Boston’s new mayor is starting to make good on a campaign pledge:
Mayor Martin J. Walsh announced today that the City of Boston’s addiction and recovery services are about to get an upgrade, taking a major step towards one of the more personal platforms of his campaign for the mayor’s seat.
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Through a collaboration with the Blue Cross Blue Shield of Massachusetts Foundation, a grant and research organization that works to expand access to health care services in Massachusetts, the city will create an expert advisory committee to evaluate the status of addiction and recovery services in Boston. Their work will culminate in a study that is expected in 2014, which will lay the foundation for a new Office of Recovery Services that will be run out of the Boston Public Health Commission, and will be funded by $300,000 of Mayor Walsh’s 2015 fiscal budget.
Back in November, I posted about Walsh’s openness about his recovery and his army of volunteers from the recovering community.
I believe there is an implicit formula undergirding this conception of willpower that “inability to resist temptation = addiction.” All parts of the formula—inability, resistance, temptation, and addiction—are worrisome.
Regarding inability: It would seem to follow that the further a person moves down the substance use disorder continuum (mild to severe), the less one is able to exert her self-control to resist the temptation of her drug of choice. A person either loses the ability she once had or develops the inability as she moves along the continuum. But what space is there to explore the conditions under which one loses the ability? This sort of question falls off the table and instead the focus remains on the individual and her failure to exert self-control in the right direction to the right degree.
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Regarding addiction: The formula tends to reduce a very complex set of phenomena to one characteristic, namely the failure of an individual to exert the right amount of self-control. Addictions progress and manifest in many different ways. At the end of the day, I am not convinced that all addictions share one thing in common. More on this in an upcoming post.
It’s worth pointing out that there is considerable evidence that “temptation” in the brains of addicts is turned up to 11 out of 10, while there is also evidence that the regions responsible to saying “no” to drugs are impaired. And, as she points out:
Saying no to things is exhausting, as Baumeister and Tierney argue. We live in a world of unending temptations, and at times it seems as if we are constantly caught in a deluge of wants and desires. Having said no to 99 things makes it more likely that we cannot when the hundredth temptation crosses our path.
It’s too good to pull quotes from, take the time to read the whole thing. Here’s a taste:
Dr. Dodes begins his criticism of AA and related treatment by citing a 1991 study published in the prestigious New England Journal of Medicine. This paper studied the treatment of a large number of individuals with alcohol problems. Dr. Dodes notes in his book that compulsory inpatient treatment had a better outcome than AA alone. But what he fails to mention is that the inpatient unit is a 12-step-based program with AA meetings during treatment, and requirements to attend AA meetings three times a week after discharge in the year following treatment.
Importantly, too, when you compare the alcohol outcomes (average number of daily drinks, number of drinks per month, number of binges, and serious symptoms of alcohol use), AA alone was just as good as the AA-based inpatient treatment. Yet Dr. Dodes uses this study to argue that AA is poor while inpatient treatment is good — a bizarrely distorted, misleading and incorrect interpretation of the study’s findings.
The paper outlines that retention in ORT is not great, with just over half of patients sticking with methadone and fewer with Suboxone. Despite this, in Berlin, as we have said, there are growing numbers of people on ORT. These are people who are not moving on; I suppose the ones the press call ‘parked’ on methadone. Hence the question the authors pose: “Why is this?”
Both patients and staff thought ORT helped physical and mental health. Beneficial effects of ORT on the ability to work and on crime were considered significantly higher by patients compared to staff.
Staff and patients agreed that coming off ORT was hard. Patients thought it harder than coming off heroin.
Patients wanted to eventually come off ORT at a significantly higher rate than staff estimated.
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The thing that intrigues me the most is the “striking discrepancy between the patients’ and staff members’ assessment of the patients’ desire to end OMT on the long term. The large majority of patients report the desire to end OMT on the long term, whereas only a minority of staff members believe that their patients might really have such a desire.”
David Best found much the same thing (in aspirational terms) in a sample of drugs workers in the UK. They believed only 7% of their clients would eventually recover.
DJ Mac’s take:
It’s clear to me that where there is such a mismatch, when the bar is set so low and when there is little hope pervading treatment settings, then it’s no wonder that so few move on.
By the conclusion the authors find themselves at odds with the assertion at the start of the paper (that ORT has an aim of ‘abstinence from opioids’.) Here’s what they say (my emphasis):
“Finally, detoxification of OMT is not the prime objective of treatment. The prime objective of treatment is continued physiological and social stabilization. As yet, there is no validated medical cure for opioid addiction. Until a curative medication or a safe curative procedure is developed, many of the patients may have to remain in treatment for the duration of their lives to avoid relapses, increased criminality, subsequent overdoses, and death during the post treatment period.”
So the solution to the mismatch between the low expectation of staff and the higher expectation of patients is to lower the expectation of patients to that of staff?
It’s clear that issues identified in this paper are not isolated. They report on the patient experience in Germany. It resonates with DJ Mac in the Scotland. And, it resonates with me, here in the states. (Methadone’s problems in the US are often attributed to a system that’s dominated by abstinence-oriented providers who stigmatize ORT. That can’t be said of the other countries.)
The post, to my mind, ended up being a great informed consent document on one of the more concerning hazards of ORT.
This program will examine the evidence that eating disorders are true biopsychosocial diseases, similar to chemical dependency. The program will define various eating disorders and their consequences, explore neurobiological and behavioral theories of addiction, describe physiological consequences of eating disorders, discuss screening tools, and provide information on treatment options and resources for people with eating disorders.
