Commentary: Learning As We Go: Critical Assessment of Addiction Research and Practice

A recent Join Together article, entitled “Half of Addiction Counselors Say It’s OK for Some Patients to Drink Occasionally,” drew attention to the fact that some substance abuse counselors believe moderate drinking is an option for individuals with substance use disorders. As a researcher and an advocate in our field, I reacted with mixed feelings to this news.

While I applaud new research by anyone into any area of our profession, I am also aware that not all research is created equal. Does a survey of professionals’ opinions reflect research or the content of counselor education for our professionals? Both? Neither? An approach that allows an individual to continue to drink is a risk about which many of us remain most skeptical.

For decades the belief in the United States has been that abstinence is the only real solution for such individuals. This was largely due to the influence of Alcoholics Anonymous and similar philosophies. Over the years, our profession has grown and the attention to evidence-based practice has come into clear focus. That said, we have tried to consider what seems to work in other parts of the world as well.

I have clear memories of the debate over the inclusion in our exams of harm-reduction strategies and Therapeutic Community model treatment programs. In the end, subject matter experts agreed that IC&RC exams should reflect all treatment modalities, not just our personal preferences, so the exams were infused with a broader range of treatment strategies and were weighted according to our research into what was being used the most and under what circumstances.

One place we looked for guidance was the United Kingdom, whose approach was heavily weighted toward harm reduction, seeing abstinence as a last resort. So what is harm reduction? It includes everything from “controlled” drinking to methadone maintenance programs and needle exchanges. I can make a case both for and against each of these under the right circumstances and so can most readers here, I suspect.

Interestingly, in the UK, there is currently a backlash building against methadone – with some professionals referring to it as “harm maintenance” programs. It seems that abstinence is starting to catch on as they debate the real definition of recovery and consider the vast numbers of clients who live for decades on methadone and claim “recovery.” Proponents of abstinence-based treatment in the UK commonly refer to “real” or “whole” or “true” recovery.

Another gray area concerns medication-assisted treatment. Again, there is a case to be made in either direction. If medication is involved in detox, the need is clear. If medication is involved in a transition period, it can be helpful, as well. But substituting medication for a holistic approach to the individual –that includes counseling and education– is a one-size-fits-all approach that opens the door to the exact same criticism some have directed at total abstinence for all.

In the case of medication-assisted treatment, we, as professionals, must consider the source of our education about this strategy. Many of the research and educational efforts around “MAT” are funded by the pharmaceutical companies that make the drugs. It makes sense that they want us to know about what they have developed. On the other hand, “research evaluation 101” tells us to always look at who funds a study and “follow the money” before we give too much weight to the research conclusions.

So my goal is to sound a note of caution against pushing too hard, too quickly for any new approach to treating a very fragile client population. We study. We learn. We jump the gun. Let’s be mindful of that last one.

Phyllis Abel Gardner, PhD
President of IC&RC

24 Responses

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    Phyllis Gardner

    January 12, 2013 at 8:42 PM

    As always, happy to see animated discussion. This commentary was written to simply point out that we have a tendency to jump on the next big thing, sometimes too quickly. And I agree that there are different types of medication assisted treatment approaches that are appropriate for a variety of purposes. Some are invaluable. I am also conscious of the realities of misuse versus abuse, etc. In the end, I remain skeptical of medicines that are used as a complete substitute for a holistic approach to the person, which is what some have seemed to suggest. My comments about harm reduction are not intended to throw the baby out with the bath. Let’s just be cautious and learn from others about the benefits and limitations of any intervention. And if responsibly seeing multiple sides of an argument, gray areas and exceptions to the rule makes me wishy-washy, I will wear the badge with pride. Thanks again!

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    Lorraine Hill

    January 12, 2013 at 5:13 AM

    A thoughtful article and thoughtful responses. In 32 years of working in this field I have learned and held many conflicting biases which have directed me to search, to read and to work in order to understand the ebb and flow of addiction disease and addition science through contrary models. Most importantly I seek to be honest and insightful with the people I work for and with to be a simple, direct messenger of what I see from my knowledge base and to clarify what the choices they have might be at the moments of decision making in their lives. I seek to impact all or nothing thinking with challenges of reality in their experience. I prefer abstinence based therapy, I know there are other methods that are helping people manage their lives with pain and I support the medical use of those therapies. I also know that often these are shams for street sale and livelihood of those not seeking recovery at its best. Further research, additional knowledge and development of best practice models has challenged my early beliefs. I will continue to be open to anything that works to clear a path to individual health and peace. Heard years ago: “I don’t care if you have to stick carrots up your nose to get well, I support it.” That has been stuck in my head and I share it again, thinking what is my purpose and responding that it is to facilitate the process, not be the end of it, that is the world of the recovering soul.

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