Category Archives: Policy

The choice argument and pleasure cont’d

Pleasure-Island

The NY Times recently had a Room for Debate feature on addiction. They published opinions from 6 different people on addiction with one being a clear advocate for the disease model. This is a little like publishing a debate feature on climate change and having 1 of 6 experts believe that global climate change is occurring.

Two of the writers, Carl Hart (previous posts on Hart) and Gene Heyman (previous posts on Heyman), emphasized pleasure.

It’s well established that addiction is a disorder of the pleasure pathways. When other parts of the brain (related to, say, vision or movement) or other organs experience disorders, we don’t devote NY Times features to whether they really are a disease or whether choice is a factor in the illness. However, when pleasure enters the picture, we have a very difficult time surrendering the notion that we are, or should be, in full control of our behavior.

Kevin McCauley addresses the role of pleasure in advocacy for the choice argument:

Addiction is a disorder of the brain’s ability to properly perceive pleasure. I think it’s this moral loading of pleasure that makes it harder to accept that this is a disease process. It’s easier to just write addicts off as bad people who just want to feel good. In fact, that’s a corollary of the choice argument. It says exactly that, “Addicts don’t shoot gasoline into their veins, they shoot drugs into their veins! And, why? Because it feels good. Addicts do it because it feels good!”

In fact, there’s a sentence in the AA big book that says basically the same thing, “Men and women drink essentially because they like the effect produced by alcohol.” And that’s exactly right. What addiction is, is a defect in the brain’s like mechanism.  Pleasure is the capacity of the brain, and being a natural organ, the brain can break. And, addiction is, at it’s heart, a broken pleasure sense.

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Sentences to ponder

by karola riegler photography

by karola riegler photography

The more than 16,000 overdose deaths from prescription opioids each year disproves the idea that it’s easy to regulate addictive drugs if they are produced and provided legally. We can reduce the violence in markets, but we’ve paid a real cost in public health harms and in safety failures from reckless corporate behavior.

via 100 Americans die of drug overdoses each day. How do we stop that?.

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Vancouver home to Canada’s first crackpipe vending machines

image (1)Vancouver is the home to Canada’s first-ever crackpipe vending machines, which were installed in the city’s troubled Downtown Eastside in a bid to curb the spread of disease among drug users.

Portland Hotel Society’s Drug Users Resource Centre operates two of the machines. They dispense Pyrex crackpipes for just 25 cents.

“For us, this was about increasing access to safer inhalation supplies in the Downtown Eastside,” Kailin See, director of the DURC, told CTV Vancouver.

She said the pipes are very durable and less likely to chip and cut drug users’ mouths, which helps stop the spread communicable diseases including HIV and hepatitis C.

The vending machines are part of a harm-reduction strategy introduced by InSite, North America’s only medically supervised safe injection site.

via Vancouver home to Canada’s first crackpipe vending machines | CTV News.

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Addiction Recurrence after Prolonged Recovery

While there have been a lot of calls for evidence-based responses to Philip Seymour Hoffman’s relapse, Bill White points out that there is no evidence base for understanding long-term recovery and relapse after long-term recovery.

Treatment outcome studies suggest a principle:  recovery stability and permanence increase with duration of recovery, with the risk of future lifetime addiction recurrence declining to below 15% for those who have achieved 5 years of continuous recovery (see White, 2008 for a review).  That said, little information exists on the prevalence or processes involved in such recurrences after 10, 15, 20 or more years of recovery.  In 2009, Mel Schulstad and I published an article in Counselor entitled, “Relapse following Prolonged Addiction Recovery: Time for Answers to Critical Questions.”  We lamented the lack of research on long-term recovery, including research on what we referred to as late stage relapse (LSR, relapse after more than five years of stable recovery).  Here are some of the questions we posed in 2009.

