Walk Away from Temptation

The singer Paul Simon's composition, "There Must be Fifty Ways to Leave Your Lover," also holds true for leaving your addictive substances. If you ask a group of people who've gotten free of the monkey on their back what they do when they feel a craving coming on, you'll wish you knew shorthand to write down all the different solutions that work for somebody. "Take a deep breath!" "Count to 100." "Call a sober friend." "Go to a meeting." "Drink a glass of cold water." "Touch your sober talisman." "Do a meditation." And so on.

Now comes a roundup of studies in the New York Times -- thanks, Dr. Joe Mott for pointing me to it -- highlighting evidence in favor of one of the simplest ways to leave your demon: walk away. A series of studies completed in the past five years demonstrates the empowering effect of locomotion. A brisk but not strenuous walk of as little as 15 minutes enabled study subjects to turn their backs on substances they craved.

Why does walking work? The Times' science writer doesn't try to answer. Three hypotheses come to mind immediately: endorphins, distraction, and Aristotle.

Exercise, as is well known, causes the body's glands to manufacture and release endorphins. Endorphins are often called the body's own morphine; they are native opioids that take away pain and make you feel good. If you've seen the smile on the face of a bicyclist or a runner, you've seen a natural endorphin high.

So, taking a brisk walk as a device for rejecting an external drug makes sense on the theory of substitution. You allow the soft hand of your inborn neurochemistry to scratch your itch instead of the bloody claws that some liquor company, tobacco cartel, or other drug syndicate has cooked up to ensnare you. Substitution of a harmless, wholesome gratification for an addictive fix is a basic recovery strategy with a very wide range of applications.

But endorphin substitution may not be the whole story, or may not be the story at all. People vary in their rate of endorphin production, and the studies in the current report don't include blood samples that measure endorphin levels. Daniel Goleman, the brilliant popularizer of the Emotional Intelligence concept, highlights the famous marshmallow experiment, destined to take its place alongside Pavlov's dog as one of the foundational studies in psychology.

The experimenter puts a marshmallow on a dish in front of a child and says that he, the experimenter, must leave the room for a few minutes. The child is free to eat the marshmallow; but if the child waits until the experimenter returns, the experimenter will add a second marshmallow, and the child can have both.

In the original study, the children who ate the one marshmallow ended up, years later, dropping out of school, stuck in low-wage jobs, in trouble with the law, divorced, etc., while the children who resisted and waited for the double reward became valedictorians, chief executives, senators, etc. (I exaggerate wildly, of course, but that was the general drift of the results.)

Goleman's follow-up studies tried to find out how the children who waited for the two marshmallows were able to resist the marshmallow sitting in front of them. His results threw out various genetic and characterological hypotheses. Resisting the lure of the sugary treat, he found, is a teachable skill. The children who succeeded did so by distracting themselves. They took their eyes off the item and played some game or walked around the room. In short, they derailed the train of craving by setting their minds busy with some other concern. Goleman concluded that any child could learn to do this, vastly increasing their chances of success later in life.

So, the effectiveness of walking may be due partly or even wholly to the distraction effect. We set our minds to working our legs, keeping our balance, choosing a path, managing our breath, and all the other efforts required for effective ambulation, and in the process the craving fades away in the rear view mirror.

Then also, there's Aristotle, one of the ancient founders of the scientific method. Aristotle, not being an Athenian, could not own property there, and therefore taught his followers on a public walkway. His philosophical school came to be known as the Peripatetics -- the walkers. Ever since, walking has become linked in legend with stimulation of the inquisitive, analytical mind.

Why this should be so, if it is so, remains hazy, but we know that the mind and the body are a unity, and no one should be deeply surprised that ambulation might stimulate cogitation. And rational thinking certainly would lead one to avoid putting addictive substances into the body.

Does walking help avoid cravings because of substition? Or because of distraction? Or via the Aristotle effect? Or all the above? We don't have the answers yet. But we don't need to know why something works in order to benefit. For decades, doctors didn't know why Aspirin or acupuncture worked to relieve pain, yet both helped millions. Perhaps you can cogitate on the reasons as you amble.

Next time you feel a craving coming on, walk away from it. It works!

[Originally published in hellowellness.in]

Motivating Motivation

[Originally posted on hellowellness.in on Oct. 29 2010]

Everyone concerned with addiction recovery knows the importance of motivation.  As Darlene, a heroin addict portrayed in Dr. Lonny Shavelson’s wonderful book Hooked, tells her psychiatrist, “You can talk at an addict until you’re blue in the face, but if they don’t want to get clean, they’ll tell you to f**k off.”  Almost every treatment modality works if the patient is motivated;  nothing works at all if the patient isn’t.  

A group of counselors and researchers grouped under the umbrella label of Motivational Interviewing has been working for a couple of decades on cracking the secret of motivation, and they’ve shown a series of positive results.  Their latest success comes in the highly challenging area of weight loss.  

Weight control is probably more difficult than getting free of alcohol and other addictive drugs because abstinence is not an option.  You can very well live without alcohol and other addictive drugs, and abstinence creates a bright line that can guide your every step.  But you can’t live without food, and threading your way through the maze of conflicting nutritional advisers can defeat the most dedicated mind.  

Doctors, the researchers noted, frequently talk to their patients about weight.  But how the doctor talks to the patient makes a crucial difference.

Doctors who assumed the traditional role of authority, who used a confrontational approach, who appeared to judge the patient, or who pushed unasked-for advice, had no positive effect whatsoever on patients’ motivation, the study found.  Their weight was almost exactly the same as patients whose doctors never raised the issue with them.  In other words, doctors who used the conventional authoritative approach were wasting their time.  

By contrast, doctors who used an approach based on Motivational Interviewing fired up their patients’ motivation, and such patients registered a weight loss of 3.5 pounds at follow-up three months later.

A basic principle of Motivational Interviewing is that real change in feeling and behavior can only come from the patient, not from the doctor.  The key to success, therefore is to elicit and to support the patient’s own inner desire to change.  The doctor accepts the patient’s shortcomings without judgment.  The patient’s successes, no matter how small, merit recognition and praise.  The physician does not pose as an authority, but as an ally and collaborator.  

