Toward Better Theories of Addiction and Recovery
by Tom Horvath, Ph.D.
“Everyone is entitled to his own opinion, but not his own facts.”
Ironically, I have not been able to confirm (the fact of) who first expressed this idea. It is widely attributed to Daniel Patrick Moynihan, four-time US Senator from Massachusetts (1927-2003).
What are the primary “facts” or findings about addiction and recovery, of which any theory of them, and any approach to treatment and recovery, would need to take into account? I will propose a few facts (and opinions too). Of course, even our selection of “facts” can be biased. However, only by making the effort to understand the foundations of one’s own opinions can these opinions be improved.
1) Prohibition will be of limited effectiveness in preventing addiction. Alcohol prohibition in the US (1919-1933) was ended because it was viewed as causing more harm than good. Although it is uncertain whether the trend (in Portugal, Uruguay, and the states of Washington and Colorado) to decriminalize or legalize some substances will gain wider acceptance, it is clear the drug prohibition does not eliminate drug problems. Opinion: Self-control will continue to be the primary effective method of preventing and resolving addiction.
2) The opportunities for addictive behavior will continue to increase. New “designer drugs” are produced every year. Electronic media developments will create new opportunities for behavior (also known as process or activity) addictions. Opinion: Prevention efforts need to focus on developing a core set of skills for resisting addiction, rather than skills for specific drugs or activities.
3) Addiction is common. The strength of this fact will depend on how you define addiction. If you include eating (about 2/3 of the US population is overweight), and smoking (20% of US adults smoke), the fact is stronger than if you only focus on alcohol problems (about 1 in 10 with diagnosable problems) or other substance problems or behavioral addictions (less than 1 in 10 but still substantial). Opinion: Some prevention efforts need to be directed to everyone.
4) Natural recovery (recovery without treatment) is the most common route of recovery. The National Epidemiological Survey on Alcohol Related Conditions (NESARC) is perhaps the best single source for natural recovery statistics for alcohol. Other studies show similar results for other substances. The treatment community tends to focus on individuals who attend treatment, consequently missing the bigger perspective on recovery. Those who enter treatment are the “tip of an iceberg.” Opinion: Prevention efforts should support resilience in everyone.
5) Moderation is a common outcome in recovery. This fact is much harder to observe if you only look at the tip of the iceberg. But looking at the submerged iceberg (the untreated population) reveals that moderation is common. By the time someone attends treatment moderation becomes less likely, but not impossible. To “forbid it” runs the risk of arousing psychological reactance, the reaction in the client to prove their freedom (and perhaps foolishly pursue moderation when there is a very low likelihood of achieving it). Opinion: Treatment should not discourage moderation as an outcome, but support clients in making sensible choices given their values, situations and history.
6) Trauma predisposes to addiction. The Adverse Childhood Experiences study provided dramatic support for this idea. Significant adverse childhood experiences five or more) increases the likelihood of drug problems by at least a factor seven, compared to someone with zero adverse childhood experiences. Opinion: Addiction treatment needs to include trauma treatment as needed. Improving the well-being of our children reduces addiction in future years.
7) Other co-morbidity is also common in individuals who are in treatment. Depression, anxiety, ADHD, bipolar disorder, and personality disorder, as well as trauma, are commonly seen. Opinion: Addiction treatment needs to include solid professional resources for treating these disorders as well.
8) There is a wide range of efficacious treatments. We can approach treatment from a wide range of perspectives. Which is good to know, because no one treatment will be successful for everyone. Opinion: The full range of treatments needs to be available for all clients. Clients need to be informed, in particular, that although 12-step oriented treatment is the most commonly available, 12-step oriented treatment and/or 12-step groups are not necessarily the best for particular individuals. Perhaps if our offerings were more diverse more people would seek treatment.
9) Medications for addictions are somewhat helpful. Antabuse (disulfiram) has been available for over 50 years. If everyone with drinking problems (and who could tolerate the medication) took Antabuse, we would dramatically reduce alcohol problems (which has not happened). Medications can work only if individuals are motivated to take them. Other medications have also been available for substantial lengths of time, for other substances. Recovery remains, fundamentally, a motivational problem. Opinion: Medications can be of significant assistance to an individual already motivated to change.
10) Neuroscience, despite much attention, has not made any significant contribution to addiction diagnosis or treatment. We can hope that a diagnostic tool or treatment approach will someday arise out of neuroscience. The findings emerging from this field are fascinating, but not yet of practical significance. In the meantime we need to apply the tools we already have. Opinion: It is wishful thinking to await “cures” for addiction from scientific progress. We need to focus on what we already know works.
At Practical Recovery we attempt to build pragmatic (practical) recovery plans for each individual, regardless of whether the problems are minor (perhaps requiring one session of moderation training) or substantial (perhaps requiring a sequenced set of interventions that might include detox, residential treatment, intensive outpatient, and so forth). The facts and opinions above guide how we work. I’m confident that in a decade this list of facts will have changed.