Alternatives to leverage

17/09/14 4:44 PM

Other models to encourage change when facing addiction


As anyone who has turned to the Web and typed in “addiction treatment” knows, there is an ever-growing number of options that promise a cure. These range from doing nothing, to medication management, to insight therapy. The wide variety of methods may puzzle the reader who wonders why there are no “best practices” or a commonly agreed-upon professional approach to treating addiction.


The reasons for this lack of standards are threefold:

  • Unlike other areas of medicine, claims for success are completely unregulated by the FDA, FRC, or health department. So it’s a buyer-beware, anything-goes market.
  • No established criteria exist for evaluating treating outcomes.
  • Most addicts do not want to stop and so go to treatment that lacks rigor or effective protocols, despite marketing claims to the contrary.

In fact, there is a best-practices model, and that’s the therapeutic leverage approach (modeled after the physicians’ program), which we described in last week’s blog.


That blog also briefly reviewed the accepted medical view that addiction is, in part, a disorder of the autonomic nervous system where the urge to use occurs at the unconscious, limbic level. That’s the “loss of control” addicts experience over how much and when to drink or take a pill. We also discussed the lack of motivation to seek help and remain treatment-compliant for the many months needed to achieve stable sobriety.


So in thinking about other approaches, consider how they address these hallmarks of addiction:

  • lack of control at the unconscious level, and
  • lack of perception and motivation to seek help and comply with treatment recommendations.

Then evaluate how each one manages these concerns in comparison to the leverage model.

Doing nothing

Waiting until the addict wants help

Many families prefer not to use coercion (leverage) because they fear a negative response from the addict or want recovery to be the addict’s “choice.” However, because the addict’s disease results in the compulsive and harmful use of alcohol or drugs (see above), you will be waiting a long time for this “choice.”


Here is what a leading authority has to say:


A myth is that the addict must be motivated to quit – that, as it is often put, “You have to do it yourself.” Not so. Volumes of data attest to the power of coercion in shaping behavior. With a threat hanging over their heads, patients often test clean.

Sally Satel, M.D. “For Addicts, Firm Hand Can Be the Best Medicine.” The New York Times, Aug. 15, 2006.


Even after explaining how we apply the physician model to other groups and their success rates, some parents are reluctant to use pressure, saying,


“My son/daughter will be so mad, s/he will never talk to us again.”


Anger and rejection are transitory threats made by the addict to preserve the status quo. A good counselor will help you manage these responses (and take some of the heat).


Without leverage, all the love in the world will not sustain recovery. (By the way, we do advise using leverage or the implied threat of leverage in a respectful and loving manner.) But doing nothing and waiting for a serious enough consequence is not an option. The risks are too great.


‘Letting go’

Common practice from Al-Anon, therapists, and counselors is to tell family members and their advisors to “let go” and not try to affect or “control” an addict’s use or recovery. This is not a successful recovery model because the addict is often suffering serious economic, emotional, and physical harm, with the attendant damage to family members, particularly children.


For the affluent, dangerous use can go on unabated, with few consequences, until late-stage alcoholism, overdoses, or nonstop use.


In our view, letting go or waiting for the addict to choose to enter treatment is, in fact, neglect because addiction – by definition – is loss of control over the decision to drink or drug.


Letting go does not honor autonomy because, at some point, the autonomic, unconscious part of the brain will override any vows to stop.


As one beneficiary said to me, “How come nobody tried to help me when they could see I was way out of control?”, after 20 years of hard use. 

Medication management

Craving-reduction medication

Naltrexone is an anti-craving drug designed to help alcoholics reduce their alcohol use and to prevent relapse. It can be helpful, but only as part of a comprehensive recovery program; it is not sufficient on its own to lead to stable recovery. If used, it needs to be combined with effective treatment.


Substituting one drug for another

Several well-advertised treatment programs substitute benzodiazepines (e.g., Xanax and Klonopin) for alcohol and hard drug use. These prescription medications are known as “alcohol in a pill” and users are simply swapping one addictive substance for another.


