Treating substance abuse backed by research

On the rainy fall morning of their first appointment, Dr Mark Willenbring, a psychiatrist, welcomed a young Web designer into his spacious office with a firm handshake and motioned for him to sit. The slender 29-year-old patient, dressed in a plaid shirt, jeans and a baseball cap, slouched into his chair and began pouring out a story of woe stretching back a dozen years.

Addicted to heroin, he had tried more than 20 traditional faith- and abstinence-based rehabilitation programmes. In 2009, a brother died of an OxyContin overdose. Last summer, he attempted suicide by swallowing a fistful of Xanax. When he woke up to find he was still alive, he overdosed on heroin.

At a boot camp for troubled teenagers, he said, staffers beat him and withheld food. After he refused to climb a mountain in a team-building exercise, they strapped him to a gurney and dragged him up themselves. The young man in the psychiatrist’s office paused, tears sliding down his cheeks. “Sounds like a prison camp,” Willenbring said softly, leaning forward in his chair to pass a box of tissues.

He began explaining the neuroscience of alcohol and drug dependence, 60% of which, he said, is attributable to a person’s genetic makeup. Listening intently, the young patient seemed relieved at the idea that his previous failures in rehab might reflect more than a lack of will.

Willenbring, 66, has repeated this talk hundreds of times. But while scientifically unassailable, it is not what patients usually hear at addiction treatment centres.

Rehabilitation programmes largely adhere to the 12-step principles of the 80-year-old Alcoholics Anonymous and its offshoot, Narcotics Anonymous. Addicts have a moral and spiritual defect, they are told; they must abstain from alcohol and drugs and surrender to a higher power to escape substance abuse.

This treatment is typically delivered through group therapy led by counselors whose main qualification is their own completion of the programme. In some states, drug counselors with only a high school degree may treat patients, according to a 2012 study by the National Centre on Addiction and Substance Abuse .

Willenbring says he believes this approach ignores the most recent research on the subject, a judgment he is well qualified to make. From 2004 to 2009, he was the director of treatment research at the National Institute for Alcohol Abuse and Alcoholism, and he oversaw dozens of studies proving the efficacy of medications and new behavioural therapies to treat drinking problems.

But he grew frustrated at the failure of most traditional rehabilitation facilities to take advantage of the findings. “When we publish studies in our field, nobody who is running these centres reads them. If it counters what they already know, they discount them,” he continued. “In the addiction world, the knee-jerk response is typically, ‘We know what to do.’ And when that doesn’t work, we blame patients if they fail.”

And so in 2009, after five years in Washington, D C, Willenbring returned to his home state, Minnesota, the birthplace of traditional inpatient rehab, to open a private clinic called Alltyr that treats people with alcohol and drug problems on an outpatient basis.

Unlike many rehabilitation concepts, in which treatment may be limited to a few weeks or months, Willenbring’s clinic, whose name was inspired by a stone with healing properties in Russian folklore, treats addiction as a chronic medical condition. After he makes an initial evaluation, his diagnoses may include a wide range of substance and psychological disorders. His treatment plans can involve antidepressants; medication for anxiety, ADHD and chronic pain; anti-relapse medications; psychotherapy; and family training. Patients may come for a single consultation, or be treated for years.

Most of Alltyr’s 500 patients have mild to moderate alcohol-use disorder and want to try to curb their habits before they are out of control. But some have been on a long, tangled journey to multiple treatment programme.

“I don’t want anybody to have to go through the crap I had to,” said Joe Karkoska, 32, an el-der care worker. Karkoska said he had tried 10 rehab clinics before he found Alltyr. Willenbring prescribed Suboxone, the drug Karkoska credits for his not having taken opioids for three years.

Willenbring’s embrace of medications for those who struggle with addictions is anathema to many involved in traditional recovery programmes. Only about 2% of Americans with alcohol-use disorder are ever prescribed anti-craving medications, according to John Bowersox, a NIAAA spokesman. The majority of those addicted to heroin or prescription painkillers do not receive methadone or Suboxone, Willenbring and other experts said, despite evidence of their effectiveness.

Advocating alternative therapy

Willenbring is adamant that for many, such drugs are crucial for a safe recovery. Long-term use of opioids can halt the brain’s mechanism for producing its own painkilling chemicals, he said; without replacement drugs, many users remain in continuous discomfort.

In abstinence-based rehab, users are detoxed and lose their tolerance for drugs, but they do not lose the cravings. “So what do they do when they get out?” he said. “They use the same am-ount as they did before and die of an overdose.”

Willenbring supports open-ended, long-term drug-replacement therapy for his patients with opioid-use disorder. That raises eyebrows among those who favour abstinence. John Johnston, a counselor at Serenity Lane, a treatment centre in Eugene, Oregon, said that although the drugs could help prevent overdoses, they did not address the core cause of addiction.

“Substituting one drug for another is an external solution for an internal problem,” he said. Willenbring’s approach deprives “patients of the opportunity to have a full range of emotional experiences, a change of spiritual perspective and return to an improved quality of life.” But for many of Willenbring’s patients, Suboxone has been instrumental in helping find just that.

Most, like Kyle Larsen, a 23-year-old nursing student from Albert Lea, Minnesota, began misusing opioids after they were prescribed for sporting injuries or operations. He found Alltyr after a stint at Hazelden Betty Ford and another in a so-called sober-living facility. “It was one-size-fits all, except that it didn’t fit,” Larsen said.

Suboxone, he said, has eliminated his cravings, allowed him to regain the equilibrium he needed to return to school and to restore his family’s trust. Like many of Willenbring’s patients, Larsen attends a regular Suboxone group, which costs $100 a session and is offered to those who have been on a sustained, stable dose for many months. The meeting offers a forum for patients to discuss struggles and successful coping strategies, as well as the camaraderie some studies have found to be supportive in drug- and alcohol-use recovery.

Since Karkoska began taking Suboxone, he has worked with Ian McLoone, an Alltyr therapist, to learn breathing exercises and cognitive behavioural techniques that help identify and change unhelpful, irrational beliefs. They have helped him cut down on clonazepam, overcome his fear of groups and work.

“I’ve got people depending on me now,” he said. “I’m a part of my community.”

International New York Times