A New Paradigm for Substance Abuse Treatment

From Robert DuPont, MD:

Substance abuse treatment is committed to abstinence from nonmedical drug use. Yet, continued nonmedical drug and alcohol use and relapse are so common that they are often defined as part of the disease itself.

A “new paradigm” for care management has been pioneered over the past four decades by the state Physician Health Programs (PHPs).¹ PHPs provide diagnostic evaluation, treatment referral, close monitoring and support services to health care professionals who have conditions, including in particular substance use disorders, which can impair their ability to practice medicine with reasonable skill and safety. In dealing with substance use disorders, PHPs use a zero tolerance standard for any alcohol or other drug use, enforced by intensive random testing and close linkage to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous to produce remarkable long-term outcomes. These outcomes set a far higher standard for success in treatment and they cast doubt on the definition of addiction as being characterized by relapse. They demonstrate that the environment in which the decision to use or not to use alcohol and drugs is a powerful determinant of outcomes.

YES!!!!

While some may dismiss the PHP results because physicians are a uniquely advantaged patient population, a similar approach has produced outstanding results in a dramatically different population of addicted people — convicted felons on probation. A randomized control study of the pioneering HOPE Program showed that compared to a control group of standard probationers, HOPE participants were 55 percent less likely to be arrested for new crimes, 72 percent less likely to use drugs, 61 percent less likely to miss appointments with probation officers and 53 percent less likely to have their probation revoked.³ HOPE probationers were sentenced to 48 percent fewer days of incarceration.

The new paradigm of long-term monitoring with swift, certain and serious consequences for any detection of drug or alcohol has the potential to substantially improve long-term outcomes for substance abuse treatment.

Now, I’m not interested in a paradigm that makes consequences a central element.

However, what’s important here is that there is a very effective treatment for this chronic illness and, like most treatments for chronic illnesses, we struggle with engagement and compliance. In the case of addiction, why do we respond to those struggles with a lowering of the bar?

Love First!

Our friends at Love First recently launched a major overhaul of their website. I has articles and a large collection of free videos for families who are concerned about loved ones.

It’s our top site for families asking questions about how to help a loved on with a drug or alcohol problem.

Check it out and share it with friends.

 

Primary care is good for recovery

Image via Wikipedia

Primary care visits are associated with better recovery outcomes:

A yearly primary care visit was also positively associated with remission (OR, 1.39), as was continuing care (OR, 2.34), defined as:

• having at least 1 yearly primary care visit,
• completing substance abuse treatment or receiving further treatment,
• receiving alcohol or drug treatment when the alcohol or drug Addiction Severity Index (ASI) score at last assessment was higher than 0, and
• receiving psychiatric services when the psychiatric ASI score at last assessment was higher than 0.

Makes our primary care project look pretty smart.

effective…as long as it is maintained

Perhaps I'm the Wrong Tool by Tall Jerome

This summarythat recent buprenorphine study suggests that the muddy waters are settling [emphasis mine]:

This study shows, yet again, that buprenorphine / naloxone is an effective treatment for opioid dependence as long as it is maintained, and that a tapering detoxification strategy, regardless of duration, fails the majority of patients.

The summary then goes on to argue for a medicalized treatment approach that puts pharmacology front and center:

As with the treatment of hypertension or diabetes, as long as the patient takes the medication, it works; when the medication is stopped, the disorder returns. The chronic nature of opioid dependence is worth reiterating in light of recovery-oriented orthodoxy and insurance requirements that mandate time limits on opioid agonist treatment. This study also found intensive counseling added nothing to SSM. Perhaps the time is coming when appropriate treatment will be called “counseling-assisted pharmacotherapy” rather than “medication-assisted treatment,” an acknowledgment that medication, not detoxification with counseling, should be the first-line treatment for opioid dependence.

I couldn’t disagree more with the conclusions the reviewer reaches, but I appreciate the clarity.

