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