Addiction Treatment in Metamorphosis: Paradigm Shift in Theory & Practice

New York State Psychological Association Division on Addictions

April 28, 2006.

The New School, Wollman Hall, 65 W 11th St, NYC, 10003

Dear Colleagues, This conference opened with respected veteran researcher Thomas McLellan who spoke at length about his recent realisation that addiction is indeed a chronic disorder and that his and others' research over the years had missed often this essential fact. He said that it shows the futility of treating a chronic disorder with a variety of short term interventions, hoping to get different outcomes where nearly every trialled treatment for dependency found much the same (disappointing) results in the medium term. He emphasised the many consequent benefits of on-going treatment rather than 'black box' interventions lasting weeks or months. He came close to candidly conceding that much previous dependency research by himself and others was worthless, using the term 'mea culpa' at one point (see some citations below). Some people, such as Dr Vincent P. Dole, have been pointing in this direction for many years.

We were shown outcomes of various trials on diabetes, hypertension and addiction, including Project MATCH. McLellan pointed out that reports of medication compliance (now termed 'adherence') had often shown less than 50% of general medical patients actually take their medication as prescribed (eg. for asthma, arthritis, etc). We were shown other close similarities between dependency and general medical research trials. However, there was often the rather major difference was that addiction trials usually examined short periods of active treatment, reporting limited outcomes after a defined treatment had ceased.

We were also led through one 'rationale' to dispense with detoxification treatments which are expensive and 'largely ineffective'. The goals of such treatments, however, need to be more clearly defined. Crude cost benefit examinations may look negative, but with the added benefits of conduits into on-going treatment, abstinence or otherwise, far more positive figures resulted. In fact, the government of Delaware had introduced novel legislation reducing funds for open-ended detoxification but increasing payments for proven higher retention rates in treatment (any documented treatment). While only a small state, such successful interventions could pave the way for larger jurisdictions in the Union and elsewhere.

Dr McLellan's final point was that like other 'disorders', 'diseases' or 'conditions', addiction should normally be addressed by primary care doctors and their usual staff in a community setting. Difficult or complex cases should be referred to multidisciplinary specialist services which should be able to instil a degree of 'self management' after acute problems are addressed. He pointed to the parallel with new diabetic patients being taught about diet, skin care, sugar measurement, medication, etcetera. The patient should then be returned to primary care for on-going management, reviews, prescribing and follow-up.

Dr McLellan spoke privately about the somewhat discomforting challenge of being in a room full of psychologists (!). I questioned the use of 'contingency management' in view of his espousing the use of 'normal' medical interventions for addiction treatment. He replied that these were used in normal practice as well (but he gave no examples apart from general encouragement of good progress - see below for details of 'contingency' manglement).

Following, there was a series of 4 workshops after the plenaries of which I chose 'mandated addiction treatment issues' with Professor Barbara Wallace. To a packed room, she alluded to her numerous books while confronting the audience with numerous anecdotal cases. For some reason, she avoided mention of pharmacotherapies which are the mainstay of most drug court decisions in some jurisdictions. Her "menu" of treatment options read like a dozen ways of describing the same thing from my untaught medical perspective.

Next, prior to lunch, Andrew Tatarsky spoke eloquently about psychological and psychoanalytic approaches using principles of harm reduction. He has also written a book on the subject and feels passionately that such principles are consistent with good practice. He went so far as to say that the Alcoholics Anonymous "Big Book" was the original 'bible of harm reduction', although it has been hijacked recently by fundamentalists. Dr Tatarsky had been invited to give a talk to a group on addiction related topics but because of federal rules, he was asked to change the name and nature of his talk as it contained the words 'harm reduction'. This shows Dr Tatarsky's perseverance in the face of blind prejudice and ignorance, perpetuated, it would appear, by official White House policy.

We then had Dr Tatarsky and Dr McLellan taking questions from the audience. One woman challenged Dr Tatarsky on the acceptance of 'controlled drinking' by the use of an anecdote with untoward outcomes. The questioner invoked her own case of sugar, food, heroin and alcohol addiction and being tempted by occasional cakes. We were reminded by Dr Tatarsky that harm reduction was not a back-door method of legalisation, but quite the opposite.

