The term “rehab” is a Hollywood expression. Nobody refers their patients to “rehab” but we all have read about it in People magazine. Criticism of these programs is both well-deserved and unfair.
As a current addiction medicine fellow in Georgia, I find referral options are very limited for my patients. One prominent local facility rejected gabapentin for a patient with neuropathic pain. Many of these rehabs don’t allow pych meds either.
Hard to reconcile with the ASAM criteria, but ASAM is not in charge of everything.
I was just on a call with the editor in chief for the new ASAM Criteria, and he said the criteria had a better evidence base than CPR. He also noted that there were several RCTs on the previous criteria (which I haven't read) showing they were better than individual clinician judgement.
But even if true on their face, these statements aren't setting the bar that high.
If you read Matthew Perry's book, you would note that he decried rehabs and detox places as highly ineffective and that they taught him little. Detox is a waste of money without lengthy treatment after. I find it amazing that we put people through it and then send them on their way as if addiction was that easy. We must invest in programs that last longer in order to be successful. Between addiction and mental health, we have lost our way.
I am a retired pediatrician. There are many forms of rehabilitation for many ailments. Take morbid obesity. The record of successful treatment or rehabilitation after diagnosis is dismal. Alcoholics Anonymous has a better track record but, alas, its long-term success is likely not high. There is a deep and often unaddressed spiritual emptiness in many individuals with addictions to food, alcohol, sex, and drugs. Unless and until this spiritual vacuum is addressed, in my opinion, little success should be expected.
It was obviously the C19 vax that killed Matthew Perry.
For those that find the definitive nature of that comment offensive, and believe the C19 MRNA to be safe and effective, I intentionally worded my provocation to perhaps give a glimpse of how people like me felt when the majority of the world insisted with conviction that the new MRNA product, with no long-term safety data, was “safe and effective,” and then tried to force me and my family to be injected. A nadir moment in recent history in which Matthew Perry enthusiastically and commercially participated.
As far as addiction goes, the human brain is the final frontier. Maybe with a dose of humility, we’ll somehow make progress in our efforts to untangle. But given the Medical research communities’ fraudulent charade with Alzheimer’s over the last 20 years, you’ll hopefully forgive my cynicism.
"Somehow, a lengthy stay in a remote treatment “camp” – precisely the thing we decry as not evidence-based -- helped him turn the corner."
Emphasis on the word "lengthy," Doc.
As with confrontational techniques, the essential ingredient is temporal. We know from Skinner, Stoddard et al, the power of adaptive learning and association. It is the combination of reconstructive technique and removal from association that produce optimal results.
Regarding confrontation; I've seen it produce quite effective results in long-term residential settings, but there are degrees of confrontation beyond which one must not trespass; the breaking-down of emotional defense structures is, as you have noted, fraught with risk.
If you'll forgive the vernacular, those who recover from addiction without semi-permanently removing themselves to a supportive environment free of their learned association with their addictive behaviors, are unicorns.
Thank you for an astute and enlightening perspective.
Thanks very much for engaging in this conversation. One of the challenges that puts the recovery and remission of addiction a little bit at odds with the spirit of work by both Dr. Cifu and Dr. Prasad is that the randomized controlled trial (RCT) is especially less helpful to understanding how remissions are achieved. That is, an RCT treats the trial team as "administering the treatment" to persons, and the differences among those persons (their contexts, choice space, self-understandings) are "factored out as nuisance variables", to be removed consideration through randomization. But addiction is an illustrative example of where the context, choice space, self-understanding are dominant and potentially determinative of the impact of any particular treatment.
I did not know about the removal argument "in general" as you make it although of course I have enacted it with the request of patients and families.
The difficulty with Dr. Prasad's "evidenced based" leanings is that they become a flow chart to which practitioners adhere, regardless of individualized context. I'm not disparaging evidence-based praxeology, only pointing out its limitations. I offer the exclusion criteria for the ISCHEMIA trial as an example.
When I refer to removal, I'm not limiting it conceptually to institutionalization. My own experience has been that a complete change of association markedly improves the odds of success. More concisely, the example is one of an abstemious alcoholic staying away from taverns and friends whose conviviality is centered on alcohol consumption.
One of the most tragic examples in my experience was a man who successfully completed a cocaine addiction program, managed to restructure his friendships to exclude users, substituted alcohol, successfully completed another program but remained in contact with other drinkers and died of alcohol-related disease within three years.
