as a character trait that is a barrier to recovery and, unfortunately, Passages plays right into it.
Recovery Equation = 12 steps?
I have heard strong opinions from 12-step supporters that AA/NA is the only successful treatment for addiction. After all, they say, AA has been around for 70+ years for a reason: it works. But when I visited the Allegheny County Jail as an IRETA Scaife Fellow this June, I was introduced to Dr. Somov’s model and was struck by how it approached recovery from a slightly different angle.
For example, AA’s first step can be a big hurdle for many addicts, as it is difficult to accept total “powerlessness” against a substance. Pavel Somov might say that every time addicts use, they let an inanimate object control their actions and give the substance more power than it deserves. This idea gets close to the “powerlessness” that AA speaks about.
In the end, both of these models address the idea of powerlessness in addiction, but approach it from slightly different perspectives. It is up to clinicians to decide which viewpoint or viewpoints will reach each patient.
The road to recovery may travel in many directions
As a future physician, it will be my job to support my patients in staying clean and sober, no matter which way they choose to go about it. AA and NA have been around for decades and offer a vast network of support. Recovery Equation holds great promise in offering a fresh take on addiction recovery through its mixed therapy approach.
Like most chronic conditions, addiction is incredibly complex and necessitates complex, individualized treatment. “Customized care” is already being applied to certain populations with more success. For example, addicted physicians and airline pilots typically attend treatment with other physicians and airline pilots. In these two populations, the recovery rate of 75-90% is significantly higher than average.
So where does this leave our 32 year old man?
Instead of the immediate referral to a 12-step program, I envision the primary care practitioner asking additional questions to determine what support will help this patient the most. The patient can access intensive one-on-one therapy, group therapy based on the Recovery Equation model, as well as attend 12 step support groups. The “non-step” Recovery Equation method actually supports and enhances the topics discussed in 12 step groups. An individualized approach will allow the patient to choose whichever option “fits” his personality, giving the him the best possible chance of achieving and maintaining recovery.
Andrea DeSimone recently entered her second year of medical school at the Rowan University of Osteopathic Medicine. In June, she participated in IRETA’s Scaife Medical Student Fellowship, a three week intensive learning experience about addiction and its treatment hosted by IRETA since 1999.
Recovery Equation (Pavel Somov): Somov’s book forms the basis of the substance abuse and rehabilitation program at the Allegheny County Jail
Alcoholics Anonymous Fact File: Traditions, 12 steps, and principles of Alcoholics Anonymous
AA and NA online meeting locators: Find a 12 step group in your area – meetings designated as “open” allow non-addicts or anyone who is interested in learning more about the recovery process to attend. Closed meetings are only for people who desire to stop drinking and using drugs.