This conference was convened by Professor Scott Kellogg and Dr Andrew Tatarsky who are both office bearers in the Association and were also both speakers. It was a sell-out with standing room only at times.

After lunch we were exposed to the chief draw-card of the sell-out conference, "Pleasure and Addiction" "Sex Addiction 101" by Sharon Nathan, followed by an update on 'The Pleasure Project" from the South Bronx by Joyce Rivera, including her own experience introducing needle exchange in the area. We were told about the internet being "the crack cocaine of pornography" with over 300,000 sites for all manner of sex images. In addition, we were reminded that sex addiction was not a DSM III or IV diagnosis but may be in the next version. 'Frottage' equally did not rate a DSM mention although it is a widely known condition here in America (it was explained to this ignorant foreigner that it is people who rub up against others in packed subway trains or buses). While there may be females involved, nearly all cases of sex addiction referred to Dr Nathan were men. It involved numerous aspects of sex including masturbation, pornography, voyeurism, quick liaisons, prostitution and fantasies. Invariably there were negative aspects on the person's regular partner(s) and relationships.

We were given an example of her first case who, although he lived in a typical New York apartment, it seemed to him to look out onto multiple sex scenes beyond uncovered windows in neighbouring apartments. In addition, the patient/victim had once crawled down a ventilation shaft to view a women's dressing room nearby. Telephone sex was the order of the day in the 1990s when this case arose, but internet, webcams and video telephones are what we were told were the norm in the modern era.

It was interesting in this advanced city that several of the presenters were unfamiliar with power point presentations (I thought that I was old fashioned!). One workshop presenter refused to use any such modern audio-visual aids at all. Another was only familiar with Mac's and could not find the slide show button! But help was at hand.

Afternoon workshops were held on eating disorders, 'altered states and creativity' and psychoanalysis and drug abuse treatment.

The final session was on the use of contingencies in opioid maintenance and non-opioid treatment settings by Professor Scott Kellogg. Entitled "Keeping it Positive: Contingency Management In Substance Abuse Treatment", his own summary gave what he called a somewhat panoramic overview of this extremely effective, if somewhat controversial, treatment approach. Beginning with examples from history, he spoke about Alexander Maconochie's humanistic work in the penal institutions in Australia in the mid-19th century, and Charles Dickens' and Angela Georgina Burdett-Coutts' work with prostitutes in England, shortly thereafter. Both of these projects utilized early forms of token economies based on positive reinforcement. This was then followed by a review of classic alcohol studies in sixties and seventies and the more recent work by Stitzer, Higgins, Silverman, and Petry, as well as the results of the NIDA Clinical Trials Network study. After a review of the 7 core principles, he spoke of his own work with the New York Health and Hospitals Corporation - which has been the largest adoption of contingency management anywhere in the world. This project has provided contingencies to thousands of patients. Dr. Kellogg somewhat boldly closed by stating that positive reinforcement systems are the most effective psychosocial intervention in the addictions treatment field, and he spoke about his hope that treatment providers can find ways to integrate the principles and practice of positive reinforcement into their work.

Comments by Andrew Byrne (last paragraph by Scott Kellogg since Dr Byrne missed the session and also remains seriously sceptical of the whole area of 'contingency management') ..

Selected citations of Dr McLellan:

Cornish JW, Metzger D, Woody GE, Wilson D, McLellan AT, Vandergrift B, O'Brien CP. Naltrexone Pharmacotherapy for Opioid Dependent Federal Probationers. 1997 Journal of Substance Abuse Treatment 14;6:529-534

Kraft MK, Bothbard AB, Hadley TR, McLellan AT, Asch DA. Are Supplementary Services Provided During Methadone Maintenance Really Cost-Effective? Am J Psychiatry (1997) 154;9:1214-19.

McLellan AT, Arndt IO, Metzger DS, Woody GE, O'Brien CP. The Effects of Psychosocial Services in Substance Abuse Treatment. JAMA. 1993;269:1953-1959.

McLellan AT, Carise D, Kleber HD. Can the national addiction treatment infrastructure support the public's demand for quality care? Journal of Substance Abuse Treatment (2003) 25:117-121