I belong to a group of colleagues who are currently arguing about abstinence in recovery from addiction. To understand why any argument is needed, we need to have some historical context.
Back in the day before we had a good biological understanding of addiction, people who treated those with addiction divided up the sufferers by “drug of choice.” That is, those who primarily used alcohol were called alcoholics and those who primarily used drugs were called drug addicts, or more specifically heroin addicts, cocaine addicts, and the like. It was pretty clear back then that anyone who was an alcoholic should remain abstinent from alcohol for the rest of their lives. It was pretty clear that anyone who was a cocaine addict should remain abstinent from cocaine for the rest of their lives. To not do so was to court the disaster of a reactivated pathological state leading to a downhill course, and, often, death.
What was somewhat more controversial were two other issues.
Should someone who was, say, heroin dependent, but had never had a problem with alcohol remain abstinent from alcohol for life? And second, should someone who was, say, alcohol dependent, abstain from any prescribed medications that affected the same receptor systems such as benzodiazepines. These two problems can be referred to as the “cross addiction problem” and the “iatrogenic re-ignition problem.”
The cross addiction problem is rather easier to solve in hindsight using what we’ve learned about the illness. Even if you have never gotten a dopamine hit and crash leading to compulsive use with a drug that may do that, there’s no guarantee that you won’t in the future. We lose dopamine producing cells as we age; this is a progressive illness. There aren’t many addiction specialists who are knowledgable about the neurobiology of the disease that will tell a heroin addict it’s okay to have a beer. At least I don’t know any. In addition, in light of what we’ve learned that led to ASAM’s new definition, the cross addiction problem seems quaint in retrospect. It’s clear now that addiction is addiction regardless of drug or non-drug reward used. For someone to stop one dopamine spiking reward and start another, isn’t “cross addiction” but rather untreated addiction with a switch in rewards.
The iatrogenic problem is a little tougher because not all medications act as medications, and not all objections to medications are the same. There is the camp that claims that any medication for people with addiction will make them feel better and keep them from having the authentic suffering that will lead to a spiritual awakening in a recovery process. These physicians, mostly in recovery themselves, seem to have a bit of a different goal of treatment than most in medicine today. There are also those who have had bad experiences with their addicted patients taking medications prescribed by someone else who then went on to relapse, seemingly because of that medication. So this iatrogenic re-ignition problem has several facets we’ll have to take one at a time.
First, the authentic suffering argument. The most singled out heroes of spiritual growth in the history of AA were smokers, and this group of physicians don’t seem to fault the AA founders with continuing to use nicotine to keep their dopamine up. These founders aren’t derided as having been in “only chemical assisted recovery” as opposed to the real thing; in fact, they are held up as paragons of spiritual growth. I have to say that I am very impressed, no, astounded, that the book Alcoholics Anonymous was primarily written by a man only three years from his last drink that continued to use nicotine. If we ever need evidence that spiritual growth can occur and flourish while dopamine tone is being raised pharmacologically, Bill Wilson is that evidence. So I just can’t subscribe to the school of thought that believes that all people with addiction can only be in full or real recovery when they are completely medication free. In fact, as you’ll see below, I’d far rather have someone taking medication that doesn’t spike and crash dopamine and causes no change in immediate feeling than continue to reach for a cigarette whenever he needs one.
The iatrogenic argument has a few components that seem to come from a few varied places. There are those people with addiction who seek out doctors who will give them legal versions of the drugs that are their most effective reward. This is only a subset of continued active addiction, and the doctor here is merely the supply point. Don’t get me wrong, this isn’t a good situation, and I long for the day when no doctor is so ignorant of addiction that he or she would continue to give someone a medication that they don’t use as a medication rather than get the person to addiction treatment. However in the scheme of things these aren’t patients in treatment; these are untreated active addiction patient who just happen to get their drugs from someone with a license.
Another class of iatrogenic patients are those who are “sober” from one drug or another yet are seen as having another illness that requires medication that can be used as a drug. Alcoholics with ADHD who get on a stimulant or those with anxiety disorders who get on benzodiazepines are such patients. These patients may be seeing a non-addiction specialist for this other care, and, most often, are. Their addiction doctor looks on wondering what the other doctor is thinking giving Xanax to an alcoholic, while the other doctor is wondering what the addiction doctor is thinking not treating an anxiety disorder with the most effective rescue medicine available. What we have here is a failure to communicate. Now that ASAM has published its definition of addiction, we can see that the illness rarely starts with drug use, that there are usually symptoms of the illness and attachments to other dopamine spiking behaviors before the first identified drug. Once this information becomes widely known and accepted in the greater field of medicine, this problem will fall in significance. Currently, the only thing a psychiatrist can call a patient who is sober but having symptoms is a different diagnosis, often one that requires a sedative or a stimulant. This wouldn’t be much of a problem if these medications were designed to be given to people with addiction, but they aren’t. They are too powerful and too fast acting, which leads us to the third class.