Obviously, the underlying vulnerability to compulsive behaviors was not addressed, at least not effectively. The man was a good cook when sober. It is not beyond the bounds of reason to speculate that successful treatment of the alcoholism could easily have segued into morbid obesity. I've seen that happen, as well.
Thank you for writing this. We experienced exactly this. When my partner needed to transition into a detox program out of the ER, none were available. All had minimum 6 to 12 week waiting lists. (Los Angeles, CA)
Nov 14, 2023·edited Nov 14, 2023Liked by Stefan G. Kertesz, MD, MSc
It is surprising that Dr. Kerstesz, with his considerable knowledge of addiction-related policies and practices, did not mention another significant hurdle to getting people into treatment programs. That obstacle is the ideology known as harm reduction.
Having witnessed the unfolding of the unmitigated disaster that is Oregon's ill-considered experiment with decriminalization, I have concluded that harm reduction is an antisocial form of activism that is bad for the community and bad for the user. Advocates for harm reduction pride themselves on their neutrality on drug use and addiction. "No judgment" is the mantra. In fact, that very abdication of a sense of right and wrong is what’s responsible for so much personal suffering and death among addicts. Furthermore, harm reductionists' purported neutrality on drugs masks their extreme hostility to the moral values meant to yield the sort of healthy and productive individuals who contribute to healthy and productive societies. Among harm reductionists, morality is a bad word.
People addicted to meth, fentanyl and other opiates have given away every last shred of personal and bodily autonomy they ever had. To pretend otherwise, which is the central premise of harm reduction, is a cruel farce. Harm reduction abets addiction while stigmatizing recovery and sobriety. As a society, we must stigmatize addiction and launch treatment programs that promote detox, rehab and sobriety.
I have a few views about the sort of rehab program Dr. Kerstesz discusses in his piece as a result of having been through treatment for two months at Hazelden's Newberg, Oregon, facility a decade ago and following the topic of addiction treatment more closely since then than the average citizen.
One of them is astonishment and dismay at the persistence of AA's 12-step program as the centerpiece of the treatment experience. As defined by the 12 steps and the Big Book, AA's method of treating addiction is at its core a religious practice. Paradoxically, AA's etiology for what it terms a disease is a pathology of the will and character. The cure is a lifetime of divining and following God's will. The sacrament is the bad coffee after the meeting.
AA does not work for me because I am an atheist who is incapable of accepting the gloss on the AA canon that urges atheists to make their higher power a doorknob. Since AA's theology holds that the higher power is an entity both greater than and outside of one's self, the doorknob is a nonstarter.
AA's "fellowship" does me no good because I have a lifetime of being a stranger among familiar strangers. In fact, while my rejection of AA's unscientific principles inclined me to leave, it was the familiar pain of not being able to connect with others that drove me to stop attending. Moreover, contrary to the way AA meetings are portrayed in popular media, they are not a space where addicts can grow by engaging in dialogues with one another. To attempt to do so would violate the firm rule against "cross-talk." Given a choice between medically assisted talk therapy and sitting through monologues for the rest of my life, I chose the former. To its credit, Hazelden was prescribing Subutex and Naltrexone even then.
It's high time to retire the 12-step program and replace it with an evidence-based approach that deals with the root causes of addiction. Rather than performing the fourth step's "searching and fearless moral inventory" of themselves (I found it to be a labor-intensive dead end), addicts would be better off working with a qualified therapist, preferably one who does not practice CBT. My problem doesn't lie in my will or my character; it's found in the history of the first 20 years of my life.
I have a different perspective on buprenorphine - I believe it’s useful but certainly not for life. I remember Salavitz’ promotion of opioids for CNCP denying addiction is possible when someone is using opioids for CNCP; so her credibility is no good in my world. I do believe in positive regard and support for lifestyle change necessary to recover, and treating it lifelong. Bupe is a big pharma drug and - like all opioids - will continue to be a big seller. Methadone has better outcomes and is cheaper. Bupe is overhyped and should be used cautiously. https://www.justice.gov/opa/pr/justice-department-obtains-14-billion-reckitt-benckiser-group-largest-recovery-case
Are you using PEtH levels in your practice for patients who are reluctant to pursue a higher level of care as an accountability measure for AUD?
I’m learning how complicated the road to recovery is for those who struggle with alcohol addiction, and it becomes tougher to stomach relapses when decompensated cirrhosis is present particularly once you’ve exhausted other AUD pharm and psych treatments.
