Aversive Therapies for Addiction

Addiction medicine meets A Clockwork Orange

Some addiction treatment is backed by science (e.g., medications for opioid use disorder such as methadone), some is backed by empathic, sensible behavioral policies (e.g., safe injection sites), much of it is based on well-intentioned voodoo and nonsense (the 12-Steps and rehab), and some is downright abusive. An example of the latter, as featured in my addiction textbook, is the category of treatments known as “aversive therapies” for addiction. These are where the addiction specialist tries to poison, shock, punish, or asphyxiate the patient into long-term sobriety. Some of these gruesome techniques might belong better in a “how to torture prisoners of war” textbook than an addiction textbook.

With addiction, traumatized people are at their most vulnerable, and our therapies ought to lessen not increase their trauma. There is some, very modest, experimental evidence for effectiveness of these aversive treatments. My question is: even if they are marginally effective, under experimental circumstances, are they worth the cost to the patient?

Aversive therapies for addiction

Aversive therapies are based on the psychological theory known as “operant conditioning” – think Pavlov’s dog. According to this thinking, we are conditioned to certain behaviors around drug use. An example they give is people with alcohol use disorder unconsciously swallow and salivate more when exposed to pictures of alcohol. The logical corollary to this is that, with noxious stimuli, people suffering from addiction can be counter-conditioned to extinguish cues and to transcend the addiction to drugs or alcohol.

According to my textbook,

[aversive therapy’s] goal is to reduce or eliminate the ‘Hedonic memory” or craving for a drug and to simultaneously develop a distaste and avoidance response to the substance.

They claim it is not “punishment” because the negative consequence is linked to the behavior not the person. Of course, it is the person doing the behavior, and who is going to experience the effects of the punishment, so this is a nonsensical argument. They state that this treatment has “a very important benefit to self-esteem” because they are receiving positive support (i.e., not being poisoned or shocked) for not using drugs. “Hence, self-esteem is rebuilt by separating the drug from the self.”

At this point, I was forced to question what drugs the authors of this chapter are on or, if they aren’t on any, which ones they ought to be taking. I would heartily recommend something like Ecstasy (MDMA) to increase their overall empathy and compassion for the patients, in the context of providing aversive stimuli (which they wouldn’t do if they had taken Ecstasy).

My addiction textbook which features the good, the bad, and the ugly in addiction treatment –like aversive therapy.

What are the different aversive therapies?

The first type of aversion therapy that is discussed is “nausea aversion”. They expose patients to pictures and bottles of alcoholic beverages and give them an oral dose of emetine – a medicine which makes you barf uncontrollably. They also give you some water and electrolytes, “to provide a volume of easily vomited materials.” How considerate! Right before vomiting, the patient sniffs, swishes and swallows” the alcoholic beverage but throws it up before any is absorbed. Then,

After a session, the patient is returned to the hospital room, where another drink of alcoholic beverage is given containing an oral dose of emetine and tartar emetic, which produces a slower acting residual nausea lasting for three hours.

Oh, my brothers! (This is a quote from A Clockwork Orange…which is, in truth, a profound and brilliant book - if you can stomach the violence). Is this a way to treat anyone suffering from addiction? The average patient receives five treatment sessions, given every other day over ten days. My textbook cites a study in which this is demonstrated to be effective, but – is it worth it? Does it produce a lasting benefit? Why do this when we have other treatments that are not so medieval, cruel, and abusive?

Next is faradic aversion where they use electric shock treatment to painfully electrocute you into sobriety. According to my textbook,

The faradic aversion treatment paradigm consists of pairing an aversive level of electrostimulation with the sight, smell, and taste of alcoholic beverages.

This sound gruesome and unpleasant. Who comes up with this stuff? Joseph Mengele? They discuss using aversion therapy for marijuana use disorder, substituting alcohol for,

a variety of bongs, drug paraphernalia and visual imagery. An artificial marijuana substitute and marijuana aroma are used in treatment.

Shocking poor weed users! This is addiction medicine gone amok. They don’t even let them enjoy actual cannabis to deal with the pain of the electric shocks – they give them a substitute. A lot of these cannabis users quite plausibly weren’t even addicted, given the field of addiction medicine’s propensity for exaggerating the extent of cannabis addiction, claiming that up to 1/3 of adult users are addicted. In reality, many of these are medical patients who are doing well on cannabis, but who get subsumed by our older, broken definitions of cannabis addiction.

Finally, we have aversion therapy in tobacco/nicotine use disorder. Here is where they simultaneously poison and asphyxiate tobacco users to try to get them limping into recovery. “Sessions last an average of 15 minutes, during which the subject smokes an average of 5 cigarettes. The treatment sessions are usually daily for 5 days.” What is the effect?

Clients undergoing rapid smoking experience increased burning in the lungs, palpitations, facial flush, headache, and feeling faint or weak.

What happened to our Hippocratic Oath to “do no harm?” Reading this, it seems as if the entire field seems to have lost its moral bearing - to the extent it supports treatments like this.

---

In college, I accidentally performed “aversion therapy in tobacco/nicotine use disorder” on myself. It was the end of a difficult semester. My charismatic if alcoholic South American professor of “Critical Modern Social Theory”, took us out drinking to a local dive bar at the end of our intensive seminar. Driving home he was weaving between the lanes and I barely survived but…more to the point: I was somewhat inebriated myself, though alcohol isn’t my favorite drug. At the bar, I wanted to get some cigarettes. Using an 11^th century vending machine, I accidentally pulled the level for Camel Unfiltered not the Marlboro Lights which were my adjacent target. After smoking a few of the unfiltered Camels, I experienced a profound “burning in the lungs, palpitations, facial flush, headache, and feeling faint or weak”. I was a one-man superfund site. My head was spinning, and I was swimming in nausea. I was so sick I stopped smoking until…the next morning. This technique not a wonder cure for tobacco smoking. The addiction is nicotine is too strong to be foiled by something like this.

My asthmatic lungs are still recovering 40 years later.

---

Aversive therapies frequently occurs, much more subtly, at rehab, which is the biggest source of uselessness in our sprawling addiction treatment apparatus. One hears stories of people in early recovery being screamed at, singled out to be belittled, and confronted in an overbearing, hostile manner. The idea is to correct the moral defects – by bludgeoning and coercion -- that they so fervently believe underpins our addictions.

While in rehab, people are fragile and traumatized. As a person in very early recovery, you are exquisitely sensitive and vulnerable. The last thing anyone needs is to be tortured, bullied, and harassed by these cruel, unscientific treatments, meted out by unqualified providers. We should call it “abusive therapy” not “aversive therapy.” There are much better treatments available than rehab, such as hospital-based, modern, outpatient care (which we provide at my hospital MGH). Hopefully, both rehab and aversive therapy will go by the historical wayside, and we can focus more on supporting patients, building them back up, and linking them to the treatment they need.

Future directions

Addiction doctors are well-intentioned and competent practitioners who do a fantastic job advocating for and treating some of the most down and out among us. The history of addiction runs the gamut, from abusive treatments like aversion treatment, to cult-like treatments like the 12-Step programs (which somehow do seem to help a subset of people), to modern, lifesaving treatments such as Suboxone (buprenorphine), methadone, and various harm reduction practices, such as needle exchange and post-exposure prophylaxis to prevent HIV. People who are suffering from addiction are already miserable, contending with a life-threatening and demoralizing illness, and trying to navigate the wastelands of their addicted landscape. Many of them are homeless, unemployed, physically ill, and separated from their families. They deserve the best, not the worst, from addiction medicine, and from society at large. They deserve to be nurtured, validated, and treated with scientific skill.