Dr. Christensen is an Associate Professor in the Departments of OB Gyn and Psychiatry at WSU School of Medicine. He obtained his MD and PhD in Biochemistry at Wayne State University School of Medicine and did his residency in OB Gyn at Hutzel Hospital. He then completed a Fellowship in Gyn Oncology at Duke University Medical Center. He later became certified in Addiction Medicine and is also certified as a Medical Review Officer.
He is currently the Medical Director for the Student Health Monitoring Program at the WSU School of Medicine, which is designed after the Michigan Health Professional Recovery Program (HPRP). He is also currently the Vice Chairman of the Michigan Health Professional Recovery Committee, which oversees the HPRP.
In addition to treating pain and chemical dependency in his private practice at Pain Recovery Solutions in Ann Arbor, Dr Christensen specializes in treatment of chronic pain, especially pelvic pain, and the treatment of addiction in pregnant patients.
He is the current Medical Director of the James Wardell Women’s Recovery Center, an outpatient program dedicated to caring for pregnant, chemically dependent women, as well as the Medical Director at the Substance Abuse Research Division in the Department of Psychiatry at WSU. He is the current President of the Michigan Society of Addiction Medicine. He is the Associate Residency Program Director for the OB Gyn residency at Wayne State University/Detroit Medical Center and has received numerous teaching awards.
He has been named one of the “Top Docs” in Addiction Medicine in Hour Magazine for 2006, 2007 and 2008. He has also served as a past Medical Director for Dawn Farm.
He lives in Superior Township with his wife Cathy, a Nurse Practitioner, and their 3 dogs and multiple rescue cats.
Lori Perpich, MS, LLP
EDEN Program Facilitator, ED League of Michigan Member
Lori started working directly with women recovering from eating disorders in 2000 through an organization called EDEN (The Eating Disorders and Education Network). She became a facilitator in both Washtenaw and Livingston County. For 8 years she led groups through the EDEN Process. The EDEN Process is a 17- week course of one hour meetings. Each meeting covers a specific topic related to recovery and or the acquisition of behavioral skills to break disordered eating habits. Lori facilitated 2 groups per year for women recovering (ages 18-55), and a separate group in each county for families and supporters. In 2004 she began working on her Masters in Clinical Behavioral Psychology at Eastern Michigan University with a clinical interest in behavioral approaches to eating disorders. Lori became involved with Dawn Farm through EDEN, and later conducted her Psychology internship at Dawn Farm. This opened a door for Lori to work with clients experiencing co-addiction of eating disorders and chemicals. Since graduation in 2008 she has been working individually with eating disorder clients in Ann Arbor many of which are dually diagnosed with chemical addiction. Lori continues to lead an ongoing EDEN group in Ann Arbor.
Lori’s personal approach to eating disorder treatment is both whole and behavioral. She approaches eating disorders as an addiction with physiological and classically conditioned or escape maintained behaviors. She examines with her clients both their skills for intervening in habit breaking and their overall balance in emotional, social, physical, and spiritual health. She works with her clients to find their most powerful self- worth, accountability and motivations which will give them the strength to intervene in their disorder. She herself is a recovered bulimic and draws on her experience to aid clients through recovery and seeking balance.
Lori has two sons and lives in the Livingston County Area.
A new study on the relationship between access to transportation and exiting poverty caught my attention:
But a new study co-led by myself; Evelyn Blumenberg from the University of California, Los Angeles; and Casey Dawkins from the University of Maryland suggests there is at least one group that may need help to drive more, not less: low-income residents of high-poverty neighborhoods.
Our evidence comes from two Department of Housing and Urban Development demonstration programs: Moving to Opportunity for Fair Housing and Welfare to Work Vouchers. Both were designed to test whether housing choice vouchers—that is, subsidies that allowed participants to choose where they live—propelled low-income households into greater economic security.
Taken together, data sets from these studies allowed us to examine neighborhood quality, neighborhood satisfaction, and employment outcomes for almost 12,000 families from 10 cities: Atlanta, Augusta, Baltimore, Boston, Chicago, Fresno, Houston, Los Angeles, New York, and Spokane.
The results? Housing voucher recipients with cars tended to live and remain in higher-opportunity neighborhoods—places with lower poverty rates, higher social status, stronger housing markets, and lower health risks. Cars are also associated with improved neighborhood satisfaction and better employment outcomes. Among Moving to Opportunity families, those with cars were twice as likely to find a job and four times as likely to remain employed.
The importance of automobiles arises not due to the inherent superiority of driving, but because public transit systems in most metropolitan areas are slow, inconvenient, and lack sufficient metropolitan-wide coverage to rival the automobile.
When asked about Dawn Farm’s success, we make it clear we’ve had a lot of good fortune, a lot of help from good friends and we’ve made some good decisions. We also point out that we are fortunate to be in a community with good public transportation and job opportunities.
I have a few thoughts. First, this speaks to the challenge of trying to replicate our housing and support services in a different environment.
Second, so many alcoholics seeking treatment have suspended driver licenses and the suspensions seem to be getting longer and longer. I’m not necessarily a proponent of easing those suspensions—drunk driving is dangerous, though sobriety courts seem like s good strategy for managing the risk. But, this study speaks to how debilitating losing a license can be in socio-economic terms. But, how about in terms of recovery?
This also speaks to the power of the informal networks that people find in mutual aid groups that help with transportation.
Here’s the thing. Pat was incredibly generous, compassionate and a pretty amazing vector of hope. Thousands of people are immeasurably better off (great jobs, great lives and helping others) because of him. Pat found room for this generosity within a life that included 6 children. 3 of them are still school aged. Pat took good care of them. They’ll be OK. But, it won’t be easy.