Is abstinence best? redux

The link I posted to Peapod’s post about abstinence prompted a few comments on this blog and several on Wired In.

Many of the comments could be summarized as, “abstinence is best for some, for other’s it’s not.”

I think this misses the forest for some of the trees.

The real questions is, in general, what goal should the treatment system treat as the ideal, achievable outcome–abstinence or maintenance?

To me, if the choice is between elimination of symptoms or management of symptoms, the choice is clear.

To be fair, a maintenance advocate might reframe the question this way, “which treatment is likely to lead to the most improved quality of life for the most people?”

I think, as Peapod pointed out, Laudet’s research responds to this question:

“We conducted a study among former substance users, the Pathways Project, to examine the question. 289 participants had had a severe history ofDSM-IV dependence to crack or heroin lasting on average 18.7 years, and had not used any illicit drugs for an average (mean) of 31 months when they entered the study. They were asked to select the statement best corresponding to their personal definition of recovery – 86.5% endorsed total abstinence (Laudet, 2007).

Because the treatment system in the US is strongly influenced by 12-step ideology (McElrath, 1997), we repeated the study in Melbourne, Australia, where the approach to substance user services focuses on a harm-minimisation ideology. Australian participants were also people who had experienced a long and severe history of dependence, mostly to heroin, but who had not used any drugs recently. 73.5% of Australian participants endorsed total abstinence from both drugs and alcohol as their personal definition of recovery (Laudet & Storey, 2006).”

Further, whenever I’m confronted with a health question (for myself or a loved one), my first question is this, “what treatment do doctors with this problem receive?”

In the case of addiction, the answer to that question is abstinence oriented treatment, recovery support and monitoring that lasts years. And, the outcomes are outstanding.

Why would we focus on a different goal for other populations?

4 thoughts on “Is abstinence best? redux

  1. It's true, one approach for one population without much debate and quite a different approach for another.I think palliation of addiction has its merits, but remission of symptoms is preferable.Thanks for the thoughts.

  2. I posted a comment on Peapod's post on Wired In. I will amplify.Though I prefer recovery via abstinence, (it is hard to see how dependence on a chemical, such as Methadone, is recovery from chemical dependency!), I said there is a different paradigm for some populations, precisely BECAUSE they are DIFFERENT populations. My experience covered being an admissions counselor, case manager, chemical dependency counselor, discharge planner in a Salvation Army Adult Rehab, a street level Psychiatric Hospital Dual Diagnosis program, a Court mandated Domestic Violence program, (75% or more substance abuse or addiction), among others.Here you see persons who are unwilling and/or inaccessible to abstinence for several overlapping/intertwined reasons.1. Accompanying mental disorders prior to and/or due to drug brain damage, some relatively irreversable, exacerbating all other problems. 2. Personality Disorders, notoriously difficult to treat, either preceding and/or amplified by Drugoholism to being past the point of no return.3. Below average intelligence,low educational levels, low inner/outer resources in general. 4. Sociological: poverty, deprivation, developmental deficits piled on those from drugoholism anyway. Low or no employment/social skills.5. Character disorders, sociopathology, criminal thinking, lifestyle, orientation, which they have no desire or motivation to change. Con men, fantacists and psychopaths. Notoriously difficult change, or prisons would empty.Though these overlap and are amplified by addiction, some have these difficulties apart from addiction, or they are by now unwilling to change. "As the twig is bent the branch doth grow." is an old adage. I have realised that IN PRACTICE this is true for many. At times the only PRACTICAL solution is amelioration, rather than abstinence.I was an idealist, who thought everything could be improved/ fixed. Seeing numbers of these persons en masse IN PRACTICE, changed me. These persons are NOT Doctors. The combination of inaccessible unwillingness and realistic internal/external problems make them unsuitable candidates for abstinence. It just ain't gonna happen. And this is from someone who was told in his domestic violence work by his long term experienced superior, "The men who went through your sessions got such an unbelievable amount of change."But we also had a succession of young ghetto(Barrio)Hispanics in their early twenties. Drugoholics. Some possible brain damage from sniffing glue, smoking "angel dust" in addition to Crack Cocaine, Hallucinogens, etc. All gang members, with prison records and heavily tattood. All classed as depressed (I would be too!) and on medications. None of them could relate in the slightest way to the concepts of addiction or recovery. Removed to remote. None of them maintained the stability to attend a 50 week program for more than 3 or 4 sessions. Their educational level ranged from low to non-existent. Probably from disfunctional families, definitely from socially deprived surroundings. The future for the largest percentage of them is drearily predictable. Drugoholism is a field, a combination of various processes, both internal and external. And an old saying is, "As the twig is bent, the branch doth grow." Apart from a the rare exceptional few, abstinence is not a PRACTICAL possibility. I have found, not only in Drugoholism, but other problems I work with as a hypnotherapist, full recovery can be moot, too much water under he bridge.Amelioration for many is the best we can shoot for. This is not how I think things could, should or would be, it is not how I want them to be, but it is what it is. Los Angeles Hypnosis and Hypnotherapy

