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A voice from the wilderness

March 15, 2011
by Andrew D. Bennett, CADC II
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The drug-free treatment model is worth defending, now more than ever

Contemporary cosmologists feel free to say anything that pops into their heads. Unhappy examples are everywhere: absurd schemes to model time on the basis of the complex numbers, as in Stephen Hawking's A Brief History of Time; bizarre and ugly contraptions for cosmic inflation; universes multiplying beyond the reach of observation; white holes, black holes, worm holes, and naked singularities; theories of every stripe and variety, all of them uncorrected by any criticism beyond the trivial.

Abridged from David Berlinski,

“Was There a Big Bang?” Commentary, February 1998

The chemical dependency treatment field is experiencing significant changes in the service of “new technologies.” We seem to have been swept away by these changes within a professional atmosphere characterized by compliance, lacking sufficient critical review.

We are currently moving to a medical model emphasizing a psychiatric orientation embracing dual diagnosis and bio-pharmacological interventions. The primary disease concept and the drug-free model are clearly challenged. They need to be defended.

With a single major exception, an archival review of the trade magazines reveals that time and time again articles characteristically have supported medication-assisted treatment (MAT), including but not limited to Suboxone for opioid addiction and anti-craving medications.1 A recent example of this dominant point of view appears in an article not surprisingly scheduled as the first of a continuing series of columns. In the article, Marshall Rosier refers to an “anti-medication bias” and “ingrained ideologies” on the part of recovering people and addiction professionals regarding MAT.2 Could MAT proponents likewise suffer from “ingrained ideologies” regarding an “anti-drug free” bias?

Andrew D. Bennett, CADC II
Andrew D. Bennett, CADC II


Articles of this kind recommend that counselors who prefer a drug-free approach “need to be educated” concerning the “research-based evidence” regarding “breakthroughs in neuroscience.” I assume they're talking about people like me; folksy old-school Middle Cretaceous 12-Steppers who are apparently ignorant of the scientific method and who are not academically equipped or otherwise inclined to review the literature. Despite our alleged educational deficiencies, we see fundamental problems with the quality of their teaching materials.

In 1961 it was thought that alcoholics drank over underlying emotional problems and a “Valium deficiency.” In 2010, alcoholics and drug addicts drink and use over underlying emotional problems and a serotonin deficiency. Legions of psychopharmacologists are pumping out new and improved anti-craving synaptic rejuvenator pills. Professionals are telling patients that on the one hand they are powerless over alcohol and other drugs, but at the same time they are prescribed pills designed somehow to make them feel less powerless.

It's time to take a good look at how we've been doing business and what it is we're selling. It's time that chemical dependency treatment providers joined the ranks of all the other social sciences in the application of critical peer review to our work.

I take no issue with MAT or competing clinical approaches that do not claim to fit into a 12-Step context. However, if there is such a thing as an abstinence-based 12-Step treatment model that is worth preserving, boundaries need to be put around it.

Research shortcomings

Antidepressant medication, nutritional supplements and opiate antagonists are promoted to allay craving and other dysphoric feelings following classical detoxification. They are used, in theory, to help restore depleted neurotransmitters following chronic substance abuse. Agents of this kind are supposed to help restore neurological integrity at the synapse.

The short-term efficacy of this class of medications has been mixed.1 More importantly, problems of experimental research design are noted across the literature.1,3,4,5,6,7 No amount of placebo-controlled, double-blind methodological safeguards can make up for short-term studies lacking meaningful control groups and limited to a statistically compromised number of subjects willing to be experimented on within treatment facilities willing to conduct drug therapy experiments.

One cannot make any scientifically coherent statements about long-term efficacy in arresting chemical dependency based on the methodological compromises characteristic of current anti-craving or opioid agonist/antagonist medication studies.

My bachelor of science degree tells me that these kinds of trials cannot clarify whether offering drug addicts and alcoholics mood-altering substances is generally a good thing. In the March/April 2007 issue of Addiction Professional, Stuart Gitlow, MD, and Mark S. Gold, MD, offered an enlightening review of the methodological shortcomings characteristic of current CD drug trials.1 There are few, if any, long-term patient outcome studies demonstrating the efficacy of anti-craving agents.

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