Read all of the the questions here. Here are a few:

  • What is the prevalence of relapse across the life cycle of recovery? Are there points of vulnerability identifiable by age or duration of recovery?
  •  Does the rate of LSR differ by primary drug(s) involved in past dependence; across religious, spiritual, and secular frameworks of recovery; or by gender, race/ethnicity, sexual orientation, and the presence of co-occurring medical/psychiatric disorders?
  • Are there critical transition points between stages of recovery that constitute periods of increased risk of alcohol and other drug use and related problems?
  • Is there a relationship between LSR and the onset or progression of physical illnesses and their treatment (e.g., prescribed medication for acute or chronic pain)?

He minces no words about our failure to seek answers to these questions.

Philip Seymour Hoffman’s death is a tragedy that we as a country are collectively mourning.  But it is also a tragedy after billions of dollars spent on addiction research that we still do not have definitive or even preliminary answers to most of the above questions.  The reason we do not is our failure as a country to formulate and aggressively pursue a comprehensive recovery research agenda and to disseminate findings from that research to those who need it most: individuals and families seeking and in long-term addiction recovery.

Read the whole post at Addiction Recurrence after Prolonged Recovery | Blog & New Postings | William L. White.

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The choice argument and pleasure

Pleasure-IslandI know a lot of this week’s advocates of the choice argument are not, in any way, arguing that addicts are bad people. However, I can’t help but wonder what role pleasure plays in their resistance to the disease model and insistence on a choice argument. Kevin McCauley addresses the role of pleasure in advocacy for the choice argument:

Addiction is a disorder of the brain’s ability to properly perceive pleasure. I think it’s this moral loading of pleasure that makes it harder to accept that this is a disease process. It’s easier to just write addicts off as bad people who just want to feel good. In fact, that’s a corollary of the choice argument. It says exactly that, “Addicts don’t shoot gasoline into their veins, they shoot drugs into their veins! And, why? Because it feels good. Addicts do it because it feels good!”

In fact, there’s a sentence in the AA big book that says basically the same thing, “Men and women drink essentially because they like the effect produced by alcohol.” And that’s exactly right. What addiction is, is a defect in the brain’s like mechanism.  Pleasure is the capacity of the brain, and being a natural organ, the brain can break. And, addiction is, at it’s heart, a broken pleasure sense.

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Hoffman and Free Will

images (2)Some writers are using Phillip Seymour Hoffman’s death as an opportunity to attack the disease model and getting a lot of support from treatment critics.

Why would they pick an argument about the disease model and question the existence of loss of control after a man with everything to live for used heroin to his death despite efforts to stop?

I’ve addressed the matter in previous posts. Here are some highlights.

These objections seem to come down to philosophical questions about the role of free will. In a previous post I linked to a Points post that set up the issue nicely:

Although addiction may be defined and operationalized in a number of different ways, the heart and core of the concept lies in its implication of the loss of the ability to choose – that is, the loss of free will.  Hence, and logically, the concept of addiction also implies the actual existence of free will.  And there lies the rub.

The addiction concept repackages one of the Big Questions – free will and determinism – into a new and seemingly more manageable form.   But should we be entirely comfortable with the tacit implication that ordinary, non-addictive conduct is freely willed?

Of course, this assumption underlies much of our day-to-day lives.  We show up at work late and we are responsible for the choices we made that caused our lateness.  Our legal system relies on the same assumption as well.  It assumes people freely do what they do and must take responsibility for their actions.

It seems to me that most of the brain disease resistance I encounter can be boiled down to protecting the universal existence of free will. People feel compelled to protect this for good reason, our social interactions and institutions depend on it.

Another post addressed the apparent incompatibility between free will and determinism by suggesting that we conceptualize them improperly and offered a helpful metaphor:
If a machine has two controllers (one controller representing deterministic factors and the other representing free will), does that mean that only one controller works? Or, is it possible that they both are capable of controlling the machine?
If that is possible, is it also possible that various factors diminish and/or enhance the functioning of each controller?
Another post likened free will to a psychological energy that may be depleted or restored at various intervals.

