The Evidence Gap: Do Treatments Even Work?

When I saw this article in the NY Times, I literally ignored everything else around me for about ten minutes straight. Working in drug abuse research (as I do), I get a lot of questions from people asking a) what they can do to get off drugs, b) how different drugs work, and c) why don’t drug abuse treatment programs ever seem to work, or work only for the stars who get to go to Cirque Lodge. And every year or so (it seems, maybe it’s six months), the NY Times puts out an article on drug treatment programs and how they’re doing, and mostly about how they’re not doing well, and should be doing better.
This article however, had a bit of an edge of hope. I always appreciate that, it’d be nice to know that my entire career is not in vain, wouldn’t you agree?


So the short of it: those month-long rehab programs? They don’t really work. The long version: sometimes they work, most of the time they don’t. This has a lot to do with the nature of addiction itself. What makes it addiction is that you CANNOT stop doing it, and it will probably take more than a 30 day vacation to convince you.
The fact is that addiction to any drug makes long-lasting changes in your brain. This is not just tolerance, it’s also rewiring of things like memory formation and over-riding of certain thoughts. Thus, viewing crack paraphenalia is enough to elicit powerful memories, and then powerful craving, in a crack addict. And the over-riding of thoughts means that you might go to the bar for a minute, knowing you have to get to your kid’s recital, and one drink just begins to lead to another.
When we’re talking about long-lasting changes, it can include rewiring of synapses, changes in memory formation and processing, and changes in the very levels of neurotransmitters in your brain. While 30-60 live-in days of abstinence can get you through the withdrawal (and thus past the physical issues that can occur with drugs like alcohol and narcotics), and may be enough to bring your neurotransmitter levels back to normal, it’s not enough to rewire your synapses. And so the day after you get out, you’re back in your familiar surroundings, seeing all the things that you used to get high around, and all your old friends…
It seems that a 30 day detox on it’s own isn’t going to work. The article talks about the melding of counseling techniques and medicine to help combat addiction, but it doesn’t really speak to the fact that this needs to occur long term. We’re talking more than a few months. We’re talking years. In some cases, such as opiate addiction, addicts may be on methadone maintenance for LIFE. This isn’t just something that can be cured by a sojourn at a lodge. Combating addiction is a lifelong fight. Generally, positive results occur most often with constant therapy, a good support network, and possibly therapeutic interventions to help fight cravings and withdrawal.
That’s not to say that a 30 day detox won’t do anything. Rehab programs provide initial counseling, and many provide follow-up counseling. Furthermore, rehab programs can provide the beginnings of a support network to help you get clean and stay clean. But to say that 30 day programs will make you clean for life is a bit too optimistic.
I personally think that the blending of therapeutic interventions and counseling techniques may be the best route to success, a route which has been shown to be successful in many psychistric disorders. As the NY Times points out, however, scientists may not be as sensitive to counselors’ needs as they could be, and counselors may not take suggestions for change very well, as no one wants to be told that what you’ve been doing your whole life is in fact wrong.
In addition, some people think that taking new drugs to combat addiction is not combating addiction at all, just replacing one drug for another. While in some cases this may be true (like methadone), in others, therapies can help make intolerable cravings bearable, and reduce the severe physical and psychological side effects that come with drug addiction and withdrawal, helping patients to keep making it to counseling, and to help them keep away from previous patterns of use. And when it comes to drug therapies, many addicts need all the help they can get. Drug abuse is a powerful controlling force, and far more than just a question of weak willpower.
So if these 30 day treatment centers are not enough, what is? How do we fix the system and come up with therapies that work? To be honest, we’re still working on it. Even the best counseling, therapeutic, and drug treatment programs in the country cannot achieve more than about a 15% success rate. So more research is needed to find therapies that work, drugs that will help, and the mechanisms that cause addiction and cause drug use to persist.
Counseling and support networks are incredibly important parts of drug rehabilitation, and it would be better if more counseling programs went long term (many months to years), as opposed to short term. Improvements in support networks could also mean more opportunities to get people out of the areas where they used drugs (people and places of previous drug use are powerful contributors to craving and relapse), getting them somewhere where they can make a fresh start. And of course, the more people keeping an eye on you, the less likely you are to stray.
The article in the NY Times actually offers good examples of this, such as Oregon, which is requiring evidence-based therapy in addiction programs that receive state funds, and Delaware, which gives incentives to those who make benchmarks. Luckily, those benchmarks include just getting people to come back to counseling, and I hope they don’t rely on decreases in drug-positive urines or people who have gone and stayed clean. Let’s keep it at the first step first. Hopefully, with the use of evidence-based therapy, and encouragement to keep coming back to counseling, programs will be developed that combine the best of everything we have to fight addiction. These patients need all the help they can get.

6 Responses

  1. Thank you! Wonderful commentary.
    Thank you for the work you do. Your work is the reason why opiate addicts like me get better!

  2. sorry I hit post by mistake…
    I would like to add one thing. Methadone treatment is far from “just” replacing one drug for another. Methadone is different in many ways from the drugs most opiate addicts abuse (see dole/nyswander studies). For one thing it stabilizes endocrine function, craving, and endorphin deficiency in the addict. Also, treatment at a clinic includes much more than just taking a drug.
    Thanks again

  3. As Kristan wrote, I thought this was a great article, marred only by your comment about it being “true” that methadone was “trading one drug for another”. Methadone stabilizes brain chemistry without causing a high or euphoria in a tolerant patient (unlike short acting opioids) and has the additional unusual benefit of not attaching to all the opiate receptors, leaving about 30% open to encourage natural endorphin production if the brain is staill able to produce it’s own endorphins (Kreek). Changing a life of constant misery, crime, rollercoaster highs and lows and obsession for one of productiveness, functional ability, employment, reliability and stability is hardly changing one addiction for another.

  4. there are multiple “intermediate” (for lack of a better word) therapies used to move people off the abused drug. i would also argue that this is not necessarily trading one drug for another, because the intent and the effects are very different.
    the replacement drugs don’t reinforce the same biochemical milieu like continued use of the abused drug.
    but this was a great post, sci. i once heard that the well-known treatment center hazelden offered an “alumni discount” and had a hard time processing their positive spin on a relapse, but at the same time i suppose it is good to encourage relapsed patients to come back.

  5. I agree with the previous posts in that this was a great article with the exception of the “trading drugs” comment. It is nice to see someone not “burned out” by the system. I believe that recovery is not “one size fits all” but the ones (like myself) that accept there is no cure and is willing to treat there disease for life whether it be through therapy or medicinal/therapy intervention will have a greater chance of success in their recovery.

  6. This is rather interesting, the last point I ever thought people would contest was the idea that methadone is drug replacement. Shows how wrong I am. You guys are all very right, that there is a vast difference between the effects of, say, heroin, and the effects of methadone. But when I say “drug replacement therapy”, I mean it in pharmacological terms, not in terms of what gets you high. In pharmacological terms, methadone is drug replacement, it’s replacing one more potent, fast acting opiate, with another opiate that is far more slow acting and less potent. This means that the severe physical withdrawal and some of the cravings are relieved, without the highs and side effects associated with the drugs of abuse. But you guys are very right to point this out, drug replacement is not just another drug to get you high, and it has been a life-saving therapy for many people, allowing them to get their lives back on track.

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