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Faith in pharmacology

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Faith in pharmacology

Emperor’s New Clothes illustration from Wikipedia

Holy grails are few and far between. Pharmaceutical holy grails are no different. They are as rare as a moderate position in the Scottish independence debate. We have a few prescription drugs licensed to treat addiction and some make things significantly better, some have modest impacts, and some appear to have little impact. Regardless of impact, what a great deal of faith we place in molecules to manage complex bio-psycho-social problems like addiction – or depression for that matter. It looks as if our faith often exceeds the pharmacology.

I’ve been posting this week on what patients want from treatment and wondering if they are satisfied with what we give them. I also wonder how honest we are. How honest are we about laying out the impact of the medical interventions we offer? I’m a believer in opiate replacement therapy to relieve suffering and prevent harm, but I’m yet to work out how we integrate prescribing into recovery models effectively. Mike Ashton recently wondered if methadone’s ‘stickiness’ might be a liability for recovery. We certainly don’t have that sort of conversation with clients at the moment.

If we believe that patients want abstinent recovery then are we able to say that the way we ‘do’ methadone generally at the moment does not look like the best way to get there? How convinced are we about the ‘citizenship’ element of recovery in folk maintained on methadone? I’ve seen it happen – of course I have (work, family, wellbeing, quality of life) – but I’ve also seen something that I’m not sure I would settle for if it were me. I know this is complex and I know that what goes around the drug is crucial, but I am still concerned by the mismatch between expectation and what happens.

I’d like to see more discussion about where we could be doing better. On Addiction & Recovery News, Jason Schwarz highlights an illuminating meta-analysis on the impact of drugs to help patients achieve abstinence from alcohol. These are drugs which are commonly prescribed – certainly acamprosate and disulfiram (antabuse), but are patients told about how effective they are in reality?

While considered by many to be the highest form of  evidence, meta-analyses are not without their methodological problems, but even considering this the outcomes are disappointing.

One way we can illustrate how effective an intervention is at getting a result is by counting ‘numbers needed to treat’ or NNT. How it works is like this: if we have an antibiotic that cures a skin infection in 100% of cases then the NNT to get one positive outcome is 1. If the antibiotic is only effective in one in three cases, then the NNT becomes 3. In other words you have to treat three people to get one cure. Good interventions are in this range of 1-3.

Researchers looked at the effectiveness of acamprosate in helping people stop drinking altogether. Acamprosate is a drug which may help with craving for alcohol. They found that to keep one person abstinent from alcohol at 3 months of treatment, you had to treat 12 patients. The number of people (NNT) was 12. For naltrexone, which can reduce the desire to drink, NNT was 20.

They looked at disulfiram, or Antabuse, (in terms of helping achieve sobriety) and found no benefit, something that surprised me. There were modest impacts on reducing heavy drinking for people on naltrexone when they went back to drinking.

Now back to the question of faith in medication, despite limited efficacy. We live in a world where we expect almost supernatural outcomes from drugs. In the Addiction & Recovery News blog, Jason Schwarz makes the point:

You’d think that success rates of 5% to 8.3% (over the relatively short period of 12 weeks) would be pretty disappointing, right? If you agree, you and I appear to be in a tiny minority.

In the last 24 hours, Time, the NY Times, NPR, Huffington Post, CNN, Fox News, and many others are posting articles under headlines touting their effectiveness, their underuse and the “Best Meds for Alcohol Dependence Revealed”.

There’s a good discussion thread following the Addiction and Recovery News article with fair points being made about the reliability of the findings, and the challenges of treating addiction generally, but even if the numbers turn out to be a bit better than they seem they are still very disappointing. It’s very typical of the press to take the researchers’ conclusion that we are not prescribing enough and run with it without engaging the critical part of their brains. I was interested that although the study made a splash in the USA, it didn’t really travel much across the Atlantic.

I’d say that there is something of the Emperor’s New Clothes about this faith in pharmacology. I’d say it can blind us a bit. Medications are certainly easier to research than complex psychosocial interventions and the danger is that we end up with an unbalanced evidence base weighted towards medical interventions and light on recovery. It’s easy to think that recovery can’t be trusted or is dangerous when nobody’s done the research.