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The Link Between Overcrowded Prisons and a Certain Drug

images (1)Keith Humphreys points out a common misconception about incarceration rates related to drugs.

Over the past few months, I have given some talks about public policies that could reduce the extraordinary number of Americans who are in state or federal prison. The audiences in every case were blessedly bright and engaged. Yet they also had a broadly shared misunderstanding about how two drugs are related to the U.S. rate of imprisonment.

At each talk an audience member expressed the view that over-incarceration would drastically diminish soon because states were now legalizing marijuana. I responded by asking everyone present to shout out their estimate of what proportion of people currently in a state or federal prison were serving time for a marijuana-related offense. The modal answer across audiences was around one third, which explains the shocked looks that greeted my pointing out that even under the most liberal possible definition of a marijuana-linked incarceration (e.g., counting a marijuana trafficker with 10 other felony convictions as being in prison solely due to marijuana’s illegality), not even 1% of the U.S. prison population would be so classified.

Not wanting to discourage people, I said that there was a different drug that was responsible for many times as many imprisonments as marijuana and for which we could implement much better public policies. I then asked people to guess which drug it was. Give it a try yourself (answer after the jump).

It’s alcohol. People at my talks guessed every illegal drug imaginable but not alcohol, which for cultural, commercial and political reasons is not generally thought of as a drug, even though chemically that’s exactly what it is.

Police make more arrests related to the drug alcohol than they do for every other drug combined. Sizable proportions of people who commit homicide, rape, simple assault, aggravated assault and robbery are drunk at the time. And as everyone knows, alcohol is also a leading cause of vehicular manslaughter.

Why is this fact invisible in our culture?

This is not an argument for locking people up for possession, but it’s clear that legalizing a drug doesn’t end a drug problem. And, one has to wonder, how many of these harms would be reduced if alcohol weren’t a celebrated, legal drug.

via The Link Between Overcrowded Prisons and a Certain Drug.

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Recovery MAINTENANCE

imagesThere’s a lot of commentary out there on Philip Seymour Hoffman’s death. Some of it’s good, some is bad and there’s a lot in between. Much of it has focused overdose prevention and some of it has focused on a need for evidence-based treatments.

Anna David puts her finger on something very important. [emphasis mine]

Let’s explain that this isn’t a problem that goes away once you get shipped off to rehab or even get a sponsor—that this is a lifelong affliction for many of us. There seems to be this misconception that people are hope-to-die addicts and then get hit by some sort of magical sunlight of the spirit and are transported into another existence where the problem goes away.

[NOTE - I know almost nothing of Hoffman or the treatment he received from his doctors or anyone else. My comments should be considered commentary on the issues involved rather than the specifics of Hoffman or the help he received.]

What I haven’t heard discussed much is his reported relapse a year or so ago. How could that have been prevented?

From what I understand, this is someone who had been in remission for 23 years. And, it sounds like his relapse began in a physician’s office when he was prescribed an opiate for pain.

  • What’s the evidence-base around treating pain in someone who has been abstinent for 23 years?
  • What are the evidence-based practices around how professional helpers should monitor and support the recovery of a patient who has been sober for decades?
  • What are the behaviors associated with recovery maintenance over decades through pain and difficult life experiences?

20090101-new-yearCould the outcome have been different if some sort of recovery checkup had been performed by his primary care physician or the doctor who treated his pain?

If he had been in remission from some other life-threatening chronic disease, wouldn’t his doctors have watched for a symptoms of a recurrence? Or,  given serious consideration to contraindications for the use of particular medications with a history of that chronic disease?

What if he had been asked questions like:

  • How’s your recovery going?
  • Have you had any relapses? Cravings?
  • How did you initiate your recovery?
  • How have you maintained your recovery?
  • Have there been changes in the habits associated with your recovery maintenance? (Meetings, readings, sponsor, social network, etc.)
  • How’s your mood been?
  • What do your family and friends who support your recovery say about this?