Similar considerations apply to “herbal remedies,” such as ayahuasca and rue seed, which are touted to cure addiction but affect the same areas of the brain as other hard drugs.


Suboxone is given as an alternative to opioids, such as OxyContin, because it results in a lesser high and stays in the body longer. Similarly, methadone is prescribed as a substitute for heroin. The problem is that users are just as dependent on the substitute drugs and will usually return to their former drugs when available. Another huge concern is that there is a large resale market for the substitute drugs because prescriptions are loosely monitored.


Anti-use medication

Drugs such as Antabuse have been used since 1951 to help people stop drinking by making you sick to your stomach if you have a drink. If you know you can’t drink, then you won’t think about drinking as much. This is an example of an external control designed to remain in place until the person develops sufficient internal motivation to achieve recovery. The problem is that many people on Anatabuse stop taking it or drink while on it and never reach the next phase.

Insight-based therapy vs. stopping the addiction first

Some therapists and treatment centers believe the addict needs to resolve the underlying conditions (i.e., the mental health, social, or other factors) leading to addiction before recovery can take place.


This belief is completely incorrect, not supported by research, and views addiction as a disease secondary to the underlying issues.


Addiction is a primary disease that needs to be addressed first, in that the addict needs to be detoxified and in the first stages of recovery before delving into the “drivers of addiction.”


I know addicts who see their psychiatrists two or three times a week for years and never stop using drugs. (Nothing better than an addict with money to keep on paying for therapy!) Addicts will give 100 reasons why it’s hard for them to stop and claim that if they can just get them resolved or gain more insight, the problem will be solved. This is all part of their smokescreen to keep on using.

Moderation management

This approach is designed to help people reduce their drinking (or drugging) to a manageable level where they are no longer binging. The goal is to still enjoy a beverage or a pill without the hangover or negative impact on work or relationships and to socialize without the stigma of being a non-drinker or – God forbid – an alcoholic.


If a person truly has a substance use disorder and the attendant brain change, it’s nearly impossible to exercise the control needed to maintain reduced use. This means at some point, there will be a return to prior use levels and that can be very dangerous, depending on when and where it happens.


Let’s face it: People drink to get a buzz on. So it’s no fun only to have a drink a day. (Or maybe it is, depending on the size of the drink.) Many “restrictors” are unpleasant to be around because their bodies “thirst” for that next drink, and the amount of willpower needed to stop at one makes them angry and bitter (i.e., “Why did God take away the only pleasure I had in life?”).

Assessment/evaluation model

This model is based on the idea that there is unsettling conduct, behaviors, or emotions on the part of the loved one, but uncertainty as to what may be the cause. So the person of concern is asked to obtain an evaluation or assessment – either outpatient or inpatient – to get a better picture of what is going on. Great idea, but your loved one has to agree, and then there is the debate about the type of evaluation, where it should be held, and who will be sent the results.


This segues into another phenomena: the addict who goes to treatment intending to stay awhile and then being “discharged” before completion, either due to disruptive behavior or leaving AMA. The addict is changing the attitude of his/her parents by ostensibly complying with their wishes but really is only going through the motions, with no intention of doing the internal, emotional work that recovery requires.

Drug testing

The success of all of these models is dependent on addicts being truthful about their use. As addicts lie, the only way to know what drugs are being taken is through drug testing with a competent service. Most users these days are taking multiple drugs but may only admit to one or two less-serious ones – alcohol and pot, for example – when they are also on benzos and ecstasy. Drug testing is a change technique in that it provides information about what is really going on, so the family and the user are on the same page. Also, drug testing, when combined with these various models, should lead to better results – either showing the need to intensify efforts or move to a more leveraged approach.

None as successful as leverage

None of these strategies is as successful as the leverage-based physicians model. Without the help of family and friends, the addict will continue to suffer as the disease progresses.


For families, the options are not leverage or choice – they are leverage or neglect.


Your addict needs encouragement to seek help, and this requires working with a qualified counselor to strategize and create a plan to address and manage the disease over the long term.


Our next blog will detail the benefits and fine points of using leverage.

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