Image source via zimbio.com – The Heroin Epidemic In Thailand.
A heroin epidemic in the rustbelt, meth labs on the borders, prescription medications flying out of the doctor’s office and everywhere there is the rise of potent dopamine boosting technology pumping our brains’ reward systems. But is America any different to any other country in this respect? In my view, no, not really.
I am a British addictions counselor running a predominantly 12 Step abstinence based treatment center in northern Thailand and so I am looking at this from the outside in. However, I am also located in one of the world’s largest opium and methamphetamine producing areas and I can say from my professional experience working across the whole of South and East Asia and Australia, that there is little difference in the way humans pathologically reward themselves, and the reasons they do it. But America is different in one respect – treatment!
I am going to make the case for abstinence based treatment in the face of a barrage of criticism coming from harm reduction policy advocates recently, and at the same time hopefully acknowledge and answer some of their charges. I think it’s worth looking at things from a global perspective and the massive contribution the 12 Steps have made to reduce suffering all over the world, but particularly in the US.
In the US, almost everyone seems to know someone who’s in a 12 Step program. Stigma around addiction appears to be about as low as is possible anywhere in the world. Outside of the US this is not the case. Even in the UK I have to explain to people what the 12 Steps actually are, and in Thailand where I work, virtually no client will ever come forward for treatment. They are almost always intervened by their family, and even then only under the greatest of secrecy and sense of shame. In contrast, there is a plethora of support for addiction sufferers in America, with 12 Step meetings in every decent sized town and a huge treatment industry. I’ve even heard people say that 12 Steps is America’s greatest gift to the world, and whilst there are a thousand other things in American culture that could compete for that accolade, it’s a wonderful sentiment.
The 12 Step model dominates treatment in the US but American professionals and clients who have been through treatment may be surprised to know that this is not the case worldwide. In Australia, the medical establishment are firmly in control, harm reduction is almost a religion and the recovering addict/layperson counselor would have an uphill battle to even get a job in the addiction treatment field – never mind become an interest group that effectively defines the standard of care. Clients would be lucky to find a treatment center offering 12 Step treatment. Even though the fellowship is alive and well there, most physicians and psychologists (who are the gatekeepers to treatment) would be unlikely to recommend addicted patients to either a 12 Step fellowship or center. In the UK, the situation is arguably more balanced with a mixture of harm reduction and 12 Step treatment available. However, I would make the argument that this produces slightly less effective treatment than the US. Yes you read that right – more balanced and less effective. It is precisely because the US recovery movement is so uncompromising that it has been able to be so effective historically by refusing to allow its message to be diluted.
We have to understand that recovery-conscious 12 Step counselors who are prevalent in the field in the US get people clean and save many lives. It is demonstrably the case that counselors in recovery gain a greater therapeutic alliance with addiction sufferers than general counselors (on the whole). Recovering addict counselors are believable or ‘congruent’ to their clients. Do not underestimate the power of congruence in persuading an addict who is full of shame, to open up and change. Given that almost all scholarly articles on the subject acknowledge that addiction is a bio /psycho/social illness (and counselling support is the psychological part of treatment) then we can understand that counselors in recovery (potentially at least) are the elite troops. A well trained counselor in recovery with good empathy skills is worth their weight in gold on the frontline of addiction treatment.
12 Step treatment centers get thousands of people clean and sober every year. Critics who point to poor success rates of say 10-20 percent reaching ongoing sobriety (as a conservative estimate) are completely missing the point. This is a chronic, progressive and incurable illness characterized by relapse and remission (ASAM 2011). It’s a bit like saying we only managed to save 10 percent of sufferers from an extremely aggressive form of cancer. Ten percent managing long term abstinence is really significant in the face of this baffling illness which thrives on potent dopamine re-enforcers (drugs, alcohol, sex, gaming, gambling, glucose, carbohydrates) which are so abundant now in our modern environment, and which has no known medical ‘cure’, and probably never will due to its chronicity.
In my view, it is an ethical responsibility to promote abstinence as an option. However, in many parts of the world this does not happen. In 2013 I visited the Maldives (an archipelago in the Indian Ocean) to advise the government there on 12 Step-style recovery programs for their heroin epidemic. I read the UN report (Australian led) and the recommendations they gave as guidelines for that small nation;
“It is never advisable to reduce patients from their methadone maintenance dose”.
This translates roughly as ‘never risk a client tapering off opiate substitutes or achieving complete abstinence’. Whilst this undoubtedly does save some lives, because a tiny minority of people who do achieve abstinence from heroin do relapse and do overdose when their tolerance is lowered, but we have to consider the ethics of denying full physical, mental and emotional (spiritual) recovery as well.
The fact is, that a life spent using a strong opiate is not the same as a life spent not using a strong opiate. Emotions, relationships and perhaps creativity and full expression are all undoubtedly compromised by substitute opiates. We have an ethical responsibility to at least allow the possibility of freedom from those chemical chains if we can manage the risk. What is wrong with Australian and UK policy is that no one wants to take responsibility or risk – even for a brighter future. It’s gone too far and I for one, am glad American recovery culture has held on to its values.
