Naloxone is not enough – updated

 

This is a repost from earlier in the week that has been updated to include an exchange with a commenter that touches upon some important themes in responding to OD and opiate addiction.

================

NARCAN-KITFrom USA Today:

Fulcher [an emergency room physician at Sts. Mary & Elizabeth Hospital in Louisville, Ky.]says he generally supports giving greater access to naloxone, which at one point his ER administered so often doctors felt like they were running a drive-through OD clinic. But he says new laws “totally ignore” the overall problem of addiction and may communicate an underlying acceptance of intravenous heroin use. “Politicians will feel like they’ve dealt with the problem,” Fulcher says.

There’s a comment on Join Together that suggests this is a straw man, that no one says naloxone is enough. There’s some truth to this.

At the same time, how much action are we hearing about to increase access to treatment of an appropriate quality, intensity and duration?

UPDATE:
A commenter expressed concern about Dr. Fulcher’s concern that we “may communicate an underlying acceptance of intravenous heroin use.” In her comment she cited a reseacher (and harm reduction activist) Peter Davidson. The exchange touched upon some important themes. Below is my lightly edited response.

That line made me cringe too. However, not knowing anything about him, I’m willing to give him the benefit of the doubt.

First, you didn’t include an important line from that quote, “‘Politicians will feel like they’ve dealt with the problem,’ Fulcher says.” This changes the context considerably. It makes it sound less like a concern about increased drug use and more like a concern about political indifference.

Second, he’s an ED physician and his reference to ERs feeling like “drive-through OD clinics” suggest he’s witnessing what we see in our community–an OD, naloxone reversal, brief visit to the ED with (at best) a passive referral to treatment, and ODing again, sometimes fatally. It becomes normalized and is not treated like a near fatal event/symptom of a life-threatening illness with a high mortality rate.

Finally, he’s not saying we need less naloxone. He’s saying we need naloxone-plus–that we need naloxone plus addiction treatment.

Given that, I’m willing to interpret his statement as a poorly worded expression of concern about professional and social indifference to non-fatal OD.

It’s interesting. After your comment I looked to read more on Peter Davidson. I see that he created odgame.org.

While I’m not crazy about the style of it, what really bothered me was the content of the game. If you call 911, the game continues for 3 turns (unless you do something to kill the person). However, if you give the person naloxone, it’s game over, with a pat on the back and instructions to:

“If you can’t stay with them, try and leave them with someone else. If that isn’t an option either, at least try and leave them in a public place so there’s a chance some passer-by might notice if they lose consciousness again.”

I think this is exactly what Fulcher was pushing back against. No mention of getting medical help. No mention of treatment. No hope for recovery. No using this as a window of opportunity to intervene. Mission accomplished and we can feel good about ourselves.

Can you imagine instructing people to use an automated defibrillator on someone who has a heart attack and the care ending there with a congratulations? Or worse, leave them in a public place?

2 Comments

Filed under Uncategorized

Naloxone is not enough

NARCAN-KITFrom USA Today:

Fulcher [an emergency room physician at Sts. Mary & Elizabeth Hospital in Louisville, Ky.]says he generally supports giving greater access to naloxone, which at one point his ER administered so often doctors felt like they were running a drive-through OD clinic. But he says new laws “totally ignore” the overall problem of addiction and may communicate an underlying acceptance of intravenous heroin use. “Politicians will feel like they’ve dealt with the problem,” Fulcher says.

There’s a comment on Join Together that suggests this is a straw man, that no one says naloxone is enough. There’s some truth to this.

At the same time, how much action are we hearing about to increase access to treatment of an appropriate quality, intensity and duration?

UPDATE:
A commenter expressed concern about Dr. Fulcher’s concern that we “may communicate an underlying acceptance of intravenous heroin use.” In her comment she cited a reseacher (and harm reduction activist) Peter Davidson. The exchange touched upon some important themes. Below is my response.

That line made me cringe too. However, not knowing anything about him, I’m willing to give him the benefit of the doubt.