I have only ordered PEtH in inpatient internal medicine settings where we have a conundrum, perhaps pancreatitis or cirrhosis and a story of no alcohol and we can't seem to find another cause. Because I'm mostly a primary care doc who assists recovery rather than the primary "treater" it doesn't come up. Also I do have real reservations about me, the physician, as the "imposer" of accountability on the patient. I am a professional who renders a service that will require me to be honest and to show the patient why I am worthy of that person's trust. In other words, I'm not their police officer, or even their upset spouse. I'm a paid consultant. If the patient says "look, no one else will hold me accountable and I'm asking you to" that's one open door to doing whatever testing they think they need. But mostly I tend to be working squarely as an adult who is allowed, by virtue of the special boundaries of the medical relationship, to assess, to ask questions, to recommend, but always with clear eyes that the adult in front of me may decide that they don't like the advice I'm giving, or that it's not the right next step.
Yes agreed should be a consensually informed and desired approach. No room for paternalism in addiction medicine. Perhaps similar to niche indications akin to Antabuse where a broad sweeping recommendation would cause much more harm than good. Will be curious to see if and where this lands in the AUD toolkit a few years from now. Thanks for the thoughtful response.
I don't think it's quite justified to say that confrontational techniques are ineffective. Anecdotally they have certainly helped some people. Studies may have found them to be less effective than other techniques, but I think we have to be conservative when evaluating something as inherently difficult to measure as the effect of an extremely complex intervention that is not standardizable on an extremely complex problem (i.e. human brains and behavior).
I also disagree with your comparison here: "If we made getting treatment for heart attacks as difficult as we make getting treatment for addiction, there would be federal investigations." The 30-day mortality rate from untreated MI is at least in the double digits. And we are pretty certain that intervention for it is highly effective. Untreated addiction has a very low 30-day mortality rate, and there is quite a lot of uncertainty about intervention, as you describe here. I think it's entirely appropriate for it to be more difficult to obtain addiction treatment than MI treatment.
I guess you might argue that there are people, perhaps people we have met, who might say a confrontational approach actually helped them.
Because the recovery paths are so diverse, one could say “I am not arguing it is treatment per se, just that some people exist who benefitted”
In terms of a treatment being difficult to obtain and the comparison to myocardial infarction, perhaps I should have offered a comparison to an illness that is not acute but chronic in nature and yet still taken seriously and involves suffering for the patient and family, with death as a possible outcome.
Thanks for your reply. I'm certainly not arguing that confrontational approaches should be the default at residential facilities like this. I think you're probably right that there are better alternatives. But I think it makes sense to let a thousand flowers bloom and have some facilities emphasize the more confrontational approaches while others take the ones that are better supported by the evidence. That way a diversity of needs can be served.
The first thought I had about his death was: guess he went and got that booster. I'm seeing horrible cancers now among the people of my town, brain tumor, pancreatic cancer, breast cancer and others. A neighbor died of cardiac arrest a week after he got "boosted"; he had just told me that at his age (72) he really needed the jabs. If this isn't an elephant in the living room, I don't know what that phrase means.
Well the heart attack comment has been scrubbed from the internet and this is ONLY another conspiracy theory but....
"In the tweet, Perry writes, “Could I BE Any More Vaccinated? Get your shot and then get your shirt,” before directing fans to his official webstore for Matthew Perry merchandise."
It has come down to the idea that all people who are not normal (however that is defined) now suffer from some disorder or addiction and therefore require intense treatments, mostly using drugs. The only "rehab" that is needed is within the entire medical complex as it must be dismantled and rebuilt with a foundation that excludes big pharma and the AMA and government.
When the student is ready the teacher will appear. We have multiple tools in our toolbox and some work some of the time, some don’t work at all. One size does not fit all. I have worked in the “trenches “ for 40 years and it is an honor to learn from my patients. If anything we have substituted harm reduction for treatment and that has been a total nightmare.
The same analysis can be used for our involuntary treatment of those that have a mental health issue. The evidence is against the use of polypharmacy, involuntarily committing individuals and just providing them dangerous psychotropics as the answer to an event in their lives.
I am surprised that you accept the statements suggesting that drug treatments are effective. It seems that the few long-term studies on addiction treatment suggest little to no benefit over free 12-step treatments.