  3. I posted a comment on Peapod's post on Wired In. I will amplify.Though I prefer recovery via abstinence, (it is hard to see how dependence on a chemical, such as Methadone, is recovery from chemical dependency!), there is a different paradigm for some populations, precisely because they are DIFFERENT populations. My experience covered being an admissions counselor, case manager, chemical dependency counselor, discharge planner in a Salvation Army Adult Rehab, a street level Psychiatric Hospital Dual Diagnosis program, a Court mandated Domestic Violence program, (75% or more substance abuse or addiction), among others.In these programs you see a range of persons who are unwilling and/or inaccessible to abstinence for several overlapping/intertwined reasons.1. Accompanying mental disorders prior to and/or due to drug brain damage, exacerbating all other problems. 2. Personality Disorders, notoriously difficult to treat, either preceding and/or amplified by Drugoholism, past the point of no return.3. Below average intelligence,educational levels, low inner/outer resources in general. 4. Sociological factors, poverty, social deprivation, developmental deficits added to drugoholic ones. Low or no employment/social skills.5. Character disorders, sociopathology, criminal thinking, lifestyle, orientation, lacking motivation to change. Con men, fantacists and psychopaths. Notoriously difficult change, or prisons would empty.Though these overlap and are amplified by addiction, many have these difficulties apart from addiction, or by now so committed to the status quo, they are unwilling to change. I was an idealist, who thought everything could be improved/ fixed. Seeing numbers of these persons en masse in PRACTICE changed me. These persons are NOT Doctors. The combination of inaccessible unwillingness and realistic internal/external problems make them unsuitable candidates for abstinence. There are of course rare individuals who rise above, but few and far between. It just ain't gonna happen. And this is from someone who was told in his domestic violence work by his long term experienced superior, "The men who went through your sessions got such an unbelievable amount of change."But we also had a succession of young ghetto (Barrio) Hispanics in their early twenties. Drugoholics. Some possible brain damage from sniffing glue, smoking "angel dust" in addition to Crack Cocaine, Hallucinogens, etc. All gang members, with prison records, heavily tattood. All classed as depressed (I would be too!) and on medications. None of them could relate in the slightest way to the concepts of addiction or recovery. Removed to remote. Unable to maintain attendance in a 50 week program for more than 3 or 4 sessions. Educational level ranged from low to non-existent. Probably from disfunctional families, definitely from socially deprived surroundings. The future for the majority is drearily predictable. I think I have made the point.Drugoholism is a field, a combination of various processes, internal and external. "As the twig is bent the branch doth grow." is an old adage. I have realised that IN PRACTICE this is true for many. At times the only PRACTICAL solution, apart from the exceptional few is amelioration. Not only in Drugoholism, but with other problems I work with as a hypnotherapist also, full recovery is moot, too much water under he bridge. This is not how I think things could, should or would be, it is not how I want them to be, but it is what it is. Los Angeles Hypnosis and Hypnotherapy

  4. Even in the most drunken or lovestruck state, one can usually come up with a rational list of things that are going wrong in his or her life because of the addictive behavior. If this seems difficult, try the other way round, list out the reasons why the addiction needs to be indulged in. To a large extent the lists will be the same. Addiction makes us feel that the consequences of our addiction are actually the causes of our addiction. This mystic insight can often break the back of the monster called denial. A zen moment for those who upload the correct teaching. I accept that I am in denial!!Once that is done, and the cost of continuing with the addiction is weighed against the cost of bringing it to an end, the most painful part of recovery comes into play. That of initiating abstinence. I recently had a chat with Shashi Singha, a therapist I hold in high esteem, and we were talking about total abstinence and harm reduction. To the concept of social drinking by a recovering alcoholic, she pointed out that the risk of allowing an addictive behavior to remain present in one's life reinforces the subconscious association of the feeling of well-being and powerfulness with that behavior. She and I have never been able to agree on a host of things but that has not detracted from the respect I have for her.I write on addiction and recovery beyond the one size fits all model at my blog at secretchords.blogspot.comone of my more middle of the road posts can be found here –http://secretchords.blogspot.com/2010/04/first-steps-in-getting-better.html

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