How do we know if we do not ask?


listenRecovery Science shared a couple of qualitative studies on the experiences of MAT patients.

The first identified 7 themes:

  1. Patients may not be aware of treatment alternatives
  2. Treatment expectations and goals may differ between clinicians and patients
  3. Prior experiences with buprenorphine or methadone influence treatment decisions and expectations
  4. Accountability and structure facilitate treatment engagement for some, create barriers for others
  5. Desire, among some, to avoid methadone clinics or associated stigma
  6. Fear of continued addiction and perceived difficulty of withdrawal among people who have a goal to be drug-free
  7. Among patients with chronic pain, pain control is an important consideration

The second identified 4 themes:

  1. the loss of hope,
  2. trapped in OMT,
  3. substitution treatment is not enough, and
  4. stigmatization of identity.

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1 in 12 US physicians received a payment involving an opioid

From the American Journal of Public Health:

Approximately 1 in 12 US physicians received a payment involving an opioid during the 29-month study. These findings should prompt an examination of industry influences on opioid prescribing.

That’s not 1 in 12 pain specialists, or 1 in 12 addiction medicine specialists, that’s 1 in 12 US physicians.

Here are more details:

Over the study period, 375,266 nonresearch payments involving a marketed opioid were made to 68,177 physicians, totaling $46,158,388. Total payments increased from $18,958,125 in 2014 to $20,996,858 in 2015, an increase of 10.7%. The number of payments increased from 145,715 in 2014 to 184,237 in 2015, an increase of 26.4%.

The 5 opioid products constituting the greatest proportion of payments were fentanyl ($21,240,794; 46.0% of total dollars), hydrocodone ($7,123,421; 15.4%), buprenorphine transdermal patch ($5,141,808; 11.1%), oxycodone ($4,487,978; 9.7%), and tapentadol ($4,296,130; 9.3%). Overall, payments for FDA-approved abuse-deterrent formulations totaled $9,352,959 (20.3%), and payments for buprenorphine or buprenorphine/naloxone marketed for addiction treatment totaled $4,561,729 (9.9%).

The median payment was low, around $50.

However, a JAMA published study reached the following conclusions about compensation as small as a meal:

Receipt of industry-sponsored meals was associated with an increased rate of prescribing the brand-name medication that was being promoted. The findings represent an association, not a cause-and-effect relationship.

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Meanwhile . . .

While opioids get all the attention (justifiably, due to the death rates), Marc Schuckit discusses findings from a recently published study of alcohol use and alcohol use disorders (AUD):

The results documented substantial increases in the prevalence of past 12-month drinking, high-risk drinking, and AUDs. The largest increase related to the rate of the most serious problems, AUDs overall, which shot up by 49.4%, from 8.5% in 2001/2002 to 12.7% about a decade later. These figures are limited to the past 12-month, or current, diagnoses and do not include individuals who are in potentially temporary remissions. Respondents with lifetime but not current AUDs are also likely to carry future health care costs through enhanced vulnerabilities for cancers, cardiac disease, and other serious disorders associated with histories of heavy drinking.

The overall changes in prevalence over the decade were even greater for several population subgroups including women (an 83.7% increase in AUDs over the 11 years), African American individuals (a 92.8% increase in AUDs), individuals aged 45 years to 64 years and 65 years and older (with 81.5% and 106.7% increases in AUDs, respectively), those with only high school educations (a 57.8% increase in AUDs), and individuals with incomes less than $20 000 (a 65.9% increase in AUDs). During that same period, high-risk drinking, described using the previously mentioned criteria, increased from 9.7% to 12.6% (a change of 29.9%), with similar subgroups as reported for AUDs demonstrating the greatest increases. The proportion of drinkers increased from 65.4% to 72.7% (an enhancement of 11.2%). Similar results have been reported in other national surveys, indicating that the National Epidemiologic Survey on Alcohol and Related Conditions findings are not anomalies.

What the hell is going on?


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Sentences to Ponder

stop.think. by sarcasmo

photo credit: sarcasmo

. . . the clinicians of the future, really need to be oriented in a counselor mode, where they are not just telling you what the options are, but also eliciting from you very clearly what your goals are, and then making a recommendation about what most matches your goals. What are your priorities for your quality of life as well as quantity of life? People have priorities besides mere survival.

When we don’t ask and don’t know how to ask what those priorities are, the treatment is often mismatched with those priorities, and that’s where you get suffering, and that’s where you get lots of hot air from doctors, and you have total misalignment. When you are able to elicit those goals and then align the care with it, you have massively better outcomes, both for quantity and quality of life.

Atul Gawande

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Sentences to ponder


by karola riegler photography

. . . in the end, the federal government has very little control over criminal justice. About 90 percent of all prisoners—and a far greater percentage of those in jails, on probation, or who are arrested every year—are handled by states and counties, not by the federal government. And the federal government cannot directly tell states what to do when it comes to dealing with these individuals. For example, they cannot make local governments change their laws, enforce existing laws more aggressively, or determine who is released on parole or who is sent back to prison.

Read the rest here.


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It takes a treatment that works.

