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I was looking at a couple of scientific papers published recently in the British Medical Journal. They describe a particular group of patients with substance dependence problems who have astoundingly high recovery rates. The group? Doctors!
My understanding of the evidence on addicted doctors is that having a medical degree does not make one any more vulnerable to addiction, but neither does it protect one.
What is different is the way that doctors are treated. In the American study, over 900 physicians were included in an observational study. Around half had alcohol dependence and a third opiate dependence. Almost one in six were IV drug users.
Now let’s look at some statistics in one of these papers and let’s compare with treatment of other client groups in the UK.
78% went to residential treatment (about 2% in the UK)
22% went to out patient treatment (about 98% in the UK)
95% of treatment was 12-step orientated (less than 50% of residential treatment in the UK and a tiny percentage of out-patient treatment)
Therefore, at least 95% of treatment episodes were abstinence oriented (I don’t have comparable figures for the UK, but it is likely to be very, very low)
92% attended mutual aid groups (NA/CA/AA) (Again no comparative data available)
All received coordinated, high quality monitoring in specialist programmes for long periods of time afterwards (no data to compare with UK)
Here’s the bottom line: about 80% maintained a long-term abstinent recovery. In the UK, the percentage of those in treatment attaining this is in single figures.
What is there to be learned from this?
Well, we’re not comparing like with like here. Most physicians will have high recovery capital. However, might it be possible to achieve better results for addicts in the UK who identify abstinent recovery as their goal? (This represents the majority of those surveyed year after year by the NTA)
If we give people the best possible treatment (residential) for adequate duration and intensity with good follow up and aftercare, could we achieve better results?
And look at these strongly positive associations with 12-step treatment and mutual aid groups. Physicians clearly find them acceptable interventions, despite what many professionals feel in the UK.
I think we can do better for those wanting to have a drug-free recovery. To this end, the extra funding announced by the Goverment to enhance access to residential treatment is very welcome.
Concise, clear, and directly pointing at the solution for thousands who are still suffering. Thanks David. x
A good blog david, addiction goes right across the social net work, am pleased to read in DDN’s 1/12/2008 page 5 top right hand corner, News in Brief. professional help. http://www.php.nhs.uk
Thanks for bringing this up for all to read.
This is really bad science. You state that 80% remain abstinent compared to single figure %‘s in UK. You then offer no comparative data, which seems strange as you are writing a comparative article! You are also looking at highly paid, high status professionals, probably highly motivated with good support networks. Are you seriously attempting to pit this against the majoirty of those in the ‘recovery community’ in the UK? The profiles of whom will be exactly the opposite of your US physicians. Sorry to put a dampner on things, but I think we should have a serious debate using serious data and good methodology rather than this form of posturing polemic.
Steve
I have to agree with Steve. In the USA, where most treatment options are heavily 12 step oriented, the success rates of such interventions are quite low—no where near 80%. In fact, AA’s own triennial survey of it’s membership showed that only 5% were still there, clean/sober, one year after beginning attendance. In addition, though it may be helpful to some as a support group, AA/NA/CA are NOT “drug treatment”—they are a religiously based groups, working on the presumption of a stockbroker from the 1930’s with no medical background that addicts need God in order to recover, and that prayer, meditation and the making of sin lists to be shared with other addicts and “God” is the key to recovery.
In fact, addiction is a brain chemistry disease—like many other mental illnesses—and often requires medical, scientific intervention. The fact that a person is momentarily abstaining from the use of drugs does not mean they are “in recovery” from this illness. Physicians are extremely motivated to abstain—moreso than many others—but may be abstaining from drug use while still dealing with a severe alteration in their brain chemistry that is being left untreated. The use of drugs is really more of a symptom of the disease than the disease itself.
Support is important in the recovery from just about any disease—but support does not substitute for adequate medical treatment and therapy, and far too many in and outpatient facilities use it as such.
One could argue that he’s comparing apples and oranges, and recovery capital surely plays an important role, but why so quick to dismiss this?
One of the ways I evaluate possible treatments for any health problem is to ask my doctor what he/she would do if they were in my shoes. It’s amazing how many times that has led the treatment plan in another direction.
Why are you so skeptical about the potential impact of such an approach—high intensity to start, gradually stepped down over a period of a year or more, with monitoring and early re-intervention for up to 5 years. Why shouldn’t this be made available for all addicts?
The main reason that US doctors are able to benefit from such intensive therapeutic inputs is because they’re in a position to be able to fund it out of their own pockets. It’s been a very long time since the average US person’s medical insurer has been prepared to fund in-patient treatment for drug dependence. Since the introduction of the Managed Care system, almost everyone in the US who is having their treatment funded by medical insurance gets outpatient treatment. And the differences in outcomes between the standard 28 day in-patient treatment that they US providers generally offered, and community-based treatment are fairly insignificant. To quote NIDA on this issue:
“Generally, for residential or outpatient treatment, participation for less than 90 days is of limited or no effectiveness.”
I do think David is onto something though. If we want to see greater numbers in recovery, perhaps we should be putting our drug-dependent population through medical school!
Thanks to you all for your comments. I’m glad I provoked some debate.
Some thoughts in response:
A blog is not ‘science’. Neither is it ‘an article’. It’s an opinion designed to create an exchange of ideas and other opinions. Successful, then!
