Evidence versus magic in addiction science

30 March, 2007

Reading the latest issue of Addiction Professional (vol. 5, no. 2), one glimpses the strange mentality that dominates the United States, the country that once implicitly held itself up as the emblem of rationality and modernity. Alcoholics Anonymous and its Big Book and its 12-Step Program are regarded elsewhere in the world with suspicion, for their theological emphasis and “disease theory” of addiction. Certainly the rituals of a 12-step meeting match the characteristics of a cult: the creation of an artificial “family”, the regular admissions of shame and inadequacy, the strict doctrinal adherence and shunning of alternative opinions. The essential ironies of the AA world view are of course invisible to the cultists: if addiction is an incurable biological disease, how can it be treated with a “talking cure” (AA meetings)? How do some people get straight without God and the 12 steps, which AA deems essential?

In the US, these questions don’t get asked much, because AA and the disease theory are articles of faith, and the faithful control the addiction “industry”. To question their precepts isn’t simply an intellectual challenge, it’s a form of heresy. Consequently, advocates of alternative concepts and approaches have to cloak themselves in humility, paying deference at all times to the current order, advancing in tiny increments, if at all.

Recently the denizens of the United States addiction industry have caught wind of something called “evidence-based research”, and they are doing their best to suppress it. A letter in Addiction Professional embodies the attitude fairly well:

I was grateful to see the recent article on so-called evidence-based interventions (November 2006 issue). Indeed, these claims need to be examined. A recent National Institute on Drug Abuse publication announced the success of low-cost incentives in improving outcomes. When you see a magician making an elephant disappear, you know–if you understand the laws of gravity–that the elephant didn’t really disappear. Something else, something entirely different, happened.

The nature of addiction is that the victim honestly feels as if he will die if he doesn’t do the addictive drug or behavior; his brain tells him this is true. This is the irresistible urge that compels addicts to “do it one more time” to get relief from the terrible feeling. Research that makes recovery look easy, or claims that a financial incentive will reduce drug use in someone who will give up personal safety, personal relationships, financial stability, even life itself in order to use is like the disappearing elephant. Something else is happening.

Understanding the power of addiction would help policy makers make better funding decision [sic] on research, and would better ensure that treatment providers get something real rather than magic when they put evidence-based interventions to use.

[Name omitted]
Region One Mental Health Center
Clarksdale, Mississippi

First of all, I find the comparison of evidence-based practice to a magic trick rather touching. Note that, to realise that the elephant hasn’t simply evaporated, one must “understand the laws of gravity”. Is the elephant suspended above us, or did it suddenly undergo gravitational collapse? And what about the problem of mass-energy equivalence?

More importantly, the writer draws a false analogy, to conclude that the apparent result of a scientific study was in fact an illusion. No evidence is provided for the specific claim, but the writer retorts that addiction is a permanent condition, because resisting the urge to use causes a “terrible feeling”. Well, I’m guessing I’m not the only one who has minor compulsions which create a “terrible feeling” if resisted – the urge to check one’s keys, for example. However, I don’t believe I will die if I resist, and I think most addicts would reject the suggestion that they continue to use because they think they would die otherwise. The ones who do think they might die are psychotic, and they have bigger problems to worry about.

If a scientific study shows reduced drug use in some users who are given incentives, why should we assume that “something else is happening”? And why must that “something else” necessarily be negative? Studies have shown that some people who attend AA meetings reduce their drinking. Should we be alarmed at this?

Further into the issue of Addiction Professional, there is an article called “The inadequacies of the evidence”, by Stuart Gitlow and Mark S. Gold. It’s somewhat longer than the above letter, so I won’t examine it in too much detail, but it basically contains the same opinions, attitudes, and “evidence”.

Under the sub-heading “Diagnosis”, the authors say a useful study should “reflect the currently accepted definition of that disease” [in this case addiction, or “dependence”]. They state that all published definitions include reference to continuing use of a substance despite negative life effects, and go on to say that in none “of the accepted definitions are quantity or frequency of use indicated as being essential for diagnosis”.

Here the authors are being disingenuous. In the DSM-IV-TR definition for Substance Dependence, amount or frequency of use is not strictly a criteria, but it is certainly implicit in these words and phrases from the criteria: “tolerance”, “markedly increased amounts of the substance”, “continued use of the same amount”, “taken in larger amounts or over a longer period”, “desire or … efforts to cut down or control substance use”, “great deal of time is spent … [using] the substance”.

Further more, in a clinical situation, quantity and frequency of drug use are diagnostic features that I’m sure even the authors have used. If someone comes into the surgery and says, “You have to help me, Doc! Alcohol is ruining my life!” and it turns out that his drinking consists of one brandy at Christmas, a sane, ethical doctor will not diagnose alcohol dependence, even though the patient matches what the authors have cunningly positioned as the essential criteria.

They then cite an “evidence-based” study that required “participants not only to be alcoholic, but also drink heavily and frequently”, and another study whose subjects had to “be alcoholic, have abnormal GGT (gamma-glutamyl transpeptidase) and MCV (mean corpuscular volume), and have at least five days of abstinence.” They then assert that “these studies investigated inadequately characterized subsets of alcoholics. It is difficult to state with validity and conviction that any such research is applicable to the broad population of patients with alcoholism.”

Again, it is difficult to know whether to take Gitlow (MD, MPH, MBA) and Gold (MD) seriously here. Are they really so unfamiliar with scientific method? Have they honestly never read a research paper before? Examining a narrow subset of a patient group is a common and useful method of clarifying results in any sort of research. And what do they mean by “inadequately characterized subsets”? Aren’t they rather trying to say that the subsets are overcharacterised?

It would take a lot of time and effort to go through the entire article paragraph by paragraph, so you will have to take my word for it that the rest of the article repeats these examples of misdirection, omission, distortion and misinformation.

I think Gitlow and Gold are either ignorant and incompetent, and therefore inadvertantly distorting the argument, or (which I think is more likely) they are deliberately deceiving their readership and playing on their ignorance. (Addiction Professional is largely aimed at professional counsellors – but in the United States, the word “counsellor” should not be taken to suggest any reputable psychological or medical training.) Certainly, the paradox of using false evidence to argue against use of real evidence seems to have escaped the notice of this publication’s editors, which suggests they are exactly the audience for which this article is written.

Fortunately, all is not lost. Later in the issue is an article called, “Decision support can enhance patient care”, with the sub-heading, “Use of research-based guidelines will compliment addiction professionals’ decision-making”. Admittedly, the author of this paper works for a company specialising in “decision support criteria tools”, so the profit motive is present as it always is in US health care discussions, but at least this means that evidence-based practice (and “evidence-based research” – what a phrase!) still stands a chance of broader acceptance, which ultimately means better care for patients.

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