Some old Ritalin ads.
We’ve been seeing a lot of claims about the comparative effectiveness of AA or 12 step facilitation (TSF) versus motivational interviewing (MI) or motivational enhancement therapy (MET), most recently here. That AA/TSF is superstitious voodoo and MI/MET is rational, evidence-based and effective. (Interestingly, the author of the piece used an appeal to authority argument by invoking Bill Miller, one of the developers of MI. Keith Humphreys points out that, “the Miller work is cited to say things he doesn’t believe”.)
Just to be clear, Dawn Farm likes MI. We train staff in MI. We believe it’s a useful tool. However, we also believe it’s often oversold.
At any rate, a new study on MET just popped up in my feed reader. It included a very positive conclusion.
CONCLUSION: Motivational enhancement therapy (MET) appears to increase the percentage of days abstinent in patients with chronic hepatitis C, alcohol use disorders and ongoing alcohol use.
What was that conclusion based on?
FINDINGS: At baseline, subjects in MET had 34.98% days abstinent which increased to 73.15% at 6-months compared to 34.63% and 59.49% for the control condition. Multi-level models examined changes in alcohol consumption between MET and control groups. Results showed a significant increase in percent days abstinent overall [F(1,120.4)=28.0, p<.001] and a significant group by time effect [F(1,119.9)=5.23, p=.024] with the MET group showing a greater increase in percent days abstinent at 6 months compared with the education control condition.
So far, so good. Right? MET resulted in more days without drinking. It’s not total abstinence, but it’s movement in the right direction. That’s a good thing, right?
Oh, wait. There’s more.
There were no significant differences between groups for drinks per week.
If I understand correctly, that sounds like the MET group drank more when they drank.
The MET group appears to have gone from 19.5 drinking days per month with an average of 7.8 drinks per drinking day, to 8 drinking days per month with an average of 8.3 drinks per drinking day.
The control group appears to have gone from 19.5 drinking days per month with an average of 8.5 drinks per drinking day, to 12 drinking days per month with an average of average 7.8 drinks per drinking day.
Even if you accept drink counting as a good way to measure outcomes, that positive conclusion seems a little less positive, doesn’t it? And, when these authors argue AA or TSF don’t work, but MI or MET do, what does “works” mean?
This isn’t to say that MI isn’t useful, just that you should be suspicious when you see these comparative claims.
So, why do we see this over an over again? I imagine there are a lot of reasons. However, I heard something on the radio last week that might shed some light on on the persistence of these assertions and my sense that we’re caught up in a battle of the culture wars. I hesitate to bring this up, because I don’t want to nourish arguments that AA is religion (I’m an agnostic.), but last weeks’ episode of On Being was on science/religion debates. One of the guests said the following:
Dr. Bradley Correct. There’s another factor that you are alluding to here which is — is that not only is there a science and religion issue going on here, but there is also a power struggle going on, too. This is very much tied up with issues of power. Um, if you go back to the 19th century and look at the writings of people like T. H. Huxley, and, uh, Andrew Dickson White, um, these folks, um, saw so much of the formative influences in culture as coming from religion and they wanted to switch the locus of the power to shape culture to scientists.
And so it became a power struggle. And you see it on the Christian side as well. There are communities that, uh, that kind of want to stay closed, and one way is to make sure that people don’t talk too much to people who think differently themselves. And to create fear and suspicion and I think that’s a lot of what’s going on as well. So you’ve got all these power dynamics outside of the science and religion…
Has addiction treatment become an arena for these power dynamics? A struggle for the locus of power to shape culture?
“It’s hard to get the words out: I work in the White House,” said the 56-year-old Botticelli, looking slightly sheepish. “It’s really wild.”
Botticelli is the country’s acting drug czar, leading the nation’s fight against substance abuse less than two years after performing a similar job with the Massachusetts Department of Public Health.
He is also the first person in addiction recovery to hold the job
A new book, The American Health Care Paradox: Why Spending More Is Getting Us Less, offers an interesting take on why the United States’ huge investments in health care doesn’t translate into better health. Vox did an interview with the book’s authors.
