The 12-Step Program made famous by Alcoholics Anonymous is perhaps the best known treatment model for addictions – but there are others. We discuss how they are similar in many respects, and also look at some significant differences. We also look at aspects of harm-reduction and the increased use of two opioid antagonist drugs – nalaxone, used to counter the effects of opiate overdoses, and the potential of the craving-blocking drug nalmefene for many addictions.
Transcript (edited):
HOWARD: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard La Mere. We have a lot of different things to talk about today, but one that kind of caught my eye was notorious addiction specialist, Stanton Peale, who writes for Psychology Today and also for the Huffington Post. He recently endorsed St. Jude Treatment Retreats, which is a non 12-step program. Darryl, would you highlight the differences between the traditional AA approach and a non 12-step program.
DARRYL: Well, once you sit down and look closely at both programs and I suspect you will find a lot about the St. Judes Retreat and activities that are in line with a 12-step program, but the St. Jude’s program is not defined as spiritually based and does not link to a higher power. The SOS world, or Save Ourselves, or secular organizations for sobriety, stress looking at your own behavior and taking control of your own behavior, rather than depending on an outside force. This program endorses more of a harm reduction approach, solving a behavior issue and going from addiction back into controlled use or back into non-problematic interactions with drugs. And of course any 12-step program would be very much opposed to that. Both applications have some value because there is such a wide spectrum. I mean addiction and alcoholism ranges from not just youre an addict and an alcoholic and a normie or a super normie, but every shade of color in between.
HOWARD: Right and there are a lot of different people that function in different ways.
DARRYL: Right and the new DSM -V will have more of a spectrum view of addiction and alcoholism and addiction related disorders. There are moderate, severe or very low addiction use of drugs and alcohol and interventions for each of those are different. There are interventions that are successful with certain segments of the population, but when we talk about the addict per se, the person who technically meets all medical criteria with diagnostic brain imaging to back it up – well all the new ways of evaluating addicts are things that Stanton Peale unfortunately totally rejects.
HOWARD: Well I dont understand how he can reject the brain imaging.
DARRYL: Or even brain chemistry. He doesnt accept that. He doesnt accept any process or any consciousness of a disease model addiction. I question how many addicts he has really interacted with because there is such a wide spectrum. Those individuals referred to as male limited, sometimes Type 2 addict or sometimes alpha addict or various other names youre talking about a person who really has no ability to control their use of drugs and alcohol and will continue to relapse with horrendous consequences and what we have to do in terms of treating them is be patient and bring the same message to them all the time that theyre different, that they have this very, very vulnerable brain and if they accept that and they embrace the 12 steps or another long term absence protocol – their lives will come back together and theyll be actually happier without drugs. If someone hasn’t worked with clients with that type of addiction, and there are many types – they may assume .all addiction is the same and everyone will respond to treatment this way, and everyone is going to follow the same steps I think that is one of the difficulties and a mistakes that recovering people make. For them – what they had to embrace and what worked for them in recovery is what they think will work for everybody else.
HOWARD: Right.
DARRYL: Their friends, their relatives, their children and if addiction affects any of those people, they try and take them down the same path and do the same things and lots of times it doesn’t work. They really have to embrace that this is a spectrum disorder and there are many different ways of interacting with addicts. One thing is constant though – the unconditional positive regard for the wellbeing of people – if drugs are impairing them, or alcohol is impairing them, or gambling is impairing them in a way that causes dysfunction – that person should be offered help to overcome that impairment and provide them with more benefits for better health. And that is what were trying to do.
HOWARD: But one of the things I noted in the article – in a discussion about the traditional 12-step approach, approaching people with the problem as if they had no personal power – powerlessness and I thought that was an interesting distinction.
DARRYL: Yes thats the basis of the 12-steps – step 1 is to admit that you are powerless against drugs and alcohol and step 2 is recognizing that only a higher power is going to be able to restore you to your own sanity or your own quality of life.
HOWARD: And that doesnt necessarily work for all people.