Dr. Kathryn Pollak, Ph.D. of Duke University, lead author of the study, commented that the physician’s traditional role as expert dispenser of pills or advice has its utility in treating acute distress, but is ineffective in changing patients’ attitudes and motivating long-term, sustainable behavior change.  

“When it comes to behavior change, the patient is the expert, not the doctor.  The whole point is to help the patient solve the problem himself.  Doctors have to see the difference between behavioral counseling and the rest of their job,”  Dr. Pollak said.

The study appears in the October issue of the Journal of Preventive Medicine.

LifeRing groups are abstinence-based, but the Motivational Interviewing approach is deeply congruent with the LifeRing pathway to recovery from alcohol and other drug addiction.  The strategic pathway to recovery is empowerment of the sober self, which means recognition and support of the recovering person’s own inner desire to change.  I’ve written about this approach in detail in my book Empowering Your Sober Self, for those who wish to know more about it.

Pain Relief Without Addiction: Walking the Tightrope

[Originally published on hellowellness.in on 29 Oct. 2010]

Roger T., a middle-aged systems analyst, showed up at a LifeRing recovery support group looking for help with addiction to painkillers.  Years earlier he had been a passenger in an auto collision which left him with chronic pain in his lower back and hips.  His doctors had prescribed the standard opiates, and this had provided him with some relief, but over time he needed larger and larger doses.  He said he had been taking 300 Vicodins® per day.  He knew he had to stop the drugs -- but he couldn’t live with the pain.  

Not only patients but also their physicians have to walk a tightrope between pain and addiction.  A hot case in point is the jury trial involving Dr. Sandeep Kapoor, the 42-year old Hollywood internist and physician to celebrity model Anna Nicole Smith.  Smith died of a drug overdose in 2007.  Dr. Kapoor and two other defendants were not charged in her death -- this was ruled accidental -- but were charged with conspiracy to provide her with excessive quantities of pain medications while knowing she was an addict.  

In other words, Dr. Kapoor was charged with crossing the line from medical helper to drug pusher.  It’s an issue that inflames hundred-year old wounds on the U.S. medical community.  With the passage of the Harrison Act in 1914 and regulations and court decisions shortly thereafter, the federal government severely limited physicians’ professional freedom to prescribe analgesic medications.  They could prescribe opiate painkillers only in tapering doses, and their good faith professional medical judgment was ruled irrelevant.  

In the following decades, the US Treasury Department indicted more than 25,000 physicians for prescribing opiates; some 3,000 went to jail, and more than 20,000 were forced to pay fines.  It was a shameful period, and it has left enduring scars on modern medical practice.  The California statute under which Dr. Kapoor was charged is a direct descendant of this period.  These laws have chilled physicians’ treatment of patients with chronic pain problems.  

The Harrison Act rested on paranoia about anarchists, radicals, criminals, and foreigners -- especially Chinese -- who were (wrongly) seen as the typical opiate users of their day.  Scratch any subscriber to what passes as public opinion in the US today and you’ll find, not far beneath the surface, a similar identification of drug users with social undesirables.  

All of that goes on the scrap heap when a celebrity is involved.  As everyone familiar with the criminal justice system in the U.S. must be aware, celebrities are above the law, particularly the law of addictive substances.  Lindsey Lohan, Mel Gibson, Paris Hilton ... all would be locked up for years if their names were Smith, Jones, and Johnson.  And so here.  With Anna Nicole Smith, a genuine neon blazing celebrity at the center of the trial -- even more dazzling a presence in death perhaps than in life -- the judge found ample justification for her possession, post mortem, of more than 1,500 pills.  In a phrase that will reverberate in courtrooms for years, Judge Perry T. Fine admonished the jury, "The number of pills is not a determinative factor in this case. Please keep that in mind.”  

The jury did.  After 13 days of deliberations it returned yesterday a verdict of “not guilty” for Dr. Kapoor.  It found, in other words, that Ms. Smith was not “addicted” and that Dr. Kapoor’s prescription of opiate painkillers was medically justified in view of her many and severe symptoms of pain and anguish.  

Dr. Kapoor still faces a lengthy process of rehabilitating his reputation and defending possible attacks on his medical license.  But he will not go to prison.  

With this courtroom victory, physicians who specialize in the difficult art of pain management -- a small and endangered species -- will breathe a long overdue sigh of relief.  

Most of these physicians are members of the American Society of Addiction Medicine (ASAM), a highly respected and conservative professional body of providers who more or less successfully navigate the tightrope of giving pain relief without enabling addiction, every working day.  

But  there is also a fringe element of medical opportunists who will prescribe whatever the patient asks for, so long as the check is good.  And there are well-intentioned general practitioners with zero schooling in addiction medicine whom the experienced opiate addict plays like a violin.  

There are no easy answers to pain.  I have had conversations in LifeRing meetings with a number of people like Roger T. who suffer from chronic pain, medically managed with conventional opiate-based pharmaceuticals.  They tell me that they have learned to recognize when they are crossing the boundary from pain relief into seeking euphoria.  Unfortunately that insight came only after multiple boundary crossings with harmful consequences.  I have also talked with chronic pain sufferers who have found relief through hypnosis, meditation, special exercises, nutrition, and other alternative approaches.  Pharmaceutical research is also hinting at new types of analgesics that do not involve the classic addictive brain circuits, as the opiates do.  

Obtaining pain relief without falling into addiction is one of the most difficult challenges for professional and patient alike.  One thing seems certain.  There will be more progress if this problem is left in the hands of providers and patients, without massive interference from uninformed legislators and political appointees, frequently with demagogic motives.  To that extent, the jury’s verdict freeing Dr. Kapoor is an important step forward, and Judge Fine deserves recognition for a well-reasoned set of jury instructions.

If Alcohol Were Invented Today

[Originally posted on hellowellness.in 29 Sept 2010]

The word 'alcohol' was coined around 1540 by an Arabic chemist to describe the fine powder, or 'kohl,' used to stain or paint the eyelids.  Two centuries later, British writers borrowed the word to describe the intoxicating essence of wine -- an ironic twist, since the original Arabic chemist was very likely a Muslim and, as such, forbidden to drink it.  