As a current addiction medicine fellow in Georgia, I find referral options are very limited for my patients. One prominent local facility rejected gabapentin for a patient with neuropathic pain. Many of these rehabs don’t allow pych meds either.
Hard to reconcile with the ASAM criteria, but ASAM is not in charge of everything.
I think the same criteria actually just don’t work for the care of a lot of our patients
I was just on a call with the editor in chief for the new ASAM Criteria, and he said the criteria had a better evidence base than CPR. He also noted that there were several RCTs on the previous criteria (which I haven't read) showing they were better than individual clinician judgement.
But even if true on their face, these statements aren't setting the bar that high.
If you read Matthew Perry's book, you would note that he decried rehabs and detox places as highly ineffective and that they taught him little. Detox is a waste of money without lengthy treatment after. I find it amazing that we put people through it and then send them on their way as if addiction was that easy. We must invest in programs that last longer in order to be successful. Between addiction and mental health, we have lost our way.
Did he say what kind of programs helped the most?
I am a retired pediatrician. There are many forms of rehabilitation for many ailments. Take morbid obesity. The record of successful treatment or rehabilitation after diagnosis is dismal. Alcoholics Anonymous has a better track record but, alas, its long-term success is likely not high. There is a deep and often unaddressed spiritual emptiness in many individuals with addictions to food, alcohol, sex, and drugs. Unless and until this spiritual vacuum is addressed, in my opinion, little success should be expected.
It was obviously the C19 vax that killed Matthew Perry.
For those that find the definitive nature of that comment offensive, and believe the C19 MRNA to be safe and effective, I intentionally worded my provocation to perhaps give a glimpse of how people like me felt when the majority of the world insisted with conviction that the new MRNA product, with no long-term safety data, was “safe and effective,” and then tried to force me and my family to be injected. A nadir moment in recent history in which Matthew Perry enthusiastically and commercially participated.
As far as addiction goes, the human brain is the final frontier. Maybe with a dose of humility, we’ll somehow make progress in our efforts to untangle. But given the Medical research communities’ fraudulent charade with Alzheimer’s over the last 20 years, you’ll hopefully forgive my cynicism.
"Somehow, a lengthy stay in a remote treatment “camp” – precisely the thing we decry as not evidence-based -- helped him turn the corner."
Emphasis on the word "lengthy," Doc.
As with confrontational techniques, the essential ingredient is temporal. We know from Skinner, Stoddard et al, the power of adaptive learning and association. It is the combination of reconstructive technique and removal from association that produce optimal results.
Regarding confrontation; I've seen it produce quite effective results in long-term residential settings, but there are degrees of confrontation beyond which one must not trespass; the breaking-down of emotional defense structures is, as you have noted, fraught with risk.
If you'll forgive the vernacular, those who recover from addiction without semi-permanently removing themselves to a supportive environment free of their learned association with their addictive behaviors, are unicorns.
Thank you for an astute and enlightening perspective.
Thanks very much for engaging in this conversation. One of the challenges that puts the recovery and remission of addiction a little bit at odds with the spirit of work by both Dr. Cifu and Dr. Prasad is that the randomized controlled trial (RCT) is especially less helpful to understanding how remissions are achieved. That is, an RCT treats the trial team as "administering the treatment" to persons, and the differences among those persons (their contexts, choice space, self-understandings) are "factored out as nuisance variables", to be removed consideration through randomization. But addiction is an illustrative example of where the context, choice space, self-understanding are dominant and potentially determinative of the impact of any particular treatment.
I did not know about the removal argument "in general" as you make it although of course I have enacted it with the request of patients and families.
The difficulty with Dr. Prasad's "evidenced based" leanings is that they become a flow chart to which practitioners adhere, regardless of individualized context. I'm not disparaging evidence-based praxeology, only pointing out its limitations. I offer the exclusion criteria for the ISCHEMIA trial as an example.
When I refer to removal, I'm not limiting it conceptually to institutionalization. My own experience has been that a complete change of association markedly improves the odds of success. More concisely, the example is one of an abstemious alcoholic staying away from taverns and friends whose conviviality is centered on alcohol consumption.
One of the most tragic examples in my experience was a man who successfully completed a cocaine addiction program, managed to restructure his friendships to exclude users, substituted alcohol, successfully completed another program but remained in contact with other drinkers and died of alcohol-related disease within three years.