The paradox that we outline is one that a lot of readers will be familiar with: that the United States has very high health-care costs, and in many cases middling — and sometimes lousy — health outcomes when you look at certain metrics. These are metrics — like infant mortality and life expectancy — where, when you look across developed nations, we’re really at or near the bottom.
People cited this paradox before our book, and tried to explain it in any number of different ways. That included rationales like, “Well, U.S. health outcomes are bad because too few people have insurance” or “because prices are just high.”
What our book tries to do is offer another reason that hasn’t been talked about much in health policy: maybe “health spending” isn’t telling us the whole story. Maybe we need to look at a broader summary of what resources nation puts in to support population health.
To do this, we included social services spending in our study, which captures things like housing, food assistance, and job training. The ratio of health to social-service spending was more predictive of several outcomes than health spending alone. This led us to suggest that social-service spending — and, more broadly, attention to the social determinants of health — could be a missing piece in the health reform discourse.
In explaining the concepts in the book, the authors make a very interesting and provocative statement.
To address the problem of over-medicalization of health we need to actually get to the way people relate to their own health, no matter how wealthy they are.
What?!? “Over-medicalization of health”?!?
What do they mean by that?
Think about shoulder pain or back pain. It’s very common in the American public to think “What kind of MRI do I need? What kind of specialist should I go to?” as opposed to thinking “Hm, maybe the briefcase I’ve been carrying around is too heavy. Maybe I’m not sleeping well. Maybe I haven’t hit the gym for the last three weeks.”
It strikes me that this is extremely relevant to the status of addiction treatment, especially as the Affordable Care Act takes effect.
What we have is a chronic disease approach that hasn’t been executed perfectly, but has avoided over-medicalization and it is facing growing pressure to medicalize. It’s also interesting that physicians treat their addicted peers with a model that avoids over-medicalization, but we’re losing support for similar approaches with the general public.
It’s also seems to me that Recovery Management does a good job of seeking to address these social determinants.
I also just saw a very relevant quote on Recovery Review from David Best.
So this question about community recovery capital is partly about stigma and discrimination – whether professionals (in the addictions and related field) believe that people recover and act accordingly. If you are in a system where all the addiction money is spent on substitution therapies, on detox and on counselling, your system does not believe that people recover!
Over the weekend, the NY Times published an article on the Center for Motivation and Change (CMC). The article struck me as a little odd, because it presented CMC as a radically innovative program that is besieged by one-wayers who believe AA and Al-Anon are the one true path for every alcohol problem. I also thought it presented a very unbalanced description of the research on AA and 12 step facilitation. But, I get tired of responding to these articles and let it go. I assumed it was a neutral reporter who interviewed a subject who fed her misinformation and she didn’t have the time or inclination to dig further.
Anna David calls out the author, pointing out that she’s the author of a book that suggested women are questioning “the safety and efficacy” of AA.
Over the weekend, The New York Times published one of those pieces. You know those pieces. They come out whenever an AA-slammer wants to sell more books or push their considerably dangerous agenda. The author of this one is Gabrielle Glaser, who published her AA-slamming book, Her Best Kept Secret—in which she claimed that women are questioning, in her words, “the efficacy and safety of…Alcoholics Anonymous”—last year . . .
Sounds like the, “some people say” attack strategy. (I’m not trying to start a political argument. I’m sure Fox isn’t the only outlet that uses the strategy.) As I thought about Anna David’s response, I realized the whole besieged description is the same kind of thing. There’s nothing especially controversial about CMC. I’m familiar with them and we have a different approach, but there’s no controversy. I’ve never posted about them, I’ve bought their book and I’d even consider referring some clients to them. In fact, I Googled “Center for Motivation and Change” and found a lot of links–they are good at getting themselves out there. However, I didn’t even see anything critical about them.