If alcohol were invented today, international law would class it with the controlled substances, alongside opium, heroin, cocaine and the like.  The World Health Organization (WHO), in its most recent comprehensive report, writes:

Alcohol is a psychoactive substance with a known liability to produce dependence in humans and animals. If considered in the frame of the 1971 Convention on Psychotropic Substances, alcohol would qualify for scheduling as a substance that “has the capacity to produce a state of dependence, and central nervous system stimulation or depression, resulting in hallucinations or disturbances in motor function or thinking or behaviour or perception or mood”, and for which “there is suffi cient evidence that the substance is being … abused so as to constitute a public health and social problem warranting the placing of the substance under international control.”

The propensity to produce "dependence" -- a bland synonym, in this context, for the more controversial term "addiction" -- is the red flag that sets apart this relatively small class of drugs, including alcohol, from the millions of other known chemical compounds.  They are addictogenic.

The exact molecular mechanism of addictogenesis is still the focus of scientific investigation in several countries.  But the fact of its occurrence is beyond dispute.  The WHO report says, "The direct actions of alcohol on the brain and sustained alcohol exposure lead to longer–term molecular changes in the brain known as neuroadaptation."  That is, a number of neural pathways in the brain are altered to form a strongly self-reinforcing habitual behavior pattern that leads to adverse consequences for the organism.  

Among the pathways by which alcohol enters the brain is the brain's indigenous opioid system -- the same doorway by which the opiates such as heroin and codeine pass into the neural network.  

Wherever alcohol is introduced into a country on a large scale, there one finds the rise of alcohol addiction (alcoholism).  The WHO world surveys find a strong correlation between the level of alcohol consumption in a country, and its prevalence of alcohol dependence.  Statistically, more than three quarters of the dependence rate is correlated with the level of consumption, and this trend is even stronger in "developing" countries, among which the WHO report specifically names India.  

Alcohol marketing generates alcohol use.  Alcohol use generates alcohol addiction.  Alcohol addiction then sustains the alcohol market. 

In any country where alcohol use has become established, writes the WHO, a small minority of drinkers consume the bulk of the alcohol sold.  "A typical finding is that half of the alcohol consumed is consumed by 10% of the drinkers."  In the U.S., some reports indicate that 10 per cent of the drinkers drink 80 per cent of the alcohol.

Imagine, then, that by some magic pill you could  convert the 10 per cent into non-drinkers.  The alcoholic beverage market would crash more profoundly and disastrously than the mortgage and financial markets in our recent meltdown.  

The alcoholic beverage industry worldwide is absolutely built on alcohol addiction.  One has to say it; there is no way to sugarcoat it.  

Recently, after I outlined these economic facts to a person newly in recovery from alcoholism, she exclaimed, "But that's so illogical!"  

Of course, it's utterly illogical.  We have grandfathered alcohol and tobacco into the category of legal substances, even though the combined death toll from these two drugs is perhaps 15 times greater than the toll from all of the drugs proscribed as illegal.  

So, we have prisons full of people caught using or selling negligible quantities of drugs whose total impact on society is relatively small, while the pushers of mega-quantities of lethal addictive substances that kill as many people each year as die in major wars, floods and earthquakes sit in luxurious offices with princes, prime ministers, and police chiefs on their speed dials.  

Meditation can provide lucidity at times of mental turmoil.  My friend who exclaimed at the illogicality of current addiction policy became agitated and, for a while, I feared that the mental stress would tilt her toward relapse.  I suggested meditation, and she calmed down.  The next day we met and I asked for her thoughts.  

She said that after thinking it through, she was more determined to remain free of addictive substances than ever.  Said she, "I don't like being used."

The Drive to Thrive

[Originally published Sept. 4 2010 on hellowellness.in]

The great majority of young people who experience the death of a parent, divorce, emotional or physical abuse, substance abuse, mental illness, developmental disabilities, and similar ordeals end up OK.  They recover, form healthy relationships, have good marriages, and become productive citizens. That, at least, is the finding of numerous studies in a diversity of cultures, summarized by the researcher Bonnie Benard at the outset of her book on Resiliency.  

I shouldn’t have been surprised.  I lost my father before I was born, I survived bombing raids, childhood malnutrition and diseases, numerous changes of home, several addictions, and I’m OK.  And I’m not alone.  I know lots of people with worse experiences who survived -- we all do.  

How did we manage?  What is the secret of our marvelous ability to spring back from adversity?  

Resiliency, writes the author, is a creature with four legs.  First, the resilient person is able to win approval from others.  Perhaps only from one other, but that is enough.  Second, the resilient person is resourceful, inventive, able to solve problems, to make and execute plans, and adapt to changed circumstances.  Third, the resilient person displays autonomy.  They are goats rather than sheep.  Finally, the resilient person has a sense of purpose.  It may be a spiritual or secular purpose, but it gives them a sense of orientation in space and time, a reason for being alive.

With this in mind, I reflected back on my experience in overcoming my addictions to alcohol and other drugs, and I began to understand more deeply how I succeeded in freeing myself from these shackles.

In my recovery from addiction, I participated in a support group network that systematically provides its members with social approval, the first leg of resiliency.  In these groups, the basic principle is that all participants have a sound and healthy core, which we call the Sober Self, and that our work consists of affirming and empowering that positive quality within ourselves.  In the jargon of social science, our groups are “strength-based.”  

I was surprised, early on, that nobody in these groups wagged a finger at me and told me what I had to do.  On the contrary, I was expected to figure it out for myself.  I was advised to think, to marshal my inner resources, to be inventive, to solve my particular problems, to make a personal recovery plan, and to adapt my personality to clean and sober living.  Motivated in this way, I developed the second leg of resiliency.  

My group work always aimed to enhance my power to survive as a clean and sober person outside the group.  I came to believe that the group was a useful support, and I enjoyed -- and still enjoy -- the fellowship and good humor that prevails within the circle.  But no one ever tried to make me dependent on the group, to substitute group addiction for substance addiction.  On the contrary, my group experience was and is a school for personal autonomy, the third pillar of resiliency.

Finally, my participation in my support group network restored to my mind a sense of purpose, mislaid somewhere during the depths of my addiction.  I began to feel that I was useful in some modest way to others who had been similarly lost.  I developed connections with other people, the key ingredient of a sense that one’s life has meaning.  

Thanks to Benard’s book, the secret of my recovery from addictions -- a journey which I thought impossible before I began it -- is no longer so mysterious. Benard writes that the qualities that make up resiliency are hardwired into the human makeup, and all that is required to foster more recoveries is to remove the barriers and enhance the protective factors for our innate drive to thrive.