The original paper is good science; I’m trying to take a pretty impressive statistic and look at what we can learn from it. I fully accept that we can’t compare apples and oranges, but we can take a look at what enhances recovery in this group and see if lessons can be applied to others. I think they can. I’m glad to see Anne Marie, Yenwarp and Jason do too. (And well done on your own celebrations in your Dawn Farm Blog Jason, great stuff!)
I did a presentation today to our patients on current understanding of the brain science of addiction and how it can be applied to recovery. There’s a lot to be learned there. Some of them will be going to meetings tonight of mutual aid groups, the same ones that Steve disapproves of above.
Why? Because of the evidence base (the ‘good science’) that they increase the prospect of recovery. The ‘Orange Book Guidelines; the NICE Psychosocial guidelines and the NICE Opiate Detoxification Guidelines all recommend routine referral to mutual aid groups.
I quote: ‘Staff should routinely pvovide people who misuse drugs with information about self-help groups. These groups should normally be based on 12-step principles; for example, Narcotics Anonymous and Cocaine Anonymous’. Not much room for disapproval and prejudice there really.
Brain science and mutual aid are completely compatible. Mutual aid group attendence increases recovery capital and is consistently associated with positive outcomes in dozens and dozens of studies, including some in the UK.
I agree with Peter (McDermott) that good outcomes are associated with treatment of adequate duration. Some US doctors self-fund; some are covered by insurance and some are funded through their employers. Most seem to get adequate intensity and duration of treatment, plus good follow up.
Our treatment service runs from the NHS (in partnership with City of Edinburgh Council and ‘Transition’ a vocational training company). The service is core funded, so eligible clients dont have to worry about finding funding.
And yes, the duration is three months becaue of that evidence base Peter mentions. We don’t have to go to medical school to have the opportunity of recovery. (Though it does appear that it might help!)
Some very important issues are being discussed here. As David says, this is a blog discussion and not a published article. However we might want to get a bit rigorous here to see what value there is in the arguments. As it happens I agree that generalising from this to the UK drug treatment situation is problematic but I also think it is important to explore what ‘works’ for any group and try to work out what are the important factors.
As it happens my views are almost the opposite of zenith15’s: I think the ‘brain disease’ concept has all kinds of problems despite heavy propaganda from NIDA accompanied by impressive looking but essentially meaningless coloured fMRI scans of the ‘addicted brain’; I think it is potentially dangerous for addictions treatment in the 21st century (see my review of Carlton Erickson’s book published in Addiction Research & Theory (2008) Vol. 16, Issue 4, Pages 413 – 415 for some of the arguments) and I do like mutual-help groups quite a lot, because as David says, there is an absolute pile of evidence, most of which has emerged in the last 15 years, which shows this kind of support to be effective, and because mutual support addresses some of the social and cultural factors which are crucial to recovery at the individual, family and community level. The evidence about AA retention is very old and extremely misleading. A pile of stuff like this is cited in the ‘Orange Papers’, an interesting, quite intelligent (and very hostile) online critique of the 12 Step recovery movement which makes some very good points but which takes quite jaw-dropping liberties with evidence, citing it out of context and drawing bizarre inferences.
I intend to start a blog thread on both the ‘brain disease’ idea and on mutual-help because a healthy debate about these things would be valuable IMO.
What these doctor studies (and other studies of less advantaged populations) confirmed for me was that if you provide a big package of help and support and if people have good incentives to stop using then a lot of them will succeed. This is not quite as trite as it sounds. The authors of the paper David is taking about say:
“From a clinical perspective we interpret these results as evidence that the combination of identification, intervention, formal treatment, professional support, and monitoring by physician health programmes is effective in rehabilitating most of these addicted physicians, over at least five years.”
McLellan et al. (2008) Five year outcomes in a cohort study of physicians treated
for substance use disorders in the United States, British Medical Journal 337 (41): a2038.
available free at http://www.bmj.com/cgi/content/full/337/nov04_1/a2038
That is a huge package of stuff there. It could be, and I think it very likely, that the most important bit is the professional monitoring and testing on which their continuing careers depended, but the package does seem to combine the best of what we know works. I believe we can transfer some of this to UK drug users, both in terms of providing much better, more focussed psychosocial treatment, wrap-around support and aftercare and in encouraging long term mutual support which is not a cost on the health care system, encourages conjoint responsibility and potentially generates stronger communities of recovery.
A couple of other interesting and related studies are these:
Brewster et al. (2008) Characteristics and outcomes of doctors in a substance dependence monitoring programme in Canada: prospective descriptive study, British Medical Journal, 337:a2098. available free at http://www.bmj.com/cgi/content/full/337/nov03_4/a2098
This one shows that the picture for British doctors is not that different:
Lloyd (2002) One hundred alcoholic doctors: a 21-year follow-up, Alcohol & Alcoholism Vol. 37, No. 4, pp. 370-374. available free at http://alcalc.oxfordjournals.org/cgi/content/full/37/4/370
I lke the points you make Tim. I agree we need to be careful with the science, but I wouldn’t want to throw out any babies here. I look forward to hearing your take on the neuroscience.
The thing that struck me with the alcoholic doctors study the first time I read it was the high mortality: 24% were reported to have died directly due to alcoholism. However the overall recovery rate was very high and, guess what, there was a strong positive association between going to mutual aid groups and recovery.
Given some of the issues that some have around mutual-aid groups I was also thinking on dashing off a line or two. This needs to be about client choice, but let’s give them the facts so folk can make informed decisions.
