Precept #5: As with any other illness, the prevention strategies and treatments most likely to work aren't based on tradition, wishful thinking, or faith, but science.

If a person does not know they have a disease, they are obviously not going to seek medical care.  Instead, they seek “help” in ways that are proven to be ineffective.

  --Dr. Bryan Borland

.    How do you respond to precept #5?

This precept attempts to clarify that alcoholism and drug addiction are chronic medical diseases that require medical treatment for the person to get better.  If a person does not know they have a disease, they are obviously not going to seek medical care.  Instead, they seek “help” in ways that are proven to be ineffective.  Science has given us the ability to perform research so that we can confidently say what works and what doesn’t.  Sadly, most (>80%) addicts and alcoholics will never be given an opportunity to receive the treatment that has been proven to work. 

We have excellent data that shows there are two factors that influence how likely a person is to become an alcoholic/addict.  These factors are genetics (family history of addiction) and the age that a person begins to use alcohol/drugs.  We can’t alter a person’s genetics, but we can certainly educate children (especially those with an alcoholic/addict parent) on the risks of using drugs/alcohol at an early age. 

      What does our best understanding/current science tell us about effective treatment of addiction?

This question is one I like to simplify because each alcoholic/addict requires an individualized treatment plan that considers a multitude of factors.  I feel secure in simplifying my answer because we (the medical community) are doing such a horrible job that we need to start with the basics.  I will also specifically address and clarify several misconceptions that currently exist in regards to treatment. 

Many alcoholics and addicts require detoxification in a controlled medical setting.  When an alcoholic/addict is no longer permitted to use alcohol or drugs, they experience the symptoms of withdrawal.  The symptoms can be dangerous and extremely uncomfortable.  Therefore, medications are given to help the patient safely and comfortably stop using alcohol or drugs.  Detox is not a treatment for alcoholism or drug addiction.  Without further alcoholism or addiction treatment, detox is essentially useless and in no way increases the likelihood that a person will remain sober.

The Basics of Effective Treatment:

- treatment at a treatment center (rehab), aftercare, and drug screen monitoring

- consideration of a medication to assist treatment

- ongoing long term social support (counseling, AA, NA)

Individually, rehab is the only modality proven to significantly increase the likelihood of achieving long term sobriety (~40%).  Medications and social support alone are not effective.  Patients that participate in all three treatment modalities simultaneously have an excellent chance--more than a 60% likelihood--of achieving long term sobriety.  As an example: physicians, attorneys and airline pilots must participate in all three basics of treatment.  Because of this, these groups have recovery rates greater than 80% at five years. 

Why then does it seem like most alcoholics and addicts never get better?  Well, most alcoholics and addicts are never given the opportunity to obtain the treatment we know to be effective.  Why is this?  Let's explore some of these reasons.

Medical providers have little knowledge in the field of addiction.  Here we have a disease, and patients who are seeking treatment, but the treatment providers do not know how to effectively treat the disease.  Only 11% of patients discharged after a hospital admission for opioid use disorder were provided with at least two of the above listed treatment recommendations. 

Many communities have no access to a quality treatment center.  How can alcoholics and addicts get treatment if there is no treatment facility?

Treatment is expensive and most patients require more than 90 days of treatment.  I understand how inconvenient it is (I spent a ton of money and over 100 days in inpatient treatment… twice), yet patients diagnosed with cancer will readily spend whatever it takes and accept treatments that are beyond horrible.  If they can do it, we can too.

Everyone has commitments in life that can be used to justify why now is not the right time to get treatment – but this is simply not true.  What can possibly be more important than your health and for many, your life?  In reality, if people think you need to go to treatment, you are probably the last person you would choose to be in charge of important things in your life.  There’s a saying in AA: Anything you put before your recovery will be the first thing you lose.  I have personally seen this to be true in my own life, as well as countless others.  That wife will leave, your children will be taken, you will be fired from that CEO position, your money will run out, and your poor health will become permanent.  You can get treatment now, or you can let your life continue to get worse.  It’s your choice – you hit your bottom when YOU decide to stop digging.

Alcoholism and drug addiction are diseases that affect the brain – the brain is what we use to make rational decisions – thus, alcoholics and addicts do not make rational decisions.  This concept is so crucial to understanding the seemingly insane behavior of alcoholics and addicts.  Successful treatment requires the alcoholic and addict to understand that their brain is dependent on drugs and alcohol and will do everything in its power to get them to continue using.  Every decision and thought has a hidden ulterior motive that will ultimately lead us back to using.  Our brain tells us lies, and we believe it.  Why wouldn’t we?  Our brains would certainly never do us any harm – right?  Wrong.  I am sure everyone has watched someone they love nearly die or lose everything in life, only to immediately go back to using.  The brain needs its chemical first and doesn’t care about your life or anything else in it.   