Obviously, the underlying vulnerability to compulsive behaviors was not addressed, at least not effectively. The man was a good cook when sober. It is not beyond the bounds of reason to speculate that successful treatment of the alcoholism could easily have segued into morbid obesity. I've seen that happen, as well.
Thanks for responding.
Thank you for writing this. We experienced exactly this. When my partner needed to transition into a detox program out of the ER, none were available. All had minimum 6 to 12 week waiting lists. (Los Angeles, CA)
It is surprising that Dr. Kerstesz, with his considerable knowledge of addiction-related policies and practices, did not mention another significant hurdle to getting people into treatment programs. That obstacle is the ideology known as harm reduction.
Having witnessed the unfolding of the unmitigated disaster that is Oregon's ill-considered experiment with decriminalization, I have concluded that harm reduction is an antisocial form of activism that is bad for the community and bad for the user. Advocates for harm reduction pride themselves on their neutrality on drug use and addiction. "No judgment" is the mantra. In fact, that very abdication of a sense of right and wrong is what’s responsible for so much personal suffering and death among addicts. Furthermore, harm reductionists' purported neutrality on drugs masks their extreme hostility to the moral values meant to yield the sort of healthy and productive individuals who contribute to healthy and productive societies. Among harm reductionists, morality is a bad word.
People addicted to meth, fentanyl and other opiates have given away every last shred of personal and bodily autonomy they ever had. To pretend otherwise, which is the central premise of harm reduction, is a cruel farce. Harm reduction abets addiction while stigmatizing recovery and sobriety. As a society, we must stigmatize addiction and launch treatment programs that promote detox, rehab and sobriety.
I have a few views about the sort of rehab program Dr. Kerstesz discusses in his piece as a result of having been through treatment for two months at Hazelden's Newberg, Oregon, facility a decade ago and following the topic of addiction treatment more closely since then than the average citizen.
One of them is astonishment and dismay at the persistence of AA's 12-step program as the centerpiece of the treatment experience. As defined by the 12 steps and the Big Book, AA's method of treating addiction is at its core a religious practice. Paradoxically, AA's etiology for what it terms a disease is a pathology of the will and character. The cure is a lifetime of divining and following God's will. The sacrament is the bad coffee after the meeting.
AA does not work for me because I am an atheist who is incapable of accepting the gloss on the AA canon that urges atheists to make their higher power a doorknob. Since AA's theology holds that the higher power is an entity both greater than and outside of one's self, the doorknob is a nonstarter.
AA's "fellowship" does me no good because I have a lifetime of being a stranger among familiar strangers. In fact, while my rejection of AA's unscientific principles inclined me to leave, it was the familiar pain of not being able to connect with others that drove me to stop attending. Moreover, contrary to the way AA meetings are portrayed in popular media, they are not a space where addicts can grow by engaging in dialogues with one another. To attempt to do so would violate the firm rule against "cross-talk." Given a choice between medically assisted talk therapy and sitting through monologues for the rest of my life, I chose the former. To its credit, Hazelden was prescribing Subutex and Naltrexone even then.
It's high time to retire the 12-step program and replace it with an evidence-based approach that deals with the root causes of addiction. Rather than performing the fourth step's "searching and fearless moral inventory" of themselves (I found it to be a labor-intensive dead end), addicts would be better off working with a qualified therapist, preferably one who does not practice CBT. My problem doesn't lie in my will or my character; it's found in the history of the first 20 years of my life.
I have a different perspective on buprenorphine - I believe it’s useful but certainly not for life. I remember Salavitz’ promotion of opioids for CNCP denying addiction is possible when someone is using opioids for CNCP; so her credibility is no good in my world. I do believe in positive regard and support for lifestyle change necessary to recover, and treating it lifelong. Bupe is a big pharma drug and - like all opioids - will continue to be a big seller. Methadone has better outcomes and is cheaper. Bupe is overhyped and should be used cautiously. https://www.justice.gov/opa/pr/justice-department-obtains-14-billion-reckitt-benckiser-group-largest-recovery-case
Great read! Very informative.
Are you using PEtH levels in your practice for patients who are reluctant to pursue a higher level of care as an accountability measure for AUD?
I’m learning how complicated the road to recovery is for those who struggle with alcohol addiction, and it becomes tougher to stomach relapses when decompensated cirrhosis is present particularly once you’ve exhausted other AUD pharm and psych treatments.