I usually bristle at attempts to correct and manage other people’s well-meaning speech. However, this headline from the Washington Post grabbed me.

It doesn’t take a warrior to beat cancer. It takes a treatment that works.

How true this is for addiction, too.

There is a treatment that delivers long term abstinence rates north of 70%. (One study of 904 patients found 5 year abstinence rates of 79% with only 4% experiencing 2 or more relapses.) Research also indicates that it is just as effective with patients who are injection drug users.

What’s sad is that very few people get access to this model.

To make matters worse, this model is rarely discussed. Advocates focus their efforts on approaches associated with reduced drug use and symptoms rather than long term abstinence and, often, are silent on this gold standard approach.

The treatment industry is full of hustlers. How do we know this isn’t just another hustle? There are at least 2 reasons to believe in it.

  1. It’s been studied and published.
  2. This approach is used on addicted physicians and pilots. (If you want to know the best treatment option for a health problem, find out which approach doctors choose for themselves, their peers, and loved ones.)

They get a certain combination of treatment, monitoring, and support. And, importantly, they get the right dose, duration, and quality.

Why do we hear so little about this?

It does demand a lot of the patient. It demands a lot of health care providers.

This being the case, it should not be the only option.

But, every patient ought to know about it and it should be an option for all.

Here’s a previous post that provides more information on common objections.



I frequently point to health professional recovery programs when discussing the effectiveness of drug-free treatment when it’s delivered in the appropriate dose, frequency and duration. They have stellar outcomes. (More details here.)

The programs were abstinence-based, requiring physicians to abstain from any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Tests rapidly identified any return to substance use, leading to swift and significant consequences. Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. … The unique PHP care management included close linkages to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous and the use of residential and outpatient treatment programs that were selected for their excellence.

I generally get three counter-arguments:

  1. That health professionals have more recovery capital and are more likely to recover than other addicts.
  2. That the threat of license suspension/revocation provides a unique combination of carrot and stick. We’ll never get that kind of engagement with regular people.
  3. That treating everyone in this manner would be too expensive—we’ve made a decision, as a culture, that we’re willing to invest this time and capital into addicted doctors but we can’t do it for everyone.

I want to respond to these arguments in this post.

1. “Health professionals have more recovery capital and are more likely to recover than other addicts.”

There may be ways in which health professionals are unique in terms of recovery capital. This may be true. However, they also face a unique set of barriers when initiating recovery. A study of physician recovery programs (this excludes health professionals other than physicians) found high rates of opioid addiction (35%), high rates of combined alcohol and drug problems (31%) and high rates of psychiatric problems (48%). In addition, 74% were not self-referred.

Further, health professionals confront easy access to drugs and with this ease of access to prescription drugs, they often develop tolerance levels that dwarf those of street addicts.

Two pieces of folk wisdom may also be relevant:

  • “Doctors make the worst patients.”
  • “I’ve never met anyone too dumb for recovery, but I’ve met plenty of people who were too smart.”

So…they may have unique advantages, but they also have unique barriers. If there is a difference, is there reason to believe it’s stark enough to it wouldn’t work for other addicts?

2. “Heath professionals are uniquely motivated because of the threat of license suspension/revocation.”

This is probably the strongest counter-argument.

Health professionals place incredibly high value on their profession. They often put enormous time, effort and money into becoming a health professional, but it’s more than that. Their profession often becomes integral to their identity and is a key source of meaning and purpose. In health professional recovery programs, we’ve constructed a system that uses this incredibly powerful element of the addict’s life to initiate and maintain their recovery. And, it’s not just threats. They offer a path to returning to work in a pretty expeditious time-frame, they provide peer support, they develop contracts with employers that provide both support and monitoring.

What would happen if we constructed systems that identified and used (not through coercion or manipulation) elements of the addict’s life that are integral to their identity and are a key sources of meaning and purpose? Debra Jay has developed one model of recovery support that seeks to do exactly this. (Interestingly, she’s had to develop a model that doesn’t require professionally directed services, because it’s not covered by insurance and many families may not be able to afford it.)

What else could be done? We don’t know. Because, as a system, we haven’t tried.

I recently blogged on the issue of coercion and health professional recovery programs and said this:

. . . it is our experience that attracting people to the front door is pretty easy if you have an attractive back door. In our case, this includes:

  • safe, affordable and stable sober housing;
  • opportunities for stable employment with advancement opportunities;
  • a large, welcoming and energetic recovering community (with lots of opioid addicts in long term recovery);
  • two local collegiate recovery programs that support a path to college degrees; and
  • lots of recovery role models providing support and demonstrating that all of this is do-able.

If we can create systems that provide this kind of back door and integrate long term recovery monitoring and support, I think it could go a very long way toward overcoming the long-term-voluntary-engagement-without-coercion issue.

. . .

I’m not suggesting that we’ll have relapse rates as low as 22% over 5 years. I’m also not suggesting that it’d be easy to keep people engaged for 5 years. But, what’s possible? Huge improvements, I’d imagine. But, we don’t know, because we haven’t tried.

Imagine that we tried and engaged in continuous improvement for 10 years. How far could we go?

3. “Treating everyone in this manner would be too expensive.”