Stiffness of the Mind

[Originally posted Sept. 4 2010 on hellowellness.in]

If the brain is like a muscle, then the onset of addiction is like rheumatism -- a growing stiffness and pain with movement.  That, at least, is the finding of a group of international researchers based in France, and published in a recent issue of Science.  

The scientists studied what happens in the brains of rats when exposed to various addictive substances.  Rats and scores of other species from the great apes down to tiny worms and fruit flies, can be turned into addicts by infusing their bloodstreams with the addictive substance.  Researchers either hook up the animals to intravenous tubes that inject the drug, or they confine the animals in a vapor chamber where the air is infused with the substance.  It doesn't take long before the animals display a set of behaviors and physiological symptoms that we humans know all too well, if we have alcoholics or other drug addicts in our family or friendship circles.

The fact that animals can readily be turned into addicts, by the way, is important evidence that it's the substance, and not some qualities in the person's psychology, that makes addicts of us. Despite the creative work of Walt Disney's animators, rodents don't have human personality profiles, and they probably don't suffer from spiritual maladjustment.  Quite a few theories blame the person's emotional and spiritual deficiencies for the onset of addiction.  The animal experiments teach that there's a neurobiological process at work.  The molecules in the substance are like so many little vandals in the brain, hammering, bending, mutilating and wrecking the intricate circuits of the most complex apparatus on earth -- one that we all carry between our ears.

What long-term use of the addictive substances does, the researchers found, is to decrease synaptic plasticity.  Synapses, of course, are the connections between brain cells.  Connections are the rails on which our thoughts and feelings run.  When we process a new experience, the brain cells rewire themselves to integrate the new elements into our existing web of ideas and emotions.  The power of brain cells to form new connections, their plasticity, is the foundation of all kinds of learning. A brain with high synaptic plasticity is like a body that's flexible, loose, limber, toned -- the kind we love to see jogging in the park or performing acrobatic feats on television.  

So, the next time you hear somebody use slang terms like "let's get hammered" or "stupid" or "stoned," take it as a neurobiological reality.  The chronic use of addictive substances such as alcohol, cocaine, etc. creates stiffness in the brain cells, even while it tends to take away men's stiffness elsewhere in the anatomy (but that's another story). A kind of mental rigidity sets in; the ability to learn and to adapt declines; the person's mind becomes unresponsive to new ideas and feelings.  Does this describe anyone you know?

[For more details, read Kasanetz et al., "Transition to Addiction is Associated with a Persistent Impairment in Synaptic Plasticity," Science 328:5986 pp. 1709-1712.

Genetics: DNA Causation Unravels

In several earlier posts here, I quoted from scientific journals reporting on the findings of modern genetic research -- or rather, the surprising absence of such findings.  For the first time ever, science has the tools to find out exactly where the genes are that we have long believed underly major diseases.  What the tools are telling us is that the supposed genetic causality isn't there, or it's much weaker than previously thought.  We can now say with confidence that the "alcoholism gene" does not exist; that the genetic contribution to alcoholism, such as it is, is spread over an as yet unknown number of genes, each of which has only a minute influence, and that this influence is profoundly mixed up with and moderated by environmental factors.
Now the current issue of Scientific American (Oct. 2010) reports similar findings for genetic research into a broad range of other diseases.  In its article, "Revolution Postponed: the Human Genome Project has failed so far to produce the medical miracles that scientists promised,"  the journal describes a growing realization in the scientific community that the old model of genetic science, where variations in specific genes cause specific illnesses, has very limited validity.    The journal quotes David Goldstein, director of the Center for Human Genome Variation at Duke University, one of the major research centers:

It's an astounding thing that we have cracked open the human genome and can look at the entire complement of common genetic variants, and what do we find? Almost nothing.  That is absolutely beyond belief.

Another researcher, David Botstein of Princeton, describes the effort to map disease-causing genetic variations as an experiment that had to be done in order to know that it did not work.  It was, he said, "a magnificent failure."

Walter Bodmer, a pioneer of the modern genomics research effort, says that the effort to find genetic variants that cause major diseases is a biological dead end.  "The vast majority of [common] variants have shed no light on the biology of diseases."

These findings are profoundly upsetting long-held beliefs about genetic causality and forcing scientists to rethink the whole model of what genes do.  The old model which saw DNA as a kind of computer program that determines the fate of the organism is out the window.  The processes are much more complex and involve a great deal more interaction with the environment than had been previously thought.

The takeaway for people who have serious issues with alcohol and/or other addictive substances is:  don't blame your genes.  Your genes are OK.  Your DNA will be just as happy, and very likely much happier, when you stop hammering your brain cells with addictive substances.

New criteria for addiction

The DSM -- Diagnostic and Statistical Manual -- defines the disorders that the psychiatric profession officially recognizes.  Where a patient has insurance coverage, the treatment professional needs to fit the client's issues into one of the recognized categories in order to obtain payment.  Thus the DSM is much like a statement of the law, which is why the making of each new edition of the DSM has been compared to the making of laws and sausages -- the less you see, the more you'll have respect. A participant in the making of the current edition, years ago, told me that it was like a smoke-filled room in old Chicago, with the loudest egos battering each other into submission. This year, the creators of the DSM-V have broken with that sordid tradition by opening a public window into the current state of the draft.  Dr. Nora Volkow, the director of the National Institute of Drug Abuse (NIDA) recently sent an email blast to just about everyone concerned with addiction to publicize the current draft and solicit comment.
I have been tied up with other work and have not had a chance to review the material.  Fortunately, LifeRing convenor Lloyd E. has stepped into the breach, and has composed the following comment, for which I am grateful to him:

Diagnostic criteria for the medical conditions commonly known as alcoholism and addiction will be significantly changed in the new DSM-5.  The Diagnostic and Statistical Manual of Mental Disorders  is produced by the American Psychiatric Association and is the standard diagnostic tool used by doctors and insurance companies.

The DSM-5 Substance-Use Disorders Workgroup is recommending that the currently separate categories of substance abuse and dependence be dropped in favor of a single disorder of graded clinical severity.