The next big question will be what kind of recovery this approach produces. Do these patients enjoy full recovery or some more limited version? (Brings me back to the question of whether mutual aid recovery is to addiction what exercise is to cardiac treatment. This would make buprenorphine like a stent.)

Related articles

• Goodbye detox, hello maintenance
• Top Posts of 2011 #2 – Dawn Farm’s Position on Buprenorphine Maintenance
• Doctors against medicalization
• bringing recognition, respectability and rigor
• “real addiction treatment”

New-ish Recovery Coaching Manual

I’m about 6 months behind the times, but here’s a recovery coaching manual and training curriculum from the McShin Foundation.

Ritalin Gone Wrong

Not surprisingly, we get a lot of clients who have been diagnosed with ADD or ADHD. Many are concerned about suggestions to discontinue prescription stimulants.

This NYT opinion piece has gotten a lot of buzz over the last couple of days:

In 30 years there has been a twentyfold increase in the consumption of drugs for attention-deficit disorder. …

TO date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems, the very things we would most want to improve. …

But in 2009, findings were published from a well-controlled study that had been going on for more than a decade, and the results were very clear. The study randomly assigned almost 600 children with attention problems to four treatment conditions. Some received medication alone, some cognitive-behavior therapy alone, some medication plus therapy, and some were in a community-care control group that received no systematic treatment. At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.

Indeed, all of the treatment successes faded over time…

He draws these conclusions:

Our present course poses numerous risks. First, there will never be a single solution for all children with learning and behavior problems. While some smaller number may benefit from short-term drug treatment, large-scale, long-term treatment for millions of children is not the answer.

Second, the large-scale medication of children feeds into a societal view that all of life’s problems can be solved with a pill and gives millions of children the impression that there is something inherently defective in them.

Finally, the illusion that children’s behavior problems can be cured with drugs prevents us as a society from seeking the more complex solutions that will be necessary. Drugs get everyone — politicians, scientists, teachers and parents — off the hook. Everyone except the children, that is.

 

Related articles

• Troubling news on attention-deficit medication for young people (macleans.ca)
• Time to Start Just Tranquilizing the Annoying Little Buggers: (brothersjuddblog.com)
• New ADHD guidelines could increase treatment in preschoolers and high schoolers (boston.com)
• ADHD in Kids Improves With ‘Healthy Diet,’ Elimination Has Little to No Effect (inquisitr.com)

PROMETA ineffective…duh

Image via Wikipedia

PROMETA as been demonstrated to be the sham we all knew it was.

Keith Humphreys offers a brief history of the “treatment” and some lessons:

1. …when the next wonder drug for addiction comes along (and it will), we must not yield to our powerful collective desire to believe before we have hard evidence of effectiveness from disinterested, respected sources. The simpler, faster and more miraculous-seeming the cure, the greater should be our skepticism.
2. There is a worrisome vulnerability in the US FDA’s new drug approval process. As was the case with another would-be ‘miracle cure’—ultra-rapid opiate-detoxification—a manufacturer was able to market an untested treatment protocol to addicted patients because the components of the treatment protocol had been previously FDA-approved for the treatment of other disorders.
3. Independent scientific research on addiction is essential for public health and safety.

If only it was easier to know what research and perspectives are independent and disinterested.

Related articles

• Join Together withdraws PROMETA article
• More on Prometa
• End of the Line for Prometa? (addiction-dirkh.blogspot.com)
• Anti-depressant Confusion
• Pain, Meds and Money
• a curious lack of skepticism
• Dr. Drew accepted pharma money?
• Top Posts of 2011 #1 – The Suboxone “Solution”

Everyone deserves a second chance

Reihan Salam directs us to this speech given by prominent Republican Chris Christie.

What’s so compelling is that this is a tough on crime speech by a rising and influential Republican governor who resume includes having been a prosecutor and he calls for diversion, compassion and treatment for addicts:

At the same time, let us reclaim the lives of those drug offenders who have not committed a violent crime. By investing time and money in drug treatment – in an in-house, secure facility – rather than putting them in prison.