So, then, what is provided and what might it cost to replicate it?

First, what is provided:

The first phase of formal addiction treatment for two thirds of these physicians (69%) was residential care often for 90 days. The remaining 31% began treatment in an intensive day treatment setting. The participants at this stage usually received multiple intensive sessions of group, individual, and family counseling as well as an introduction to an abstinence-oriented lifestyle through required attendance at Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Caduceus meetings (a collegial support association for recovering health professionals) and other mutual-aide community groups. Frequent status reports on treatment progress were required by most PHPs.

Use of pharmacotherapy as a component of treatment for SUDs was rare. Very few of the treatment programs or the medical directors of the PHPs used any of the available maintenance or antagonist medications.

After completion of initial formal addiction treatment, all PHPs developed a continuing care contract with the identified physician consisting of support, counseling, and monitoring for usually 5 years. Most PHPs (95%) also required frequent participation in AA, NA, or other self-help groups and verification of attendance at personal counseling and/or Caduceus meetings.

Physicians were tested randomly throughout the course of their PHP care, typically being subject to testing 5 of 7 days a week.

Physicians were typically tested an average of four times per month in the first year of their contracts for a total of about 48 tests in the year. By the fifth year, the average frequency of testing was about 20 tests per year.

How much would this cost to replicate? The following is based on Dawn Farm’s fees and costs.

  • $16,800 – 120 days of residential treatment plus unlimited aftercare groups
  • $5460 – 364 drug screens over 5 years ($15 per screen. 2x per week for first 2 years, 1x per week for years 3-5.)
  • $10,000 – 100 outpatient group sessions ($25) and 100 outpatient individual sessions ($75)
  • $5000 – 5 years of recovery support and monitoring from a Recovery Support Specialist with a caseload of 40 (A former head of Michigan’s monitoring program reports that their Case Managers have approximately 150 cases each.)
  • Total = $37,260

Now, this does not include one important element—a workplace monitor and a career employer making contract compliance a condition of employment. However, we offer transitional housing to clients for up to two years.

At less than $38,000 for the whole package, in the context of American healthcare spending, this does not seem to be an unsustainable burden and, in fact, is likely to be a very wise investment in pure financial terms. It’s in the same ballpark as inserting a stent–just the procedure, excluding continuing care, medications, etc. We implant 2,000,000 stents per year.

Imagine what would be possible if 2,000,000 addicts were given that opportunity. Imagine what we could learn.

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Another buprenorphine retention finding

Source: Abby Covert

There has been a lot of discussion about the use of buprenorphine to treat addiction and prevent overdose.

I’ve pointed out that weak retention rates weaken this rationale.

One common response is that the treatment system and recovering community reinforce stigma associated with maintenance medications and undermine outcomes, including retention.

This makes retention findings from other countries and cultures of interest.

The Journal of Substance Abuse Treatment just published a report on a small study of buprenorphine maintenance retention in young adults in India.

First, a natural question is, “What does treatment look like in India?”

The current study was conducted at an apex (tertiary level) substance use disorder treatment centre from the northern part of India. It is a WHO Collaborating Centre on Substance Abuse. The facility is a 50 bedded centre which is involved in providing clinical services, capacity building, conducting research, and guiding policy decisions for addiction related issues in India. The centre offers both inpatient and outpatient treatment, along with services for psychotherapeutic interventions and psycho-social rehabilitation.

Patients are primarily admitted at the centre for opioid and alcohol detoxification. The duration of admission is typically for 2–3 weeks. During the inpatient stay, patients are provided medications for symptomatic management of withdrawal symptoms. Medications for detoxification at the centre typically include benzodiazepines for alcohol use disorders and buprenorphine for opioid use disorders. After detoxification, the patients are started on medications for long term phase. Treatment for co-occurring psychiatric disorders is also provided (Sarkar, Balhara, Gautam, & Singh, 2016).

The centre offers maintenance therapy for opioid use disorders in form of buprenorphine (including buprenorphine-naloxone combination) (Balhara & Jain, 2012; Prakash & Balhara, 2016). Buprenophine induction can occur in the out-patient as well as in-patient setting. After initial period of dose stabilization buprenorphine is dispensed on a daily basis for a period of three months. Subsequently, the patient is shifted to take home doses of buprenorphine-naloxone combination that is dispensed on a biweekly basis, before shifting the patients to a weekly dispensing regimen. The earlier practice of alternate day dispensing (dose for two days administered on one day and the patient shall visit on alternate day) has been discontinued at the centre before the data collection period for the current study (Balhara, 2014). The patients are also provided counseling and rehabilitation services. These interventions are more intensive in the in-patient setting as compared to the out-patient setting.

What did they find?

The current study found the retention rates on buprenorphine maintenance to be 33.8% at 90 days, 19.11% at 6 months and 11.8% at 12 months.

See other posts about buprenorphine findings here.

As I’ve said many times, none of this is to suggest that buprenorphine should not be available to any patient who chooses it. It’s just a push for good informed consent that empowers patients to advocate and choose for themselves.

This information is too often elided, even when delivering legitimate criticisms of other treatment approaches.

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