First, you didn’t include an important line from that quote, “‘Politicians will feel like they’ve dealt with the problem,’ Fulcher says.” This changes the context considerably. It makes it sound less like a concern about increased drug use and more like a concern about political indifference.

Second, he’s an ED physician and his reference to ERs feeling like “drive-through OD clinics” suggest he’s witnessing what we see in our community–an OD, naloxone reversal, brief visit to the ED with (at best) a passive referral to treatment, and ODing again, sometimes fatally. It becomes normalized and is not treated like a near fatal event/symptom of a life-threatening illness with a high mortality rate.

Finally, he’s not saying we need less naloxone. He’s saying we need naloxone-plus–that we need naloxone plus addiction treatment.

Given that, I’m willing to interpret his statement as a poorly worded expression of concern about professional and social indifference to non-fatal OD.

It’s interesting. After your comment I looked to read more on Peter Davidson. I see that he created odgame.org.

While I’m not crazy about the style of it, what really bothered me was the content of the game. If you call 911, the game continues for 3 turns (unless you do something to kill the person). However, if you give the person naloxone, it’s game over, with a pat on the back and instructions to:

“If you can’t stay with them, try and leave them with someone else. If that isn’t an option either, at least try and leave them in a public place so there’s a chance some passer-by might notice if they lose consciousness again.”

I think this is exactly what Fulcher was pushing back against. No mention of getting medical help. No mention of treatment. No hope for recovery. No using this as a window of opportunity to intervene. Mission accomplished and we can feel good about ourselves.

Can you imagine instructing people to use an automated defibrillator on someone who has a heart attack and the care ending there with a congratulations? Or worse, leave them in a public place?

4 Comments

Filed under Uncategorized

Why so irrational about AA?

AA isn't the only way to recover, but no reasonable person can say it's ineffective.

AA isn’t the only way to recover, but no reasonable person can say it’s ineffective.

Gabrielle Glaser has gotten another AA bashing article published and it’s getting a lot of attention. Of course she doesn’t really offer a tangible alternative.

I’m not going to write another piece rebutting it, but I’ll point you to a few relevant posts.

First, in New York magazine, Jesse Singal dismantles Glaser’s arguments.

As with any story about a complicated social-science issue, there are aspects of Glaser’s argument with which one could easily quibble. For one thing, she repeatedly conflates and switches between discussing AA, a program that, whatever one thinks about it, is clearly defined and has been studied, in one form or another, for decades, and the broader world of for-profit addiction-recovery programs, which is indeed an underregulated Wild West of snake-oil salesman offering treatments that haven’t been sufficiently tested in clinical settings. Her argument also leans too heavily on the work of Lance Dodes, a former Harvard Medical School psychiatrist. He has estimated, as Glaser puts it, that “AA’s actual success rate [is] somewhere between 5 and 8 percent,” but this is a very controversial figure among addiction researchers. (I should admit here that I recently passed along this number much too credulously.)

But on Glaser’s central claim that there’s no rigorous scientific evidence that AA and other 12-step programs work, there’s no quibbling: It’s wrong.

Next, one of my previous posts lays out the evidence for the use of 12 step groups.

Then, here are some of my responses to Dodes.

Finally, some posts on addiction treatment and recovery being made a front in the culture wars, including a response to a previous Glaser article.

8 Comments

Filed under Uncategorized

Residential Treatment Matters

locations-dawn-farmDavid Sack, in Psychology Today reviews a recently publish 11 year study of heroin users finding that residential treatment may “set the best course”:

A sweeping 11-year study out of Australia adds fresh understanding to our knowledge of heroin dependence and, in the process, challenges a widely held misconception—that residential rehab doesn’t really do much to help the heroin addict. Instead, the research shows residential rehabilitation may well set the best course to long-term improvement.