 

      Does personality determine what treatment is effective? If so, can you elaborate?

Not really.  Research shows that people who are forced into treatment do just as well as those who willingly go.  Effective treatment must follow the basics we discussed in Question 2.  A combination of rehab, consideration of a medication to assist treatment, long term aftercare with urine drug screening (normally one-year duration) and social support (counseling, AA, NA).  We know that if a patient completes that treatment sequence, they are very likely to get well – regardless of personality. 

There are certain personality disorders that can complicate treatment.  These disorders are generally screened for while the patient is receiving treatment.  If identified, the patient’s treatment then relies on simultaneous treatment of the personality disorder and their substance use disorder.  This is also true for mental health (depression, bipolar, anxiety), gambling, and eating disorders. 

      Many people would be upset at the thought that faith, attitude, etc., are ineffective in treatment. Does faith play a role? Is there value in the power of positive thinking in addiction recovery?

When I first began lecturing on addiction I would tense up and feel my heart racing as I stumbled to answer this question.  It’s actually quite simple now.  I don’t care what you do as long as it is in addition to – and does NOT replace - the treatment we know works.  You want to go to Church? Absolutely you can, but you are still going to attend aftercare and AA meetings.  Does faith in God, an unquenchable desire to get well, and a positive outlook help?  Probably, but these are not requirements by any means. 

Do we tell diabetics to skip the insulin and just pray for their blood sugars to be lower?  Maybe that kid having an asthma attack just needs to “man up.”  These diseases have nothing to do with faith, strength, or will power.  Substance abuse falls into the same category.  The brain is dependent on the substance – it MUST have it.  To tell an addict to “not use” is like telling a non-addict to “not breathe”. 

      What can families, loved ones, friends, etc., do to identify the science that will help their addicted loved one?

Great question.  First and foremost: Do not try to get your family member sober!  Yes, that’s really what I meant to type.  This is incredibly hard to hear because we want to help the ones we love, but most of the time we aren’t helping.  If a family member is in a car accident, I would hope you would call the Emergency Squad; if they have cancer you would take them to a cancer specialist.  Substance Abuse is no different; they need to go to a treatment center and see an addictionologist. Let the addictionologist treat their addiction – that’s their job and they are good at it.  I’ll make a bold statement here that may seem harsh and uncomfortable: Any attempt to do anything other than get them to treatment is actually doing them harm.

Can a person get sober without treatment?  Yes, RARELY: there's a less than 5% chance.  I can’t accept those odds, so I encourage treatment for everyone. 

 

      What else needs to be said about this precept?

We are fighting a war on drugs and losing.  We know how to treat this disease and yet no one is getting treatment.  How do we get people into treatment?  All I hear is we can’t (insurance, distance, money, they won’t go, they never get well, they all relapse). 

Bear with me as I make this lengthy hypothetical point:

I grew up in Thornville, Ohio.  Imagine if today a man goes into the Thornville community bank and robs it.  The police come and a shootout takes place.  A police officer is killed and the robber is critically shot in the chest.  The emergency squad comes and a young EMT relays the information.  A penetrating chest wound is a Level 1 trauma and thus requires immediate treatment at a Level 1 Trauma Center.  A helicopter is sent out to Thornville carrying a highly trained medical professional (Doctor, Nurse Practitioner, or Medic).  The robber is loaded into the helicopter and they take off.  Now, en route to downtown Columbus, no one checks the robber’s insurance, nor do they ask him for any money.  They arrive at the Level 1 Trauma Center where the man is greeted by no less than two, and probably three, physicians, several nurses, a pharmacist, a chaplain, hospital administrators, registration clerks, x-ray technicians, residents, interns, students, and a social worker.  They still haven’t checked his insurance or asked for payment.  The robber has multiple surgeries and spends two weeks in the trauma ICU.  The next month he is on the trauma step down floor, and finally he is discharged to a Correctional Facility.  He will likely pay nothing for this treatment. (He was robbing a bank so I doubt he has much cash lying around.)

If this is possible, why can’t drug addicts get treatment?  Maybe we need to try harder.  Where are the Level 1 Addiction Treatment Centers?  If this is a WAR on drugs, we are losing.  One in seven Americans will be diagnosed with Substance Use Disorder.  I don’t want to tell patients that I can’t give them the lifesaving treatment they need. 

We have sick patients and we know how to help them – Let’s get to work.

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Dr. Bryan Borland graduated from the Ohio University School of Osteopathic Medicine in 2011, and completed three years of his residency in emergency medicine at the Ohio Health Doctors Hospital. He was named the Outstanding Student Leader of the Class of 2011, and was twice nominated for the Doctors Hospital Spirit of Caring award. Dr. Borland, a drug addict and alcoholic himself, was fortunate to receive the high quality treatment proven to get people sober.  He is determined to make this treatment available to anyone struggling with addiction.