Editorial Comment: A full deck

 

They say that a parent should not clearly identify any one of the children as a favorite. "They" are unlikely to be child psychiatrists, who would realize the impossibility of avoiding that trap, and would warn of the risks of dishonesty as a parenting strategy. Still, the admonition is much easier to honor with the selections in this week's issue. Research, policy, education, they are all here and all favorite children.  At least two of the pieces entail exciting controversy, although “excitement” is seldom a good selling-point in medicine or in government: the unintended consequences for chronic pain patients of employing opioid-prescribing guidelines as doctrine; and the President’s essay into capital punishment as drug control policy.  Glutamatergic stuff.

All that, and with one article contrasting the requirements of therapy with the practicalities of recovery: the New Republic piece, beginning with the experience of an Alcoholics Anonymous member receiving opioid agonist medication.  The title is inflammatory.  The article rambles, mixing distressing but poignant imagery, with useful data, with unfortunate distortions. It speaks of a “ decades-old 12 Step philosophy” that excludes those who are receiving medications for the management of their substance use disorders, when the applicable tenet of AA is its third tradition: “the only requirement for AA membership is a desire to stop drinking.” This tradition is reflected in Narcotics Anonymous literature as well, where the only requirement for membership is a desire to stop using. Advisory literature in the form of pamphlets repeatedly emphasizes that neither community, AA nor NA, seeks to provide medical opinions or medical care. 

This is an old story.  We witness a deficiency in the education by each group, of the other: the recovering community and the professional community. The polarization may be blamed, at least in part, on the distrust of those in recovery for physicians who have historically over-prescribed both opioids and sedatives, regardless of good intent.  The article, then, can be best read as a demonstration of culture-clash. …Interestingly, the controversy is less intense, is in most cases nonexistent, when those participating in 12-step groups are receiving medications for other disorders, as for schizophrenia or affective disorders. 

- Dr. William Haning