The research team, representing Australia’s National Drug and Alcohol Research Centre, followed 615 heroin users, checking in with them at 3, 12, 24 and 36 months and, finally, at 11 years. The goal was to determine just how they would fare over time in terms of drug use patterns, mortality, remission, overdose rates, suicide attempts, criminality, and mental and physical health. By the final year, 10 percent had died, almost half were still in some form of treatment, and those still using heroin fell to a quarter. With the drop in use came less crime, less risk-taking and better overall health. In the final analysis, residential rehab treatment was associated with positive outcomes across the board and was the only factor significantly associated with better physical health.

In the first year of the long-term study, residential rehab appeared to be about as effective as other forms of help, such as methadone maintenance. Ultimately, however, it was those who spent time in residential rehabilitation who recorded the best outcomes, especially if that rehab stay came early in the course of treatment.

2 Comments

Filed under Uncategorized

Sentences to ponder

Dr_Jekyll_and_Mr_Hyde_poster_edit2

 

“The addiction must go, the person must stay.”

Swedish business’ approach to addicted employees

2 Comments

Filed under Uncategorized

Their every truth . . .

…most men have bound their eyes with one or another handkerchief, and attached themselves to some one of these communities of opinion. This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars. Their every truth is not quite true. Their two is not the real two, their four not the real four: so that every word they say chagrins us and we know not where to begin to set them right. ~ Emerson

Now the Huffington Post frames people with a preference for abstinence-based recovery as anti-science and backward. Ugh!

How bad is this article? Let me count the ways.

One: They use a variation of the “some people say” tactic (emphasis mine):

Many in the medical establishment oppose the abstinence model — as do officials at the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Administration

Really? Then why do they treat their colleagues with an abstinence-based approach? Actually, they go even further, requiring that their colleagues be treated with an abstinence-based approach. (And, they are very successful with this abstinence-based approach.)

Two: They abandon the “some people” qualifier and frame advocates of abstinence-based recovery as irrational zealots.

Advocates of the abstinence model consider the use of Suboxone or methadone to be tantamount to using heroin itself.

What serious person says it’s equivalent to using heroin? This is a straw man.

image

Three: They they say abstinence-based approaches cost lives.

. . . a recent Huffington Post investigation found that the bias in favor of abstinence is costing the lives of those it regularly fails.

I posted about that investigation and its problems earlier.

I’ve also posted about a study finding high mortality rates among methadone patients in Australia. (6.5 times higher than the general population with an average of 44 years of potential life lost for each fatality.)

There’s no doubt that being on an opiate replacement drug reduces overdose risk, but only if they take the drug and those drugs have big patient retention problems too. (Here, here, herehere and here.)

Four: They then use relapse rates against abstinence-based treatment:

Over 90 percent of people treated with the abstinence method will relapse.

Note that there is no source and they are holding methadone and abstinence-based treatment to different standards. They don’t report on relapses for drug maintenance patients because studies of maintenance drugs tend to look for reductions in illicit drug use rather than abstinence.

As I recently wrote, the treatment system is failing opiate addicts, but the problem isn’t abstinence-based treatment. It’s the failure to provide treatment of the adequate duration, intensity and quality. In fact, when patients get good care of the adequate intensity and duration, they do very well.

Five: They seek comments from Bankole Johnson, a treatment critic, medication investor and researcher who failed to report conflicts of interest in a timely manner and left one job after losing a whistleblower lawsuit.

Six: They inserted an inane poll asking:

. . . whether it’s more effective for heroin addicts to detox completely and attend Narcotics Anonymous meetings, or for them to receive synthetic opiates under medical supervision . . .

This question feels like a setup. Detoxing addicts and sending them to NA is bad care. And, almost every expert agrees that just giving addicts maintenance drugs is bad care. So, those who are polled are given two bad options and then treated as ignorant because of their answer.

Seven: Then they insert partisan politics into they equation by breaking down responses by Republicans and Democrats. I’ve wondered before whether these attacks on abstinence-based treatment and recovery are part of the culture wars. This would seem to support that notion.

I have more problems with this series of articles that don’t rise to the level of the problems above.

First, the article reports that maintenance drugs are the standard of care in the rest of the developed world. This is largely true, but some countries are re-evaluating their approach. Also, we’ve developed relationships with Japanese treatment providers and addicts and have learned that addicts there believe that maintenance approaches failed them focusing on stability over quality of life.