The DSM-4 used the terms “abuse” and “dependence” in an attempt to blunt the stigma of addiction, but they have proved untenable and misleading.  The term “dependence” is problematic because it encourages people to associate addiction to withdrawal symptoms rather than the obsessive nature of drug cravings.   And it is difficult to see why the word should be used for the ongoing condition of someone who is having success in recovery.  The term “abuse” has been criticized because it is a moral, not a medical, term.  And really, it is the addicted person who is abused, not the drug.  The new criteria will suggest a single continuum, instead of two discrete conditions.

The distinct diagnoses of substance dependence and abuse will be replaced by a single Substance-Use Disorder  with varying severity.   The disorder will have a subcategory for each of the popular drugs such as Alcohol-Use Disorder or Amphetamine-Use Disorder.

It is important to remember that the DSM is only a diagnostic tool.  It is not concerned with the biology or etiology of addiction. It does not preclude that specific biological changes may occur in the brain, but it bases diagnosis on behavioral criteria because the biology of the brain is not well enough understood and is not accessible to clinicians.

DSM-5 will identify Substance-Use Disorder as “a maladaptive pattern of substance use leading to clinically significant impairment or distress.”  The lists of manifestations previously given for abuse and dependence will be combined into one list.  If a person manifests two or three items, a diagnosis of “moderate” Substance-Use Disorder is given.  For four or more, the disorder qualifies as “severe.”  The presence of cravings, or strong desires use a specific substance, is proposed as an additional manifestation not present in DSM-4.  For those in recovery the disorder is characterized as being in various stages of remission from Early-partial to Sustained-Full remission.

The APA is soliciting comments until April 20, 2010.  The DSM-5 will be published in May 2013.

Substance-Use Disorder:

A.  A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period: 

1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) 

2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) 

3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

4. tolerance, as defined by either of the following: 

a.   a need for markedly increased amounts of the substance to achieve intoxication or desired effect 

b.   markedly diminished effect with continued use of the same amount of the substance

(Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)

5. withdrawal, as manifested by either of the following: 

a.   the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances) 

b.   the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

(Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)

6. the substance is often taken in larger amounts or over a longer period than was intended 

7. there is a persistent desire or unsuccessful efforts to cut down or control substance use 

8. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects 

9. important social, occupational, or recreational activities are given up or reduced because of substance use 

10. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance 

11. Craving or a strong desire or urge to use a specific substance.

Severity specifiers:

Moderate:  2-3 criteria positive

Severe:  4 or more criteria positive

Specify if:

With Physiological Dependence:  evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)

Without Physiological Dependence:  no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present) 

Course specifiers (see text for definitions):

Early Full Remission

Early Partial Remission

Sustained Full Remission

Sustained Partial Remission

On Agonist Therapy 

In a Controlled Environment

 For more details, click to the APA Call for Comments site.

Goodbye Genetics, Hello Epigenetics

For the first time in history, science now has tools that can definitively answer long-standing questions about the role of genetics as the cause of diseases.  So far, the results have been devastating for believers in genetic causality.  The better we can see, the less genetic causality we find.

I've previously summarized the minimalist findings of modern genetics research for a number of psychiatric disorders, including addiction, here and here in this blog, and in my book, Empowering Your Sober Self.

Now comes another blockbuster study, this time of schizophrenia, a disease commonly believed to have a strong genetic component.  According to the November issue of Scientific American, summarizing a recent report in Nature, "three crack teams of investigators pooled genomic data from 8,000 schizophrenics of European ancestry but could lay claim to only a handful of weak genetic risk markers."

By contrast, says the same article, epidemiologists have been able to find significant correlations between schizophrenia and environmental and cultural conditions.  Growing up as an immigrant or as a racial minority in a big city, particularly in densely populated and troubled neighborhoods, is a significant risk factor for the disease.

These studies have given a boost to the field of epigenetics -- the study of how environmental conditions evoke or overwrite genetic predispositions.  The primitive notion that our DNA is our destiny is giving way to the understanding that our genes do nothing until they are activated.  Environmental conditions (including not only the chemicals that enter our body but also the decisions we make, the people we hang with, and the stress we undergo) determine whether a gene gets turned on or off.  Our genetic array is like a keyboard, and our interaction with the world governs what melody gets played on it.

By coincidence, a recent issue of Counselor, the magazine for addiction professionals, features an article, "Epigenetics Has Come to the Addiction Field," by Mike Taleff, Ph.D.  Taleff's main point is that it's not genetics that makes a person an alcoholic or other addict.  It is the repeated consumption of alcohol and other drugs that programs a person's genetic material to crave the drug and prioritize its consumption.

This epigenetic understanding, says Taleff, can help a recovering person shed some common myths, such as the belief that "they are somehow morally, bad, defective, or otherwise flawed.  Often, this kind of thinking gets in the way of recovery."  Epigenetics teaches, by contrast, that becoming addicted "has little to do with your moral character."  Addiction is a result of the programming that addictive substances perform on your brain.

Many questions remain to be settled before science can claim that we have a comprehensive understanding of the causes of addiction.  But progress is being made.  For decades, addictionology was stuck in the belief that the alcoholic/addict's disorder was genetically programmed. Thanks to the enormous strides made by genetic science in the past decades, with the deciphering of the human genome and the subsequent advances, we can now say with considerable certainty that genetics supplies only a weak explanation at best. Now we need to turn our eyes toward the epigenetic factors:  environment, culture, and above all the neurochemical properties of the addictive substances themselves.

Choice Theory Conference

It was my privilege yesterday to attend the Choice Theory Education Conference at the Hilton in Sacramento. I staffed a LifeRing literature table there, met with LifeRing convenors and future convenors, attended some of the sessions, and met some of the leading figures in the choice movement.

Georgellen Hofine, one of the oldest students of Choice Theory founder Dr. William Glasser (photo), personally welcomed me to the gathering. LifeRing keynote speaker and DVD author Dr. B. J. Davis was the closing speaker on the conference program, and I much enjoyed listening to his presentation and chatting with him informally.

Choice Theory advocates Resa Stendel Brown and Jack Harnden spoke about the application of Choice Theory in education. Author Mike Rice gave a talk on addiction. B. J. Davis, in addition to his own discussion of Choice Theory in addiction treatment settings, introduced a DVD showing how Reality Therapy (an earlier name for Choice Theory) was applied in a prison setting.