Experience has shown that treating non-violent drug offenders is two-thirds less expensive than housing them in prison. And more importantly – as long as they have not violently victimized society – everyone deserves a second chance, because no life is disposable.

I am not satisfied to have this as merely a pilot project; I am calling for a transformation of the way we deal with drug abuse and incarceration in every corner of New Jersey.

So today I ask this Legislature and the Chief Justice to join me in this commitment that no life is disposable.

I propose mandatory treatment for every non-violent offender with a drug abuse problem in New Jersey, not just a select few. It will send a clear message to those who have fallen victim to the disease of drug abuse – we want to help you, not throw you away. We will require you to get treatment. Your life has value. Every one of God’s creations can be redeemed. Everyone deserves a second chance.

Salam summarizes:

he … made the case that nonviolent drug offenders should be given treatment rather than imprisoned because (1) it is cost-effective, (2) it is decent and humane, and (3) it recognizes that we can’t afford to waste human potential.

 

Missing the point

The American Journal of Public Heath (behind a paywall) has a new study looking at 2 year trajectories of residents in a “wet shelter”.  The found that the residents reduced their drinking by 40%.

Reducing drinking in these cases is a very good thing.

To me, there are several important questions but the first might be, “then what?”

Do we pat ourselves on the back that they are housed and drinking less? Mission accomplished? Or, do we view this gradual change as a start and continue to move them toward recovery?

If we’re talking about the latter, I have no quarrel with a program like this, in principle. (I say, in principle, because, in the context of scarce resources, my bias will probably be that funds would be better spent on improving treatment access and services.)

The study and coverage of it makes me bristle a bit because it responds to and refutes an “enabling hypothesis” that a housing first approach will increase an alcoholic’s drinking. This seems like a bit of a straw man.

Maybe I’m an outlier among people who are concerned about these kinds of programs, but my concerns are:

1. That this kind of program does nothing to address the individual’s alcoholism. (Not that it would make it worse.)
2. That it’s a palliative response to a treatable condition.

The study does address #1 to an extent. My response is that drink counting doesn’t tell you a whole lot about alcoholism, particularly with very severe cases. Addiction’s impact is so multidimensional to the individual and the loss of  control extends so far beyond drinking that it’s dot as though a 10% reduction in drinking equals a 10% improvement. Several analogies come to mind, for one, if your’re in chronic and severe pain and the pain is reduced by 10%, is that success? Does it equate to a 10% improvement in well being? Not necessarily. Sometimes, small improvements in a symptom are accompanied by disappointment and depression that this might be as good at is gets. The person may still be disabled. The pain may still be severe enough to interfere with sleep, relationships, other pleasures or participating in activities that are associated with wellness.

Again, I welcome improvement, IF it’s accompanied by an effort to continue moving in the direction of recovery.

My concern about the palliate approach is that it’s based on the assumption that these people can’t get well. This assumption often rests on other assumptions:

• That they’ve had access to treatment before and have not responded.
• That they don’t want recovery.
• That treatment is too expensive.

The problems with these assumptions are that:

• They probably never got treatment of the appropriate duration and intensity.
• Context is important in wanting recovery. Does the person see living proof that recovery is possible? Does the person work with helpers that express hope and optimism about their capacity to recover? Is help of adequate intensity and duration available on-demand?
• Treatment and recovery support doesn’t have to be expensive.
  • Arguments based on costs and savings are arguments within the economic monoculture and deserve re-examination. (Hospice is probably much cheaper than cancer treatment too, does that make it the right thing to do?)

There’s a way in which this is two things at once. An aggressive attempt to meet the basic needs of some very vulnerable community members, AND a form of abandonment by lowing expectations and offering no hope for recovery and wellness. (There was no reference to recovery  or gradual movement in the direction of abstinence in the article.)

Dr. Drew accepted pharma money?

Here are the details. No response from him yet.