Also, if it’s determined that a high risk treatment (like prescribing opiates to someone with a history of opiate addiction) is needed, what kind of relapse prevention plan was put into place? What kind of monitoring and support?

There are two issues here. One is the lack of research, training and support that physicians get around treating addiction and supporting recovery.

The second issue is the role of the patient.

I listened to a talk by Dr. Kevin McCauley this morning in which he addressed objections to the disease model. One of the objections was that the disease model lets addicts off the hook. His response was that, given the cultural context, there were grounds for this concern. BUT, the contextual problem was with the treatment of diseases rather than classifying addiction as a disease. He pointed out that our medical model positions the patient as a passive recipient of medical intervention. As long as the role of the patient is to be passive, this concern has merit. He suggests we need to expect and facilitate patients playing an active role in their recovery and wellness.

So…this was someone who had been in remission for decades. He clearly had a responsibility to maintain his recovery. At the same time, the medical and/or treatment system has a responsibility to monitor and support his recovery.

I happen to have celebrated 23 years of recovery several months ago. I’m still actively engaged in behaviors to maintain my recovery. (Much like I’m actively engaged in behaviors to keep my cholesterol low.)

In 23 years, has a doctor or nurse EVER asked me how my recovery is going? No. Have they ever evaluated my recovery in ANY way? No.

Do they want to check my cholesterol every so often. Like clockwork.

This is a critical failure of the system and the evidence-base. And, we don’t just fail people with decades of recovery. Even more so, we fail people with 90 days, 6 months, a year, 5 years, etc. Then we blame the approach that helped them stabilize and initiate their recovery when the real problem was that we never helped them maintain their recovery. (Then, too often, our solution is to insist that they get into that passive patient role, just take their meds and let the experts do their work.)

via Another Senseless Overdose.

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Hell no, they ain’t doing that to me again

You may remember a few posts a while back about Dr. Carl Hart. He argues that addictive drug use is a rational choice by addicts and bases these arguments on his studies that involve giving crack to addicts and paying them for their participation in the study.

Some of you raised the obvious ethical questions about this kind of research. Well, Cassie Rodenberg shares a poem from an addict who is a former subject of a similar study. (I have no idea if it was actually one of Dr. Hart’s studies.)

One time I did this crack

Study for $2500,

Saw it on the train.

The building and the rock

Pristine Colo(u)mbian.

Never had any shit that good

In my life:

Small but potent,

Crack,

It’s psychological. They did me up

And down

In the head for days. No one told me

About the dance of the razors:

Hell no they ain’t doing

That to me

Again in their hospital

Chapel of

Help

via A Crack Study? Never Again | The White Noise, Scientific American Blog Network.

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Capitalism + Addictive Drugs = ?

money by Images_of_Money

money by Images_of_Money

When legalization advocates point to alcohol and tobacco, this kind of thing comes to mind.

A report published last week in the journal Nicotine and Tobacco Research found that while the nicotine content of cigarettes has remained relatively stable for more than a decade, the amount of that nicotine delivered to the machines researchers use as surrogates for smokers has been rising. The researchers, from the Massachusetts Department of Public Health and the University of Massachusetts Medical School, analyzed data from four manufacturers as required by state law. The findings varied among the companies and brands, but the overall trend led the researchers to conclude that changes in cigarette design have increased the efficiency of delivering nicotine to a smoker’s lungs. Young people who experiment with smoking may thus become addicted more easily and existing smokers may find it harder to quit.

Those provocative findings will need to be verified by other experts but are consistent with the surgeon general’s report. That report, issued on Jan. 17, found that some of today’s cigarettes are more addictive than those from earlier decades, based on the findings of a Federal District Court judge in 2006 who had access to industry documents spelling out how cigarettes were designed to make them more addictive. The industry’s tactics included designing filters and selecting cigarette paper to maximize the ingestion of nicotine and adding chemicals to make cigarettes taste less harsh and easier to inhale deeply.

 

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