I took time out to meet and chat with convenors of the LifeRing meetings in Placerville and one of the Sacramento locations. One of the conference participants expressed determination to start a LifeRing meeting in Lodi. Two of the treatment professionals in attendance spoke of plans to start LifeRing meetings at their centers in the Sacramento area.

It was a very positive crowd, including quite a few people with an interest in addiction recovery, and I should have brought more books, as Empowering Your Sober Self sold out by noon.

The only shadow over the event was the news that Dr. Glasser himself, who had been scheduled as keynote speaker, had been admitted to the hospital with a cardiac issue. There is as of this writing no further news on his condition.

Don't drink that marshmallow

The marshamallow experiments are famous by now, thanks in large part to Daniel Goleman's Emotional Intelligence books, and their relevance to addiction seems obvious.  In 1968, Stanford psychology prof Walter Mischel presented four-year olds with a marshmallow and the choice: Eat it now, or wait 15 minutes and get two.  The kids who could delay the gratification ended up, a decade and more later, with higher SAT scores, higher graduation rates, better jobs -- in short, twice as many of the marshmallows life had to offer.  

It was often believed that the kids who could delay gratification did so thanks to more "will power."  Mischel -- according to a helpful and informative summary in this week's New Yorker, by Jonah Lehrer -- analyzed what this "will power" really consisted of.  He paid very careful attention to what went through the delaying kids' minds as they resisted the bait.  They succeeded because they had methods of distracting their minds from the lure.  They covered their eyes, or played hide-and-seek under the desk, or sang songs.  "Their desire wasn't defeated -- it was merely forgotten."  The key, Mischel found, was not to resist the marshmallow -- that didn't work --- but to avoid thinking about it.  

In further experiments, Mischel found that children could be taught cognitive tricks that helped them distract themselves.  Even reducing the intensity of the temptation by pretending that the marshmallow was only a picture of a marshmallow or that the marshmallow was really a cloud worked for some children.   

Mischel and other researchers Lehrer quotes are skeptical of finding a genetic basis for the ability to delay gratification.  Too many genes are involved in even the simplest aspects of personality.  The cutting edge of research lies in classroom curricula that teach self-distraction, and in educating parents to cultivate simple cognitive skills in children.  Says Mischel:

"We should give mashmallows to every kindergartner... We should say, 'You see this marshmallow"  You don't have to eat it.  You can wait.  Here's how.'"

Well said, in Washington

The Bush years, by wide consensus, were a dismal era for science.  But by a strange paradox, some bright stars emerged in what is normally a dismal field under any administration: addiction science.  

One is the brilliant Nora Volkow, who brings a rare mix of research experience, clear thinking, and leadership ability to the National Institute on Drug Abuse (NIDA).  

Another is Mark Willenbring, Director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA).  In a letter to the current New Yorker (the one with the cartoon of Obama as George Washington on the cover), Willenbring precisely skewers a piece that this normally astute mag published in its December 1 issue.  The article, titled "Special Treatment," by Amanda Fortini, featured a Los Angeles area deluxe treatment facility.  

After a string of well-worn 12-step platitudes about addiction and the difficulties of recovery, the owners of the facility claimed that in essence treatment could make no difference, everything depended on the addicted person's motivation.  So why bill the client for clinical services on top of the normal cost of luxury room and board? 

Willenbring's letter goes directly for the jugular.  He writes that the piece:

... shows the irony that paying more does not guarantee access to the most current therapies... The program that Fortini describes appears to base its services on a treatment model that is more than thirty years old .... Although clients may or may not receive some benefit, they are vulnerable to unnecessary relapse risk if more contemporary treatments are not also made available.  For example, research funded by the National Institutes of Health has identified several medications that reduce relapse in early recovery from alcohol dependence.  Newer behavioral approaches, such as cognitive-behavior therapy and motivational interviewing, also increase recovery and provide alternatives to the traditional Twelve Step approach (which in updated form is also effective).  This menu of services makes possible truly individualized treament and  increases client choice and engagement, but only if people have access to it.

The treatment program Fortini described in her article was so clinically clueless and bereft of ideas that the piece might have been a subliminal parody.  It isn't often that I get to cheer somebody in Washington for saying the right stuff.  Could this be the beginning of a change we can believe in?  

End Stage

Is nothing sacred? Michael Shermer, Scientific American's Skeptic columnist, reports in the November issue that one of the icons of psychology, the five stages of grief, has been debunked.

Launched by Elizabeth Kubler-Ross in her book On Death and Dying (1969), the model of denial-anger-bargaining-depression-acceptance is one of the most widely known paradigms in modern psychology. But, according to Shermer's sources, there appears to be no evidence that most people most of the time go through most of those stages in that order, or any other order.

The five stages of grief, along with similar "stage" theories, Shermer says, satisfy people's craving for simplicity and predictability. Unfortunately, the scientific basis for them is just not there. And they can also impose feelings of guilt and shame on people who are not feeling what they think they should. And, in today's world, people who follow the simple "stages" narrative are the exception, while diversity and individual variation are the rule.

Good grief! What's next? Are we going to learn that there is no evidence that most people recovering from addiction go through a certain well known set of steps?

Genetics of mental illnesses: More is Less

Genetic research into psychiatic disorders appears to be undergoing a systemic deflation not unlike that in the financial markets. As I posted a couple of weeks ago, a survey article in the then-current Scientific American showed that genetic studies of human intelligence had labored mountainously and brought forth a 0.4 per cent mouse. Today comes a special issue of Nature Neuroscience dedicated to the neuropsychiatric diseases, and it's the same story. The initial radiant hope that today's mega-billion dollar genetic research apparatus would nail the culprit genes responsible for schizophrenia, autism, bipolar disorder, or depression, has dimmed to a faint glimmer. The more we can see, the less we find.

In the roundup article, Steven Hyman (Department of Neurobiology, Harvard) works hard at sounding upbeat, but has little to work with. Family studies, rich in anecdotal material, suggest that autism, schizophrenia, bipolar illness, and major depression must have major genetic components. Therefore it should be a simple matter to find the genes, and then to develop medications that target those genes.

Over the past two decades, however, efforts to identify risk-conferring alleles for the common forms of neuropsychiatric disorder have largely been unrewarding. Despite the significant role for genes highlighted by aggregate measures of their influence (Table 1), the underlying genetics of common neuropsychiatric disorders has proved highly complex, as attested by unpredictable patterns of segregation in families, lack of Mendelian ratios in twin studies and serious difficulties in replicating genetic linkage studies.

