Between Addiction & Abstinence
By BENEDICT CAREY
Copyright 2006 The New York Times Company
May 7, 2006
Ideas & Trends
A HUMILIATING accident. An apparent memory lapse. A sudden, emotional confession.
Representative Patrick Kennedy's car crash on Capitol Hill early Thursday and a news conference a day later had a familiar rhythm, especially for those who study addiction or know it firsthand.
Mr. Kennedy, a six-term Democrat from Rhode Island, said that his addiction was to prescription medication and that he planned to seek treatment at an addiction clinic, as he had done before.
"I struggle every day with this disease, as do millions of Americans," said Mr. Kennedy, who is 38.
But will a cure that apparently didn't take the first time be successful the second time around? Mr. Kennedy, for one, ruefully acknowledged how easy it was for him to backslide.
Mr. Kennedy is seeking treatment at a time when the entire field is undergoing a transformation. Once akin to exorcists, committed to casting out the demons altogether, those who work with addictive behavior of all kinds are now trying less dogmatic approaches – ones that allow for moderate use as a bridge to abstinence.
A government-financed study of alcoholism released last week, the largest to date, suggests how deeply this "moderate use" idea has taken hold. The study found that the treatment produced "good clinical outcomes" in about three-quarters of the almost 1,400 heavy, chronic drinkers in the study. Some quit altogether; most, however, had moderated their drinking – to 14 drinks a week or fewer for men, 11 or fewer for women.
"The fact is that these moderate measures are becoming more and more accepted in judging treatments," said Dr. Edward Nunes, a professor of clinical psychiatry at Columbia University.
Millions of recovering addicts and their families as well as counselors working in the trenches consider this approach to be foolhardy and immoral. Addicts are by definition unable to control or manage their addictions, they say, and leaving an opening for moderate use only encourages the experimentation that can lead to ruin or death.
Cases like that of Mr. Kennedy dramatically illustrate how close to breakdown many addicts live, they say. "Implying you can simply cut down does a tremendous disservice to those who have this addiction," said Stanley L., a recovering alcoholic in Pennsylvania who still attends group counseling sessions.
Yet the openness to moderate use is likely to increase, driven by changes in the science of addiction, like pharmaceutical treatments.
The latest option for opiate addiction, bupenorphine, is a substitute drug, like methadone, replacing one habit with another. The drug naltrexone, which seems to numb the brain to the euphoria from drinking or gambling binges, is more likely to reduce the consumption than shut it down altogether. And perhaps the biggest recent advance in smoking cessation, the nicotine patch, is itself a badge of compromise, an admission that many smokers need a habit to lean on, temporarily or perhaps indefinitely, as they strive for life without.
When studying these pharmaceutical crutches and prescribing them, doctors tend to emphasize improvement over abstinence for good reasons, researchers say.
"Third-party payers," said Dr. Barbara Mason of the Scripps Research Institute, where she treats and studies addiction. "One way you can convince people holding the purse strings to cover treatment is to say, look, if you pay for this and it lowers the level of drinking or substance use you won't have to pay for E.R. visits. That's really important. If you prevent one case of fetal alcohol syndrome, you don't have to pay for a lifetime of care."
Some studies of drug use and gambling have also contributed to shifting the thinking about addiction. For example, surveys find that most smokers who quit do so on their own, after many attempts and periods of moderation. An estimated 20 percent of compulsive drug users and drinkers have had similar recoveries, experts say.
In a 2002 study, researchers at Harvard Medical School tracked the behavior of more than 6,000 casino employees, many of whom were heavy drinkers, gamblers or both. Over a period of three years, many of those with diagnosable disorders changed their behavior, moving from heavy use to moderate levels, and sometimes back up again.
"The conventional wisdom is that you get the habit and start down this slippery slope and it just gets worse and worse, but that was not true for many of these people," said Christine Reilly, executive director of the Institute for Research on Pathological Gambling and Related Disorders, in Medford, Mass.