DARRYL: No. As a matter of fact, when we were working in San Francisco with some African American communities who saw the statement that youre powerless as invoking something akin to PTSD, or posttraumatic stress consciousness – racism and all of the prejudices that African Americans had. They rejected that, so we didn’t use that word. We had to present “powerlessness” in reference to something a person couldn’t overcome and a person had no power as an individual, but within the community within the brotherhood and sisterhood and as part of a fellowship of warriors in recovery, you can gain power to overcome your nemesis and that was the approach we had to take. 12-steps takes that approach because its founder Bill W. was a chronic relapser as was his cofounder, Bob Smith. They underwent several formal treatments, hospital-based treatments before they were able to gain sobriety. And even on his death bed I understand Bill was still powerless against the effects of alcohol and he cried out for it, but he knew . he had no power in stopping or in controlling use. And so, powerlessness must be examined in other conscious ways – not that you are ineffective or to make you feel like you cant do things – because you can do things, but if you drink or use drugs and have a vulnerability or addiction, youre going to lose control – and thats the concept of powerlessness in terms of the 12-step tradition.
HOWARD: Some of the other stories in the news the use of a new drug to make people drink less alcohol – its called nalmefene and it looks like this research is going on in Europe? Is that right? Is there much going on here that you know about?
DARRYL: There has been and actually its been around for over 20 years in development. It was on the fast track for awhile to treat alcoholism, but its not yet FDA approved and basically nalmefene is another opiate antagonist like Naltrexone and Naloxone these are drugs that block the effects of opiate receptor sites, which have been found to block craving in alcohol and craving in many other drug addictions. So it was originally thought to be a drug that could replace something like Naloxone .Naltrexone, excuse me could replace a drug like Naltrexone, which has been proven to be very effective in blocking craving to alcohol and heroin and blocks craving for gambling, blocks craving for sexual addictions, blocks the need for autistic head banging, cutting, blocks craving for cocaine and a variety of drugs and people are using it for those situations. One problem with Naltrexone is the liver toxicity potential. Im not so sure how strong it is, but there is a black box warning saying that the FDA has approved it for the treatment of alcoholism and heroin, but it can hurt the liver. But, nalmefene
HOWARD: And youve already potentially hurt your liver if youve been drinking a lot.
DARRYL: Thats the problem with the original research findings in animal and in some human tests, because when follow up tests were done to see if the medication would be effective for the treatment of alcoholism what they found was that the patients who were getting the drug (it was a double blind study, some patients were getting the drug, some were not) actually had better liver health than the patients who werent getting it. Why? Because those not on the drug had much higher rates of slips and relapses. Heroin, alcohol and other drugs are potentially more damaging to your liver than Naltrexone could ever be and so they had better health. So Im not sure if thats a warning that should be heeded, but nalmefene was developed because it was originally thought that it would avoid any hepatotoxicity (toxic to the liver) and could be the new Naltrexone for use in the treatment of alcoholism as well as opiate addiction and perhaps other drug addictions and even process addictions.
HOWARD: And speaking of that class of drugs, there was a story on I think MSNBC recently about Naloxone and how a lot of people are keeping it on hand especially those who have a relative or someone that theyre involved with who has an opioid addiction to prescription drugs or to heroin and the story talks about a couple of parents who were keeping it close at hand because it saved their mid 20s age son from heroin overdose.