I have only ordered PEtH in inpatient internal medicine settings where we have a conundrum, perhaps pancreatitis or cirrhosis and a story of no alcohol and we can't seem to find another cause. Because I'm mostly a primary care doc who assists recovery rather than the primary "treater" it doesn't come up. Also I do have real reservations about me, the physician, as the "imposer" of accountability on the patient. I am a professional who renders a service that will require me to be honest and to show the patient why I am worthy of that person's trust. In other words, I'm not their police officer, or even their upset spouse. I'm a paid consultant. If the patient says "look, no one else will hold me accountable and I'm asking you to" that's one open door to doing whatever testing they think they need. But mostly I tend to be working squarely as an adult who is allowed, by virtue of the special boundaries of the medical relationship, to assess, to ask questions, to recommend, but always with clear eyes that the adult in front of me may decide that they don't like the advice I'm giving, or that it's not the right next step.
Yes agreed should be a consensually informed and desired approach. No room for paternalism in addiction medicine. Perhaps similar to niche indications akin to Antabuse where a broad sweeping recommendation would cause much more harm than good. Will be curious to see if and where this lands in the AUD toolkit a few years from now. Thanks for the thoughtful response.
Thanks for the article! It was informative.
I don't think it's quite justified to say that confrontational techniques are ineffective. Anecdotally they have certainly helped some people. Studies may have found them to be less effective than other techniques, but I think we have to be conservative when evaluating something as inherently difficult to measure as the effect of an extremely complex intervention that is not standardizable on an extremely complex problem (i.e. human brains and behavior).
I also disagree with your comparison here: "If we made getting treatment for heart attacks as difficult as we make getting treatment for addiction, there would be federal investigations." The 30-day mortality rate from untreated MI is at least in the double digits. And we are pretty certain that intervention for it is highly effective. Untreated addiction has a very low 30-day mortality rate, and there is quite a lot of uncertainty about intervention, as you describe here. I think it's entirely appropriate for it to be more difficult to obtain addiction treatment than MI treatment.
I guess you might argue that there are people, perhaps people we have met, who might say a confrontational approach actually helped them.
Because the recovery paths are so diverse, one could say “I am not arguing it is treatment per se, just that some people exist who benefitted”
In terms of a treatment being difficult to obtain and the comparison to myocardial infarction, perhaps I should have offered a comparison to an illness that is not acute but chronic in nature and yet still taken seriously and involves suffering for the patient and family, with death as a possible outcome.
Thanks for your reply. I'm certainly not arguing that confrontational approaches should be the default at residential facilities like this. I think you're probably right that there are better alternatives. But I think it makes sense to let a thousand flowers bloom and have some facilities emphasize the more confrontational approaches while others take the ones that are better supported by the evidence. That way a diversity of needs can be served.
Hmm so what about the EMTs saying "heart attack" and Perry's advocation for the recent vaccine ??
Nothing to see here, huh?
The first thought I had about his death was: guess he went and got that booster. I'm seeing horrible cancers now among the people of my town, brain tumor, pancreatic cancer, breast cancer and others. A neighbor died of cardiac arrest a week after he got "boosted"; he had just told me that at his age (72) he really needed the jabs. If this isn't an elephant in the living room, I don't know what that phrase means.
Well the heart attack comment has been scrubbed from the internet and this is ONLY another conspiracy theory but....
"In the tweet, Perry writes, “Could I BE Any More Vaccinated? Get your shot and then get your shirt,” before directing fans to his official webstore for Matthew Perry merchandise."
It has come down to the idea that all people who are not normal (however that is defined) now suffer from some disorder or addiction and therefore require intense treatments, mostly using drugs. The only "rehab" that is needed is within the entire medical complex as it must be dismantled and rebuilt with a foundation that excludes big pharma and the AMA and government.
When the student is ready the teacher will appear. We have multiple tools in our toolbox and some work some of the time, some don’t work at all. One size does not fit all. I have worked in the “trenches “ for 40 years and it is an honor to learn from my patients. If anything we have substituted harm reduction for treatment and that has been a total nightmare.
The same analysis can be used for our involuntary treatment of those that have a mental health issue. The evidence is against the use of polypharmacy, involuntarily committing individuals and just providing them dangerous psychotropics as the answer to an event in their lives.
I am surprised that you accept the statements suggesting that drug treatments are effective. It seems that the few long-term studies on addiction treatment suggest little to no benefit over free 12-step treatments.