If we encourage our clients to trust in medication to do the work at the expense of doing the tough job of behavioural change, then we let our clients down. Too high a faith in pharmacology is disempowering. It’s not that medication doesn’t make an impact; it clearly does. My worry is that we place too much belief in medication and this may cause us to miss out on the otherwise rather obvious fact that recovery from addiction does not take place primarily because the prescription is right. While many recovering people can identify the part that prescribing played and are grateful for it, we don’t often see clients coming back to their prescribers saying “I want to thank you because your prescription was just right and because it was great it met my pharmacological deficits and I got into recovery.”

No, what they will say is “Thank you, you were great. You helped get me on my way, you connected me up to the right people and assisted me to sort out my problems. You had time for me and you listened to me. You supported me and believed in me.” That’s more efficacious than any drug.

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    5 Responses to "Faith in pharmacology"
    1. Your post brought this to mind:

      I listened to a talk by Dr. Kevin McCauley this morning in which he addressed objections to the disease model. One of the objections was that the disease model lets addicts off the hook. His response was that, given the cultural context, there were grounds for this concern. BUT, the contextual problem was with the treatment of diseases rather than classifying addiction as a disease. He pointed out that our medical model positions the patient as a passive recipient of medical intervention. As long as the role of the patient is to be passive, this concern has merit. He suggests we need to expect and facilitate patients playing an active role in their recovery and wellness.

      Also, your comment on my blog included this sentence, “We have bewildering faith in medications to solve complex disorders.”

      One of the things that was so striking abut that sentence was that, I think, when we’re talking about a complex disorder, our culture believes a medication is exactly what is called for. We have a lot of faith in medications in general, but we have even more faith in them for complex disorders. Why? (That was rhetorical. Not asking you to respond, unless you want.)

      Great post! Have a good weekend!

      • djmac says:

        I think the old, paternalistic medical model did suffer from the expectation that passive patients received treatment from experts and that this treatment was heavily weighted towards pharmacological interventions. At some point I’ll take a proper look at Mark Litt’s paper on the impact of referral to supportive social networks. It was a randomised clinical trial and found a 27% reduction in relapse to drinking in those who’d added one sober person to their social network. When you compare that to the apparent impact of naltrexone and acamprosate, then you might expect that the media would be effervescing about such a low cost and apparently effective intervention. They didn’t, they aren’t and it’s because one is a tablet and the other a psychosocial intervention. Our faith is in one and not the other and I agree, the more complex the problem the more we seem to strive to find a simple solution like a tablet for instance.

    2. Jo says:

      Its doesn’t have be an ‘either, or’, and it is possible to run the medical model & psychological model in an integrated practice model. There are some mental health conditions that fundamentally need medicating, or a person may choose to follow a medicated managed recovery route consisting of their chosen medication which works for them. We don’t have to view this subject through a polarised fixed discourse as its not very helpful, people are individuals with different needs. Everything you mentioned, social networks, behavioural change and other recovery assets can still be acheived if people take medication, I see it on a daily basis. Of course it would be ideal if everyone could get well from addiction and prosper in recovery without the need for medication but that is not a realistic, and for some not a safe possibility.

      Best Wishes
      Jo

      • djmac says:

        Thanks for commenting. I’m not advocating an ‘either or’ approach, but an honest approach where we don’t lionise medication or expect too much of it. In essence, to see it as a tool in the toolkit. My impression is that the tendency is to over-medicate, not under medicate (look at trends with antidepressants, ADHD drugs, analgesics). That doesn’t mean we throw the baby out with the bathwater, I would not want anyone to miss out on treatment that would help them, but my point is that we do seem to have great faith in drugs to sort out complex problems and we ought to be mindful of this tendency.

    3. Chrisw says:

      DJMAC, When you say there’s a tendency to over-mediate and not the reverse, let’s not forget that there’s a racial component at work, especially when we’re talking about pain medicating chronic pain. Studies are pretty consistent with this finding.
      Karen O. Anderson, et al. Racial and Ethnic Disparities in Pain: Causes and Consequences of Unequal Care. In The Journal of Pain. December 2009. Vol. 10. No. 12. Pp. 1187-1204.

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