There are those patients who are being treated with a dopamine raising (but not spiking) medication in order to treat the primary symptoms of addiction. If they are properly dosed and taking medicine as directed there are no ups and downs; that is, they don’t feel the medication taking effect. There are a few such medications, for instance bupropion, which affects the dopamine reuptake pump, and buprenrophine that affects the mu opioid receptor. If not under dosed and taken properly there should be no change in steady state levels of midbrain dopamine tone. That is, no spikes, no crashes, and therefore, no compulsive use. Just a remission of the symptoms that had required the patient to use before treatment. The group most concerned about these patients is that group wanting “abstinent” recovery, and they are concerned that as these medications work at the same site at which the patient’s most effective reward works, that they aren’t really abstinent. This group sees these medications as harm reduction rather than actual treatment, and this brings us full circle back to where we started.
When addiction was just pathological drug use, the point of treatment was stopping drug use. As no one understood the neurobiology and no one had developed proper medications affecting that biology, the only successful recoveries were those where people didn’t take medication, the medications of the day being short acting powerful agonists that spiked and led to crashes. There just weren’t that many successful treatments of alcoholic using benzodiazepines or stimulants. There were dose escalations and tolerance. As expected, once you know the neurobiology involved, patients eventually started getting spikes from those as well, and compulsive use ensued. Physicians in recovery themselves, who became leaders of addiction medicine in its early days, just never saw anything good come from giving medications to patients with addiction. And those that stayed sober and rose in power and prestige were those that were able to stay sober without medication. They became the proof of their own theory. “I got sober without medication, so you can too.” This is an illogical leap that assumes every one with addiction has the same biology and the same response to recovery activities. Later studies have shown an amazing variety of genetic abnormalities in people with addiction, and this position is just no longer tenable. But not to worry, because addiction is no longer just pathological drug use.
ASAM’s definition of addiction states that it is a primary illness with symptoms, and it is these symptoms that lead the patient to seek reward or relief in the first use. It outlines the biology which leads that first use to compulsive use, a biology that, from the beginnings of addiction medicine was thought to be different from non-addicted people (see Silkworth in Alcoholics Anonymous). It is not possible to see the point of treatment to be merely the cessation of a single drug or class of drugs. It is not even possible any longer to see the point of treatment to be the cessation of all drugs while the person continues to spike dopamine from other non-drug taking behaviors (overeating, gambling, compulsive sex, etc). What is happening now is a wholesale reoganization of thought about addiction. Is it still good treatment to get the person to stop drinking while they gain 100 pounds and die of a heart attack? Is it still good public policy to ignore the causative illness and focus on the drug de jour and then decry the “new epidemic” of the next one? The findings of the neurobiology of addiction, and their incorporation in ASAM’s new definition are watershed events. Nothing can be or will be the same again with regard to thinking about addiction.
So what is abstinence and does it matter anymore? Two really good questions. I’ll give you my answers, but they are only mine. The rest of addiction medicine is going to have to hash this out over months and years. The next answers we hear from organized medicine may be just stepping stones to the final answer, and that final answer may itself be overthrown by future evidence.
Abstinence is the act of refraining from seeking a dopamine spike in order to feel better right now. Does it matter? Yes, and no.
If I take a medication that doesn’t change how I feel now but keeps me stable over the course of the day, I’m abstinent. If I get bored when not drinking and need to shop on the internet to feel alive, I’m not. The chemical has nothing to do with it. Notice I said abstinence is an act, not a state or a process. It is the act of the moment. We are abstinent in this moment only.
Because abstinence is a momentary event it can be integrated over longer periods of time such as, “I have three weeks of sustained abstinence.” However, in practice this is rarely to the point. I have met no one in recovery who has maintained complete abstinence from any dopamine spiking behavior for 24 hours. At least that’s how it looks from the outside.
From the inside it’s different. I know many people who believe they have days and weeks and months and years of sustained abstinence. What we see, from the inside, is our subjective view of what spikes our dopamine, and as the midbrain is incredibly powerful at forming our perceptions of what is necessary, we may only see what it wants us to see. What becomes clear over time, with sustained recovery and active involvement of other recovering people in our introspection, is that things we thought were necessary are now seen as rewards that can be abstained from. So abstinence changes from time to time for each person. Therefore one could say, “I am abstinent from alcohol and nicotine today,” and in two years say, “I am abstinent from alcohol, nicotine, compulsive overeating, and righteous indignation today.” So what matters more than abstinence is the seeking of abstinence and the recognition that for the person with addiction the illness is not as simple as a drug or a medicine, but is as complex as the brain. It changes over time, and we and our recovery have to change also.
So to those who worry about medication in people with addiction I’d ask this, “Does it cause a dopamine spike?” If so, it’s probably something that should not be part of the patient’s care plan. If it doesn’t but you worry that one day it might, then continue to bring it up with the patient in their treatment and teach what you know about the progressive nature of the brain. If you’re worried about people on medicine not making great spiritual progress, don’t be. The evidence for that just isn’t there, and besides, can you think of anything more spiritual than coming to understand that I now have to abstain from one more thing? Medication actually makes that an easier, more likely thing to happen in my experience.
But in any case, let’s stop worrying about the chemical name or specifically where it acts and start looking at the whole patient and their life long care plan as they envision it today. It’s a chronic illness so you aren’t going to cure them anyway. If you’re doing this right you’ll be there with them for a long time. Just keep teaching and more will be revealed.