Heavy gamblers and drug users are much more diverse groups, in short, than many presume, and their compulsions have different meanings in the context of their lives that are important guides for treatment.
Some addicts are depressed and anxious and in need of psychotherapy but can't get it because therapists require that they give up their habits first, said Alan Marlatt, director of the Addictive Behaviors Research Center at the University of Washington. "Maybe the drug use is responsible for the depression, or the depression led to the drug, but it's all mixed up and they never find out, because they can't get treatment," he said.
Many addicts, it is true, spiral only downward, and must quit to stay alive. But others are ambivalent about whether they want to quit or not. Their routines, their pleasures, some of their most sustaining relationships are tied up with their habits, and it is far from clear what will nourish them if they suddenly give up. The very idea, common in abstinence-based programs, that one "slip" can lead to total loss of control may undermine their best efforts to self-regulate.
"It's very scary for them to contemplate life without this habit, because it has become very meaningful for them," Ms. Reilly said.
Offering moderate use as a first step, some therapists say, is the only way of "meeting people where they are," and getting them down to a level of use that keeps them from driving under the influence, petty crime or other trouble.
"The idea is to reduce the consequences of the heavy use, and work from there," said Mr. Marlatt.
This was more or less the view offered by Charles Barkley, the former N.B.A. star, in an interview on ESPN last week: "Do I have a gambling problem? Yeah, I do have a gambling problem but I don't consider it a problem because I can afford to gamble. It's just a stupid habit that I've got to get under control, because it's just not a good thing to be broke after all of these years."
By treating the habit as just that – a habit – and not a disease, therapists may be able to make progress in reducing the bad consequences, whether a broken marriage or an embarrassing car accident.
On the other hand, the risk to addicts of this approach is incontestably real, and no one knows in advance who can and cannot safely moderate their addictive behavior.
"I am deeply concerned about my reaction to the medication and my lack of knowledge of the accident that evening," Representative Kennedy said on Friday. "But I do know enough to know that I need to seek expert help."
Copyright 2006 The New York Times Company
May 7, 2006
Ideas & Trends
A HUMILIATING accident. An apparent memory lapse. A sudden, emotional confession.
Representative Patrick Kennedy's car crash on Capitol Hill early Thursday and a news conference a day later had a familiar rhythm, especially for those who study addiction or know it firsthand.
Mr. Kennedy, a six-term Democrat from Rhode Island, said that his addiction was to prescription medication and that he planned to seek treatment at an addiction clinic, as he had done before.
"I struggle every day with this disease, as do millions of Americans," said Mr. Kennedy, who is 38.
But will a cure that apparently didn't take the first time be successful the second time around? Mr. Kennedy, for one, ruefully acknowledged how easy it was for him to backslide.
Mr. Kennedy is seeking treatment at a time when the entire field is undergoing a transformation. Once akin to exorcists, committed to casting out the demons altogether, those who work with addictive behavior of all kinds are now trying less dogmatic approaches – ones that allow for moderate use as a bridge to abstinence.
A government-financed study of alcoholism released last week, the largest to date, suggests how deeply this "moderate use" idea has taken hold. The study found that the treatment produced "good clinical outcomes" in about three-quarters of the almost 1,400 heavy, chronic drinkers in the study. Some quit altogether; most, however, had moderated their drinking – to 14 drinks a week or fewer for men, 11 or fewer for women.
"The fact is that these moderate measures are becoming more and more accepted in judging treatments," said Dr. Edward Nunes, a professor of clinical psychiatry at Columbia University.
Millions of recovering addicts and their families as well as counselors working in the trenches consider this approach to be foolhardy and immoral. Addicts are by definition unable to control or manage their addictions, they say, and leaving an opening for moderate use only encourages the experimentation that can lead to ruin or death.
Cases like that of Mr. Kennedy dramatically illustrate how close to breakdown many addicts live, they say. "Implying you can simply cut down does a tremendous disservice to those who have this addiction," said Stanley L., a recovering alcoholic in Pennsylvania who still attends group counseling sessions.