The problem is, that heroin dependence in particular involves a risk of death after a period of abstinence in a way that most other addictions don’t. Another problem is that 21 day opiate detoxes in 28 day programs which are now commonplace, may not be enough – especially for younger addicts. Who is to blame here? Insurers because they won’t fund treatment for long enough? Treatment centers because they haven’t adapted their programs for the short treatment episodes that are now commonplace? Addicts, because they don’t ‘get it’? Well the reality is – we probably all share some responsibility.
Everyone has a role to play here. Treatment centers need to be clear with clients and their families that one month of inpatient treatment even with intensive aftercare is probably too short a period to detoxify a young opiate addict to complete abstinence. There just isn’t the time for the young addicted brain to start rewarding itself naturally again and relapse is quite likely – even with the best program in the world. Insurers need to accept this and start funding accordingly, and gains have been made recently at a judicial level in forcing them to do just that. Meanwhile, unfortunately, clients and their families need to accept the reality of doing whatever it takes to get that ideal period of 3 months minimum in a secure environment, wherever or however that is possible. But one thing is for sure.
Abstinence based treatment run according to 12 Step principles has saved untold millions from hopeless suffering, and America has led the way in that. You should be proud of what you have
I do agree that insurance companies do not allow enough time in the facilities to really help an addict begin to recover. I saw people being brought in and even county would only give them two weeks. I would sit and try ans comfort them you could see they wanted to be there their eyes filling up with tears because they were back to feeling hopeless and feeling like they had no choice but to go back to the same old life style. I also had to hear of people that did only the 28 looking and sounding great just to find out as soon as they got off the bus home they went at it harder then before and were on their way to the hospital for an overdose. I did the couple day detox and thirty day in patient followed by several months of out patient. I really think out patient after in patient is absolutely necessary so that we have help building our new life T W Ponessa is an amazing facility for out patient and was very helpful for me I’m very thankful for the people who care and are trying to help addicts get and stay clean and sober. Thanks for the article and for all the work you do.
Thanks for the article Ali, unfortunately this attitude is abound in Australia and treatment is hard to find for middle class people. It’s good to see that this is noticed by the rest of the world, so that Australia can hopefully pull their socks up and treat addiction correctly. The big issue, I think, is that addiction is constantly seen as a social problem, rather than a medical one, and treatment focusses only on this.
Science has been presenting varying theories about physiological bases for substance abuse and vulnerability in connection with addictions and obsessive behaviors for over a century. In all this time, they have still failed to construct a full dimensional picture of just what addiction is—to explain how it progresses—or why people can’t stop doing the things they no longer want to do.
In disregarding the spiritual etiology of ALL obsessions, these clinicians are wasting their time. With the pathology of spiritual disease beyond the scope and training, they are wasting everyone’s time. And yet the solution is so simple.
Addiction is a metaphysical phenomenon founded in a spiritual cause. Science is way out of its league in the area. Hence their horrendous rate of failure where, “RARELY HAVE WE seen a person fails” is common for those who pursue awakening and ongoing God-consciousness – as proposed in the spiritually inspired 12 step method.
A perfectly peaceful life comes to recovered addicts and alcoholics who through spiritual awakening experience the nearness of God and proceed on the journey with Him leading the way.
Esteem is restored; stigma reverses, through each individual’s transformation from within. A former substance abuser who can honestly look the world in the eye, has the world look back, and with a keen sense can see that here is a fearless, confident person with whom they can place trust. An illicit past never comes into question. It is irrelevant.
Each man need not prove themselves to anyone, their grace and deportment says volumes.
Clinicians attempting to facilitate a spiritual method such as the 12 step recovery presentation, by the nature of their ‘training’ only diffuse its effectiveness. Yes of course there are biological, psychological and social connections with addiction, but glaring eliminating God – that the 12 step solution is a spiritual one, is probably no coincidence. Is it?
Absolutely. Meetings are medicine, no one realizes this is the treatment. After you leave treatment find meetings, asap!
Thank you for writing this, I don’t think a lot of people appreciate the simplicity–it works!
but God caused addiction too. Please dont confuse people with spiritual mumbo jumbo. 12 step works because of the people connection which is real sustenance, not imaginary. If 12 steps stopped banging on about god they may be more accessible to the 60% of Australians who are smart enough to sit God next to santa claus and medical scientist would be comfortable including them in treatment recommendations. I think godbelief is an outside issue and it breaks 12 step traditions to include it
This is a very interesting standpoint. I wonder if you would be interested in writing an article about this better articulating your feelings. I think there are a lot of people who are hesitant to use the 12 steps because of the God aspect, and I think many people would relate to you. Email me at tim@sobernation.com if you are interested.