Anecdotes notwithstanding, the given illness frequently appears in people without the suspected genetic traits, fails to appear in people with the traits, and appears in people with other traits believed to be associated with an entirely disparate disorder. Current technology can easily identify "highly penetrant" genetic variations that cause a narrow subset of disorders, such as some types of Alzheimer's disease and macular degeneration, but the candidate genes involved with the most common psychiatric disorders make only a very slight dent in the etiology. It doesn't help that the clinical definitions of the psychiatric disorders tend to lack objective physiological markers, so that diagnosis rests ultimately on clinicians' opinions, which may vary widely.

Neither Hyman's article nor the remaining items in the special issue of Nature Neuroscience focus on addictive substance abuse, but you could substitute "alcoholism" into the paragraphs just quoted and come out with the same result. I've summarized the research on that topic in my forthcoming book. By April, when the book comes out, it should be amply clear that the deflation of the genetic myth in alcoholism is only part of a larger panorama of reassessment. The better our genetic research tools become, the more clearly we can see, the more obvious it becomes that we cannot blame our genes for our disorders, nor can we hope for a magic pill to set us right. It's just not going to be that easy.

Genetics: The more we see, the less there is

In the concluding chapter of my forthcoming book (link), I look at the evidence for an alcoholism gene.  My research showed that the more powerful our tools become, the less we find in the way of genetic causality.  Modern genetic research has wiped away any basis for the idea that alcoholism is a genetically transmitted disease.  The most that can be said is that some people appear to inherit a lower responsiveness to alcohol, so that if they drink, they must drink more to get the same high.  For details, see my book, due out in April.  

Now comes an article in Scientific American, by science journalist Carl Zimmer,  reporting on modern research into the genetics of intelligence.  Here too, the conventional wisdom has been that genes play a major role.  But when the most powerful computer-assisted research tools are turned on the human genome, the supposed genetic factor all but evaporates.  Intelligence turns out to depend very weakly on a diversity of genes. The most influential of these genes contributes just 0.4 per cent (less than one half of one per cent), and this gene is believed to influence also a variety of other cell functions -- so that it is not specific to intelligence as such.  

Much of the myth of genetic causality rests on twin studies.  This is true both in alcoholism and in intelligence research, as well as in other fields (for example, autism).   Zimmer cites research showing that twin studies involving affluent families show a strong apparent genetic influence, while similar studies involving twins from poorer families show virtually no genetic factor at work.  The modern molecular genetic studies suggest that the apparent genetic influence reported in some twin studies may be a chimera due to false methodological assumptions.   Twin studies have been severely criticized, and some scientists consider them junk.  The SciAm article is in the October 2008 issue at p. 68; a link is (temporarily) here.

Spirituality strikes out

Two controlled trials of the effect of spirituality on addiction recovery showed no improvement for the patients given spiritual guidance as part of the usual treatment regimen, either in their addiction recovery or in their spiritual practices.  In fact, in one trial, the patients provided with spiritual guidance made less progress in overcoming depression and anxiety than the patients not given spiritual treatment.

Details are in the Journal of Substance Abuse Treatment, July 25 2008.  The abstract is here.  Thanks to David Kaiser Ph.D. for flagging the item.  

Confrontation Therapy, R.I.P.

Two of my favorite scholars have combined to write a powerhouse of an article that everyone interested in addiction treatment will want to read. William R. Miller, co-author of the Handbook of Alcoholism Treatment Approaches (reviewed here), and William L. White, author of the monumental history Slaying the Dragon (reviewed here), have written what hopefully will be an obituary for an era, entitled "Confrontation in Addiction Treatment." It's in Counselor Magazine. Here are a few snippets from this substantial, strongly researched and comprehensive treatment:

The use of confrontational strategies in individual, group and family substance abuse counseling emerged through a confluence of cultural factors in U.S. history, pre-dating the development of methods for reliably evaluating the effects of such treatment. Originally practiced within voluntary peer-based communities, confrontational approaches soon extended to authority-based professional relationships where the potential for abuse and harm greatly increased. Four decades of research have failed to yield a single clinical trial showing efficacy of confrontational counseling, whereas a number have documented harmful effects, particularly for more vulnerable populations. There are now numerous evidence-based alternatives to confrontational counseling, and clinical studies show that more effective substance abuse counselors are those who practice with an empathic, supportive style. It is time to accept that the harsh confrontational practices of the past are generally ineffective, potentially harmful, and professionally inappropriate.

....

Early claims of the superior effectiveness of confrontation and counterclaims that it was ineffective and potentially harmful relied primarily on statement of opinion buttressed by anecdotes. With the emergence of more science-grounded treatment approaches in the 1980s and 1990s came studies that began to tip the scales of this debate. Two recent reports, however, suggest that confrontation still has its proponents. A 2001 study on staff attitudes toward addiction treatment found that 46 percent of those surveyed agreed that “confrontation should be used more” (Forman, Bavasso & Woody, 2001); and a 2004 ethnographic survey of adolescent addiction treatment in the United States commonly encountered programs that were “explicitly designed to demean and humiliate” (Currie, 2004).

...

There never has been a scientific basis for believing that people with substance use disorders, let alone their family members, possess a unique personality or character disorder. Quite to the contrary, research on virtually any measure reflects wide diversity of personal characteristics among people with addictions, who are about as diverse as the general population, or as snowflakes. Studies of defense mechanisms among people in alcohol treatment have found no characteristic defensive structure, and higher denial was specifically found in a clinical sample to be associated not with worse, but with better treatment retention and outcomes (Donovan, Hague & O’Leary, 1975).

...

Reviewing four decades of treatment outcome research, we found no persuasive evidence for a therapeutic effect of confrontational interventions with substance use disorders. This was not for lack of studies. A large body of trials found no therapeutic effect relative to control or comparison treatment conditions, often contrary to the researchers’ expectations. Several have reported harmful effects including increased drop-out, elevated and more rapid relapse, and higher DWI recidivism. This pattern is consistent across a variety of confrontational techniques tested. In sum, there is not and never has been a scientific evidence base for the use of confrontational therapies.