Yet the openness to moderate use is likely to increase, driven by changes in the science of addiction, like pharmaceutical treatments.
The latest option for opiate addiction, bupenorphine, is a substitute drug, like methadone, replacing one habit with another. The drug naltrexone, which seems to numb the brain to the euphoria from drinking or gambling binges, is more likely to reduce the consumption than shut it down altogether. And perhaps the biggest recent advance in smoking cessation, the nicotine patch, is itself a badge of compromise, an admission that many smokers need a habit to lean on, temporarily or perhaps indefinitely, as they strive for life without.
When studying these pharmaceutical crutches and prescribing them, doctors tend to emphasize improvement over abstinence for good reasons, researchers say.
"Third-party payers," said Dr. Barbara Mason of the Scripps Research Institute, where she treats and studies addiction. "One way you can convince people holding the purse strings to cover treatment is to say, look, if you pay for this and it lowers the level of drinking or substance use you won't have to pay for E.R. visits. That's really important. If you prevent one case of fetal alcohol syndrome, you don't have to pay for a lifetime of care."
Some studies of drug use and gambling have also contributed to shifting the thinking about addiction. For example, surveys find that most smokers who quit do so on their own, after many attempts and periods of moderation. An estimated 20 percent of compulsive drug users and drinkers have had similar recoveries, experts say.
In a 2002 study, researchers at Harvard Medical School tracked the behavior of more than 6,000 casino employees, many of whom were heavy drinkers, gamblers or both. Over a period of three years, many of those with diagnosable disorders changed their behavior, moving from heavy use to moderate levels, and sometimes back up again.
"The conventional wisdom is that you get the habit and start down this slippery slope and it just gets worse and worse, but that was not true for many of these people," said Christine Reilly, executive director of the Institute for Research on Pathological Gambling and Related Disorders, in Medford, Mass.
Heavy gamblers and drug users are much more diverse groups, in short, than many presume, and their compulsions have different meanings in the context of their lives that are important guides for treatment.
Some addicts are depressed and anxious and in need of psychotherapy but can't get it because therapists require that they give up their habits first, said Alan Marlatt, director of the Addictive Behaviors Research Center at the University of Washington. "Maybe the drug use is responsible for the depression, or the depression led to the drug, but it's all mixed up and they never find out, because they can't get treatment," he said.
Many addicts, it is true, spiral only downward, and must quit to stay alive. But others are ambivalent about whether they want to quit or not. Their routines, their pleasures, some of their most sustaining relationships are tied up with their habits, and it is far from clear what will nourish them if they suddenly give up. The very idea, common in abstinence-based programs, that one "slip" can lead to total loss of control may undermine their best efforts to self-regulate.
"It's very scary for them to contemplate life without this habit, because it has become very meaningful for them," Ms. Reilly said.
Offering moderate use as a first step, some therapists say, is the only way of "meeting people where they are," and getting them down to a level of use that keeps them from driving under the influence, petty crime or other trouble.
"The idea is to reduce the consequences of the heavy use, and work from there," said Mr. Marlatt.
This was more or less the view offered by Charles Barkley, the former N.B.A. star, in an interview on ESPN last week: "Do I have a gambling problem? Yeah, I do have a gambling problem but I don't consider it a problem because I can afford to gamble. It's just a stupid habit that I've got to get under control, because it's just not a good thing to be broke after all of these years."
By treating the habit as just that – a habit – and not a disease, therapists may be able to make progress in reducing the bad consequences, whether a broken marriage or an embarrassing car accident.
On the other hand, the risk to addicts of this approach is incontestably real, and no one knows in advance who can and cannot safely moderate their addictive behavior.
"I am deeply concerned about my reaction to the medication and my lack of knowledge of the accident that evening," Representative Kennedy said on Friday. "But I do know enough to know that I need to seek expert help."
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