So, then . . . what’s this all about? It’s interesting that they didn’t take the approach, “This works too.” or some other approach that makes the case for CMC’s model without trying to tear down AA and 12 step facilitation. Anna David suggests its about book sales but seems to wonder if there’s more going on. Could be.
I’ve written often about the subtle bigotry of low expectations, these two posts illustrate that concern. (I like my reference to “pessimistic paternalism disguised as compassionate pragmatism.”)
A horrifying excerpt from a debate in a British treatment provider magazine. (It’s at the bottom of both pages.) I don’t completely understand the context–whether they are debating a “motion” in a binding way for the specialty society that publishes the magazine or if it’s a devise for a magazine column.
One of the participants proposed that detox is dangerous due to the possibility of reduced tolerance and unintentional overdose in the event of a relapse. Harm reduction advocates used to argue that they represented a needed choice philosophy in working with addicts. The is the worst kind of pessimistic paternalism disguised as compassionate pragmatism–and there’s nothing representing real choice.
…Detox can be dangerous and is not very often successful. Death rates are higher in recently detoxed patients.
Many people request detox but we need to recognise that maintenance is a very worthwhile option. Maintenance patients need our support – including psychological support – and harm reduction has to be our goal.
The NTA says rehab providers have to provide mechanisms for rapid referral into maintenance programmes. Getting people off drugs is dangerous.
Bill Nelles,founder of The Alliance,said: ‘Let’s take the morality out of drug treatment and put the humanity back in’. Judy Bury [GP] said it is our job as GPs to keep people alive until they are ready to change.
There’s not much evidence for long-term effectiveness of detox,but it can reduce tolerance. People cannot do abstinence when they walk in the service. The move toward abstinence-based treatment is dangerous and will increase drug-related deaths.
Let’s hope that the concept of “recovery impatience” does not catch on. Keep in mind that this is in the context of a country with a big emphasis on methadone and 60% of the methadone recipients have expressed a preference for abstinence based treatment.
“We are now seeing the emergence of a culture of “recovery impatience”: the demand for people to move quickly to a drug-free lifestyle while denying the signiﬁcance of other factors – such as low income and life in neglected communities – which make rapid achievement to a drug-free life impossible for the majority,” she said.
“The combination of totally unrealistic expectations, along with the demonisation of drug users, is having a trickle-down effect on practice, with “ﬁrmer” responses becoming more acceptable.
“We are in danger of harking back to the days when those seeking treatment were labelled as feckless and chaotic, deemed as having given up their right to be involved in their own treatment or to be treated with the dignity, respect and quality of care afforded other vulnerable groups in society.”
I missed this a while back. Turns out that ASAM’s president works for a buprenorphine manufacturer.
Stuart Gitlow, M.D., is the president of the American Society of Addiction Medicine (ASAM) and also medical director — as a consultant — for Orexo, which makes Zubsolv, a newly approved buprenorphine-naloxone medication (see ADAW, July 15).
The first public charge of a conflict of interest was made last month via Twitter by Mark Willenbring, M.D., former director of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism. In the tweet, Willenbring suggested that ASAM should examine its policies about conflicts of interest. While the connection with Orexo doesn’t mean that Gitlow’s beliefs and statements about buprenorphine are incorrect, it does raise questions, said Willenbring, now in private practice in St. Paul, Minnesota, where he provides treatment for substance use disorders and is a strong proponent of medication-assisted treatment. “At the same time, how can someone who is employed by the drug company have any credibility when his financial interest is in selling the drug?” Willenbring told ADAW. “My concern is with the increasing public perception, especially in psychiatry and addiction treatment, that financial interests taint and discredit professional opinions.” Gitlow’s dual roles, said Willenbring, raise this question: “Is he speaking for ASAM as a professional or for the pharmaceutical company as a salesman?”
While I don’t follow ASAM closely, I’ve seen no evidence of Gitlow advocating for any policy that would not receive broad agreement among ASAM membership.
However, as ASAM engages in advocacy around prescribing limits for buprenorphine, is it a conflict that the organization’s president gets a paycheck from a manufacturer?