If you've ever been exposed to confrontation therapy, or have a confrontational counselor now, by all means read this article, sure to be reprinted in textbooks and to become a classic.

If there's one defect in it, it's in glossing over the confrontational therapy element in AA itself. Dr. Harry Tiebout, whose psychiatric theorizing framed the confrontational approach, was hugely influential on Bill Wilson, and he was not alone. Dr. Silkworth echoed the theme, with his advice to Wilson to "give them the medical business, and give it to them hard." The "medical business" meant to convince the alcoholic that he was suffering from an incurable fatal illness. This revelation was designed to attack and to "shatter" the alcoholic's defenses, to "deflate" his ego, and render him hopelessly dependent on his "physician." The very first clause of step one, the foundation of the whole edifice, "powerless over alcohol," expresses a confrontational strategy, as thousands of counselors have found out in practice. To be fair, this is not the only element in AA; there are other strands that tend to counterbalance it. But the article is certainly wrong in claiming, as it does, that there is no attack therapy strand in AA at all. -- This cavil aside, the article is a masterful piece of work, by two giants in the field. Highly recommended.

Abstinence leads to rapid brain repair

Abstinence leads to rapid repair of gross brain damage seen in alcohol dependent persons, according to a review of neuroimaging studies by a group of Japanese researchers.

In uncomplicated alcoholic patients, a high incidence of cortical shrinkage and ventricular dilatation were reported using brain CT scans. In older alcoholics, prefrontal gray matter deficits were especially marked when compared with younger alcoholics. Reversibility of brain shrinkage is a common neuroimaging finding in patients with alcohol dependence.

Regrowth of shrunken brain areas was particularly vigorous during the first month of abstinence, the scans showed. Besides the gray matter, areas "with significantly greater recovery in abstainers were the temporal lobes, thalamus, brainstem, cerebellum, corpus callosum, anterior cingulate, insula, and subcortical white matter." Follow-up studies showed that the regrowth was not simply due to rehydration.

The study appeared in the Dec. 2007 issue of the Japanese Journal of Alcohol Studies and Drug Dependence. The abstract is here.

Brazil study: Does AA really work?

"Do Alcoholics Anonymous groups really work? Factors of adherence in a Brazilian sample of hospitalized alcohol dependents." -- That's the title of a study in the current issue of the American Journal of Addiction, published by a American Academy of Psychiatrists in Alcoholism and Addiction. A team of researchers headed by M.B. Terra followed 300 alcoholics committed to three hospitals in Puerto Allegre, Brazil. Results (from the abstract):

AA adherence was below 20%. The main factors reported by patients as reasons for non-adherence to AA were relapse, lack of identification with the method, lack of need, and lack of credibility. The factors reported by patients as reasons for adherence were identification with the method and a way to avoid relapse. Although AA is considered an effective intervention for alcoholism, its adherence rate was excessively low. The identification of these nonadherence factors could help health professionals in referring certain alcoholic patients to therapeutic interventions other than AA.

The result of this study is unsurprising; essentially the same finding was made in a meta-analysis almost two years ago reported in the Cochran Report (Source) What's noteworthy here is that patients were asked their reasons. It would be useful if the various threads in the responses (objections to the 12-step approach on the one hand, denial on the other) were explored in more depth and an attempt made to untangle them.

Humility R Us [NOT]

It's been six years since AA Trustee Dr. George Vaillant's article in the AA Grapevine, saying that "It doesn't hurt at the level of the GSO for AA to have humility and understand that 60 per cent do it without AA." Source. He was talking about the research finding that 60 per cent of alcoholics who achieve at least five years of abstinence do it without using AA.

It's been six years, and Vaillant's plea for humility has either not been heard or already forgotten. In this months' issue of Addiction Professional, columnist Carlton Erickson reports that "fourteen experts" recently met at a "consensus conference" in Rancho Mirage CA to define "recovery," and came up with a definition that includes an implied endorsement for "peer support groups such as AA and practices consistent with the 12 Steps and 12 Traditions."

In other words, judging by Erickson's column, if you're part of the majority that are staying sober without AA you're not considered in recovery. But if you're a chain-smoking Big-Book thumper whose entire social, moral, and intellectual life is wrapped up in AA meetings, then you're a model of recovery. The mind boggles.

The panel's full report, published in the Journal of Substance Abuse Treatment, is considerably more balanced than Erickson's column makes it seem. The report says that "the founders of AA recognized that there were many paths to the same position ... and did not suggest that their specific methods were the only means to attain the overall goal." (Thanks Jason Schwartz for forwarding the full article.) The panel considered but expressly rejected the definition of recovery as "abstinence attained through adherence to 12-step principles."

That's progress. But the plug for AA and the 12 steps is highlighted in the report, and Erickson's column picked up on that highlight, as most hurried readers will.

This endorsement is completely gratuitous. It comes in the absence of any evidence cited in the report showing either (a) superior efficacy of 12-step over other paths in reaching long-term sobriety, or (b) a positive association between long-term participation in 12-step groups and measures of "personal health and citizenship."

The report admits that no validated instrument for measuring "personal health and citizenship" exists. Then what scientific ground is there for making the claim?

The implied beneficial effect of AA participation on "personal health" is indefensible given the notorious prevalence of nicotine addiction among AA members. The report takes note of the nicotine problem, including "significant rates of emphysema, cancer, and other terminal health conditions associated with these products among those otherwise in recovery" (read: in AA). But come to the bottom line, the panel tucked tail between legs and "considered it best to remain silent on tobacco use within the sobriety component of the recovery definition."

The next line is lovely: "It is admitted that there is no clinical justification for this position."

The claim that long-term AA participation enhances "citizenship" is equally dubious. The cited ground for it is the AA homilies for doing service, "giving back." But this "service," to the limited extent people actually do it, is in the nature of recruiting for the AA organization. AA has no outward-directed community service component on the order of the Masons, Shriners, Rotarians, and many other groups. So where does "citizenship" come in?

Trying to come up with a definition of recovery is a laudable project. The panel notes that recovery science (as distinct from addiction science) is a poorly developed field, and that the lack of a validated definition of 'recovery' is a significant obstacle. But when you enter the gates of science, the motto is "lasciare ogni sospetto" -- here drop all hesitation, abandon all fear. So long as recovery scientists keep genuflecting to the sacred cow in the room, little progress and considerable dung is to be expected.