DARRYL: You know, that is something that the harm reduction people have been advocating for a long time. Theres even a San Francisco drug users union that is a political advocacy group for people who use drugs and don’t want to stop. San Francisco was one of the first cities to allow, or to distribute, the vials, and now the shorter acting Naloxone, which was originally administered intravenously but it can be inhaled, so now there is an inhaler that can be used. The city distributed these at their needle exchange sites and to people who are opiate addicts because the focus was to save lives. If youve ever seen it work, its unfortunately a miracle drug. Somebody is totally not breathing theyve got pulmonary edema, theyre dying for all intents and purposes and you inject either Naloxone into their veins sometimes it was even injected under the tongue, or you spray it into the nose, and in a matter of seconds, the person is up on their feet and usually out of danger. There are two downsides though – one of them is Naloxone is shorter acting than most street opiates, so even if you reverse an overdose of heroin, which is fairly short acting with Naloxone, the addict wakes up and looks healthy they look like theyre vital, vigorous and they can go on with life and so you kind of lower you guard on them and forget about them and the Naloxone wears off in about 20 minutes or an hour but the heroin is still in their system so they can go back into overdose and die without you being vigilant about that. The other thing about Naloxone that really worried me, when they released it was that when we used it at rock concerts and other events we had medical staff administering it, you had to hit a vein of course so we were injecting it into peoples veins who came in overdosed and were dying of an opiate drug we would bring them out of the overdose very quickly unless they were polydrugged. If they were also taking valium or drinking alcohol, they wouldnt come out of it so quickly. But if it was a pure heroin overdose or pure Oxycontin or pure Vicodin overdose or methadone, Demerol or Dilaudid, the person would come out if within 8 to 10 seconds, 15 seconds theyre on their feet and theyre raring to go, but theyre usually very angry and upset because it is a narcotic antagonist, .an opiate antagonist is a more proper name so when a person is physically addicted to heroin or Vicodin and something blocks that in their brain to bring them out of an overdose, it also precipitates withdrawal symptoms. And that makes them angry … angry as a wet hen, they threaten to sue us, beat us up. A few of our staff were assaulted … addicts were saying “who allowed you to touch me, who told you that you could come and touch me. You just wasted 20 bucks, man.” We tried to tell them they were dying dying. That was my worry – angry people – but maybe it’s not as big an issue as I thought because there haven’t been any reports from the use of it from the harm reduction people in San Francisco. Families are able to get a hold of it and keep it in their medicine cabinets at home so if they have a son or daughter, as the article mentioned, who has an opiate addiction and they OD, they can save their life by using this medication. That must mean that its potential to precipitate withdrawal is not that high because one of the problems with precipitating withdrawal is the addict going into crave mode, demanding more heroin so they wont be so sick. And that combined with the heroin thats already in their system could have very, very dangerous consequences.
HOWARD: According to this article, there are a number of groups – 5 states, 48 different programs – that are making this available and teaching people how to use it in the context of helping people in your family that have an addiction.
DARRYL: I would like to see some more data. You know, here in our area Dr. Jim Shames talked about this program awhile back and he instituted more treatment opportunities of methadone and Suboxone or buprenorphine and when they monitored the coroners report on opiate overdose deaths there was a dramatic decrease in deaths. Thats real positive. They can do that epidemiology on the availability of Naloxone in the community because it does have a tremendous ability to save lives, I think thats a real positive because we want to give people a chance to put their lives back together and thats not going to happen if they die because of an overdose. And I would like to see that as a father or as evidence to counteract the negative. Im sure the government especially the DEA have very, very negative views of distributing Naloxone to the general public.
HOWARD: Interesting stuff, all of it. Thats about all the time we have for this week. Thanks for listening and if you have comments or questions, wed love to hear them. Stop by the website, which is cnsproductions.com and drop us a note there.
DARRYL: Hey, Howard just for a second here. I just wanted to mention..
HOWARD: Oh we didnt talk about Tide!
DARRYL: Our local paper the Medford Tribune mentioned it and Ive seen it across the nation Tide laundry soap has become the new barter of exchange for buying drugs.
DARRYL: Drug trade in the underground drug scene people steal Tide out of grocery stores or wherever, Tide can cost up to 15, maybe 18 dollars for a big bottle and they trade those big bottles to their drug dealer for their meth or marijuana or whatever drug theyre into. It’s a new barter of exchange. I guess because theres less actual money around these days so dealers are accepting laundry detergent and selling it to smaller stores at a discount to get their cash. Some are hanging out at Laundromats, and because the dealers sell it much cheaper than what people would pay at stores, they get their cash that way. Its just an innovative way of dealing with the recession in the drug world. It cracks me up.
HOWARD: There are always clever people out there. Okay, well talk more about Tide and other things next time. Thanks. That wraps our pod for today. Thanks for visiting the CNS Podcast. Please check back soon for the next in the series and visit our website, www.cnsproductions.com