Tuesday, February 23, 2016

Either/or Thinking about Opiate Addiction

An article about "Rehab Rooted in Science" in this morning's New York Times provokes me to rant about one of my pet peeves - either/or thinking about complex medical problems and grouping those who disagree into opposing "camps."

The story describes how Dr, Mark Willenbring, a psychiatrist specializing in addiction treatment, became frustrated at the limited uptake of medication-assisted treatment of opiate addiction, which, according a review of evidence in last year's Harvard Review of Psychiatry, doubles the likelihood of obtaining abstinence.  Dr. Willenbring started his own treatment center, at which he makes extensive use of medications that reduce cravings and help many patients achieve stable abstinence.

The NYT article quotes a counselor who favors abstinence - treatment without medications - as follows:
"Substituting one drug for another is an external solution for an internal problem. [Dr. Willenbring’s approach]  deprives his patients of the opportunity to have a full range of emotional experiences, a change of spiritual perspective and a return to an improved quality of life."
Unless there's rigorous evidence for this view - and there isn't - it's an irresponsible symptom of either/or thinking. It should be a no-brainer that treatment for opiate addiction should combine medications, psychotherapy, 12 step programs like NA and AA, and more, in whatever combination seems best for a particular patient.

When I first entered psychiatric practice I was puzzled when people asked me what "camp" I followed. Was I a Freudian? A Jungian? A medication-oriented psychiatrist? Just what was I?

Sometimes I tried to explain why I thought the question itself was misguided. Sometimes I was provocative - I remember saying things like "if standing on my head and spitting wooden nickels helped my patients get better, that's what I'd do." But if I felt that the person I was talking with needed to put me in a "camp," I said I was a follower of Dr. Adolph Meyer, a distinguished early 20th century psychiatrist who embodied balanced thinking, and whose articles were published as The Commonsense Psychiatry of Dr. Adolph Meyer.

I assume that our earliest ancestors developed "us versus them" thinking as a way or consolidating their tribe. We still see all-too-much tribal thinking all across the globe. Medicine should set an example of thoughtful gathering of evidence, respectful discussion of alternatives, and steady improvement in what we have to offer. Either/or thinking and clumping ourselves into warring camps may give us a "high," but should not be part of our efforts to deal with as difficult a problem as opiate addiction!

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