Saturday, April 7, 2007

Recovery Options: The Complete Guide

By Joseph Volpicelli, M.D., Ph.D. and Maia Szalavitz. ISBN 0-471-34575-X

Reviewed by Marty N.

Recovery Options is a consumer's guide to the treatment concepts and recovery choices available in the United States at this time. Dr. Volpicelli is a distinguished researcher and clinician at the University of Pennsylvania, and Maia Szalavitz contributes her abilities as a journalist and her insights as a former heroin addict.

The work begins with a brief introduction to the main drugs of abuse and a survey of current theories of what causes addiction, together with a discussion of the stages of addiction and recovery. In the main body of the work, the authors discuss the various treatment methods and institutions, including such topics as Dr. Volpicelli's own clinic, recovery medications, 12-Step programs, alternative self-help groups, the Minnesota Model, therapeutic communities, moderate drinking approaches, harm reduction, and methadone treatment, among others. In the concluding portion, they address relapse prevention and lifestyle changes involved in building a long-term drug-free life.

The book uses case studies and anecdotal evidence to illustrate its points, but takes its main direction from research studies about what works and what doesn't work in addiction treatment. The authors draw heavily on the excellent Handbook of Alcoholism Treatment Approaches by Profs. Hester and Miller, reviewed here earlier. In keeping with the main finding of that work, the authors of the Recovery Options book encourage people looking for treatment to try to find care that has research support and that fits their individual needs, rather than settle for the traditional "one size fits all" paradigm.

"Perhaps nowhere in all of medicine is there a bigger gulf between clinical practice and clinical research than in the field of addiction," the authors note (p. 4). As an experimentally trained research psychologist and physician, Dr. Volpicelli writes,

I have long been frustrated by the alcoholism and addiction field's reliance on miracle cures and horror stories, rather than on science, to guide patient care. After all, most Americans with diabetes or even an emotional problem such as depression wouldn't accept being told by a doctor that praying and 'turning your will and life over to the care of God as you understand Him,' as AA suggests, is the only treatment for their illness. Why shouldn't alcoholics and other addicts get research-based medicine the way people do for any other disease? While AA and other 12-step groups have certainly worked well for many, the medical profession has not best served patients or even 12-step programs by claiming that they are the only valid method of recovery. (p. 4-5).

Following the guiding principle that there are many valid methods of recovery, the authors set out to present all of the principal approaches and the debates surrounding each one, and let the person seeking treatment, and their loved ones, make up their own minds. The idea that persons seeking treatment have intelligence about what is likely to be effective for them, and that they have the right to make choices about it, is almost revolutionary in this benighted field, and to base a book on these premises is a noteworthy breakthrough. Knowing from his extensive clinical practice that more and more people are looking for alternatives, particularly now (p.5), Dr. Volpicelli and his co-author afford a level playing field not only to the traditional offerings, but also to the growing number of options that have become available in the past two decades.

The authors lead off the discussion of treatment options with a presentation of Dr. Volpicelli's own clinic at the University of Pennsylvania. This facility avoids moral and other single-factor models and takes a "biopsychosocial" perspective, viewing the addict's problem as partly pharmacological, partly psychological and partly social. Accordingly, the clinic offers an eclectic variety of recovery strategies that tries to fit the treatment to the person, rather than the other way around. This approach avoids confrontations and power struggles with patients (for example, over labels like "alcoholic" or concepts like "denial"). The therapist attempts to ally himself with the patients' sobriety-oriented desires and needs, and tries to facilitate the patient's own motivation and choice toward recovery. The clinic is both a treatment center and a research institute -- a rare and enviable combination found almost nowhere but in association with a few universities.

One special focus of this book is on medications useful in recovery, particularly the anti-craving medicine naltrexone (marketed as "Revia"). Dr. Volpicelli is perhaps the world's leading expert on naltrexone, the first medication approved by the FDA for alcoholism treatment in nearly 50 years. Chapter 11 offers a highly informative discussion of naltrexone and other medications that may be useful as recovery aids. The authors emphasize that the medications are not silver bullets for addiction and that they work best when combined with social support and assistance with long-term lifestyle changes.

The authors present a balanced approach to 12-Step groups, noting that they work for many and remain the largest and most readily available resource, but that there is a significant number of people for whom this approach does nothing, and others who feel traumatized by it. The allied Minnesota Model, similarly, gets an even-handed review of its pros and cons, including such topics as inpatient v. outpatient treatment, insurance coverage, and its unimpressive research results. There is an insightful discussion of therapeutic communities, praising some of them for their success with hard cases, but warning that others are pits of abuse to be shunned. The authors discuss the contentious issue of moderation therapy in an unhysterical manner. They note that abstinence is always safer, but that some people will not try abstinence until they have become thoroughly convinced that moderation does not work for them. In the chapter on harm reduction, the authors make a persuasive case that programs such as clean-needle exchanges do a great deal to reduce public health scourges such as AIDS and hepatitis C and, not incidentally, keep some addicts alive until they can find a ray of hope to begin their recoveries.

Chapter 18 takes on the methadone controversy. Methadone has been the most thoroughly studied of all therapies, the authors write, and the research unambiguously concludes that methadone maintenance is the most successful currently known treatment for heroin addiction. Research also shows that increases in the provision of methadone are directly correlated with decreases in the crime rate and with decreases in the rate of HIV infection.

There is also a chapter on "alternative" modalities such as acupuncture, diet therapy, and ibogaine (Ch. 19). This begins with the memorable observation: "Substance abuse treatment is one of the few areas of medicine where a treatment that would be considered alternative for most conditions -- meeting in groups and praying for help -- is mainstream and recommended by physicians, and where research-based treatments are the exception rather than the rule." (p. 209). The authors are guardedly optimistic about acupuncture, unpersuaded of the claims made for nutritional therapy, and apprehensive about ibogaine.

I could not find any reference to the Schick-Schadel treatment centers or to aversion therapies generally. In view of the fairly long history of these approaches it might have been useful to include them. There is also practically no discussion of psychoanalysis as an addiction treatment approach.

A very reasonable and insightful chapter on treatment for teenagers (Ch. 20) warns that some treatments for this age group can actually drive young people deeper into addiction, and counsels an empathetic, patient, measured approach to the teenager known or suspected to be drinking or using drugs of abuse.

In each of these and other chapters, the authors present helpful pointers to the consumer about how to spot the better programs, what questions to ask, and warning flags that signal a substandard or abusive facility. In this way the book arms the reader with knowledge useful not only in selecting a treatment program, but also in setting expectations and getting oriented once in the program. Of special value throughout the book are the sections that examine each offering from the perspective of the family or significant other of the person seeking treatment. This discussion wastes little time on overworked labels such as "codependence" but focuses instead on the concrete issues that arise in the twisted and tortured relationships between active drinkers/users and their kin and associates. The discussion throughout shows sensitivity to the special perspectives and needs of women, ethnic minorities, and gays as regards treatment and support groups. There is considerable discussion of the needs of dually diagnosed people. An extensive bibliography and listing of resources rounds out this informed, helpful, sensible consumer guide to contemporary treatment and support group options.

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