Pubdate: Sun, 20 Mar 2016
Source: Washington Post (DC)
Copyright: 2016 The Washington Post Company
Author: Jessica Gregg
Note: The writer is medical director for substance use disorders at 
Central City Concern in Portland, Ore., and an associate professor of 
medicine at Oregon Health and Science University.


Addiction has long been medicine's unwanted stepchild.

Doctors didn't understand it, didn't know how to treat it and felt 
helpless in the face of the wreckage it brought to their patients' lives.

As a result, while providers addressed the consequences of addiction 
- - endocarditis, liver failure, seizures, overdose - they rarely 
treated the disease itself.

That mysterious task has been left to others: counselors, peers in 
recovery and 12-step programs.

But this is changing.

There is now a general consensus in medicine that addiction is best 
understood as a chronic disease that can be treated with 
pharmacological interventions. Providers now have access to an array 
of medications that reduce cravings and addictive behaviors. As a 
result, doctors in increasing numbers are seeking training in 
addiction management and are willing to assume responsibility for 
treatment of this complicated disease.

This is all to the good. And yet. That attention may come at a price.

The medical profession has a long, undistinguished history of turning 
its gaze to particular conditions, assuming its own competence and 
then dismissing the hard-won expertise of other disciplines. Think, 
for instance, of the marginalization of midwives as doctors assumed 
management of pregnancy.

With addiction, as doctors grow interested in the disease, there has 
been increased criticism of traditional approaches, particularly 
medicine's old ally, the 12 steps.

The criticism is not entirely unfounded.

As an intervention based on anonymity and welcome to all comers, 
12-step groups are virtually impossible to study in a controlled way. 
Consequently, no rigorous experimental data exists demonstrating that 
12-step interventions, in and of themselves, can be credited for any 
participant's successes. Further, 12-step programs don't work for everyone.

They are a specific intervention with a particular philosophy. Many 
credit them with saving their lives.

Others find them less useful - or even harmful. Finally, many 12-step 
programs rely on a definition of abstinence that precludes the use of 
medication to treat addiction. Thus, individuals who would benefit 
from a medication may be dissuaded from its use, with potentially 
lethal results.

But it is critical that doctors pause before righteously pushing the 
12 steps aside to make way for a brave new era of medically driven 
solutions - an era of addicts as patients and doctors as cure. The 12 
steps exist because during decades of medical neglect, people 
struggling with addiction learned to look to themselves and to their 
peers for solutions.

In 12-step programs, addicts learn that they can name their disease, 
admit the problems it causes and find community in overcoming it - 
every day. According to adherents, sincerely working the steps is 
both intensely difficult and transformative. No magic pills or 
elixirs can take the place of that work, they say.

And they are correct.

Pills won't cure addiction.

They help, yes, and at the right time with the right person, they can 
be lifesaving. But the most effective treatment for any chronic 
disease involves much more than medication. These diseases are not 
resolved with a clinic visit or cured with a prescription. Rather, 
chronic disease outcomes improve most when the individuals suffering 
have the motivation, skills and confidence to monitor and manage 
their symptoms, and when the clinician plays a relatively minor role 
in disease management. Outcomes are even more robust when this 
self-management occurs within social networks that support 
individuals as they learn those skills.

Those using the 12 steps are highly engaged in the management of their disease.

Furthermore, they learn to manage their illness in an intensely 
supportive context, a variable that may be even more important for 
addiction than for other chronic illnesses.

Evidence suggests that rats and humans alike are more likely to 
become and stay addicted when their social networks are limited.

Individuals in 12-step programs can attend groups daily, or even 
multiple times a day, and in each group they can find support in 
their search for sobriety.

My point isn't that everyone struggling with addiction will recover 
with the 12 steps.

Nor is it that 12-step groups succeed because they offer training in 
chronic disease management. Rather, it is that the 12 steps work for 
many people, and it would be arrogant and shortsighted to dismiss that success.

It is imperative that, in the drive to provide our neglected 
stepchild with the newest medical bells and whistles, clinicians do 
not undermine the extraordinarily engaged community and powerful 
tools built by recovering individuals during the decades our backs were turned.
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MAP posted-by: Jay Bergstrom