Second, as mentioned above, these articles fail to acknowledge the success of health professional, lawyer and pilot recovery programs. These programs are abstinence-based, we researched and have very high long term success rates.

Third, these articles make it sound as though relatively few addicts have access to these drugs. Suboxone is the number 39 drug in the US and has sales of more than $1.4 billion. Further, a federal surveys find that ORT admissions accounted for 26% of all admissions. [Not 26% of opioid addiction admissions. 26% of all addiction treatment admissions.]

Finally, this series fails wrestle with the evidence in any meaningful way and the writers fail to ask themselves why reasonable people might prefer abstinence as a goal.

They are correct that there is a lot of evidence for these drugs reducing drug use, crime, disease transmission and overdose. However, reduce is an important word. Most people don’t want reduced drug use, they want full participation in family, professional, community and academic life. Despite the writers’ enthusiasm for maintenance drugs, they do not have an evidence-base for that kind of recovery.

None of this is to say that the treatment system isn’t broken, or that people who want them shouldn’t have access to maintenance drugs. It’s just to say we shouldn’t oversell maintenance approaches and describe abstinence-based approaches as “broken” when the real problems are the quality, dose and duration.

3 Comments

Filed under Uncategorized

The treatment system is failing opiate addicts

Doha15Stories like this are getting a lot of attention lately:

State Sen. Chris Eaton is planning to introduce legislation to encourage opiate treatment providers and doctors to break with an abstinence-based model and embrace evidence-based practices for treating addiction, the Minnesota Democrat told The Huffington Post.

I want to make it clear that I know nothing of Senator Eaton and am not questioning her motives.

If this was really motivated by a desire to spread evidence-based treatments, there’d be another, more interesting debate brewing.

That debate would be whether Senator Eaton should introduce legislation requiring that Physician Health Programs (PHP) start treating addicted health professionals with maintenance medications.

I doubt Senator Eaton wants that. I doubt she even knows much about Physician Health Programs. Her source of information about opioid addiction treatment was the Huffington Post article that painted abstinence-based treatment as hopelessly anti-evidence and ineffective while painting maintenance medications as THE answer to this problems that’s been with us for ages.

Why would she want to change opiate addiction treatment for the general population, but not for doctors? Because the treatment system for the general population is failing addicts and their families while the Physician Health Programs are producing outstanding outcomes.

Is the difference that one is abstinence-based while the other uses maintenance medications? No.

The difference is that PHPs get treatment and recovery support of an adequate quality, intensity and duration while the general population does not.

Debra Jay identified 8 essential ingredients in PHPs:

  1. Positive rewards and negative consequences
  2. Frequent random drug testing
  3. 12 step involvement and an abstinence expectation
  4. Viable role models and recovery mentors
  5. Modified lifestyles
  6. Active and sustained monitoring
  7. Active management of relapse
  8. Continuing care approach

PHPs provide treatment, recovery support and monitoring for up to 5 years and 85% of participants have no relapses. Of the 15% who relapse, most of them have only one relapse over that 5 year period.

Will maintenance medications improve treatment for the general population? It’s hard to imagine they will when they have the same retention problems that abstinence-based treatments have. Further, most of the treatment delivered with maintenance medications suffers from the same problem as abstinence-based treatment– inadequate quality, intensity and duration. (By duration, I mean the accompanying behavioral support as well as retention on the medication.)

So . . . this solution really focuses on the wrong problem.

The problem isn’t that treatment is abstinence-based. The problem is that abstinence-based and maintenance treatments too often do not provide adequate quality, intensity and duration.

So, why advocate to spread access to a treatment we won’t use on addicted physicians rather than spread access the gold standard of care that addicted physicians receive? That’s the danger of advocacy journalism that is dressed up as objective reporting.

I’m grateful to work in a place the works so hard to increase access to treatment and recovery support of an adequate quality, intensity and duration.

6 Comments

Filed under Uncategorized