Who’s “we”?

many-and-few

This article is making the rounds and getting some attention. The post below addresses the issues raised. (originally posted on 10/31/2014)

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This article has been forwarded to me by several people. Its author has been writing a series of articles that seek to redefine addiction and recovery.

As Eve Tushnet recently observed, “There’s another narrative, though, which is emerging at sites like The Fix and Substance.com.” This sentence is representative of this alternative narative:

“The addiction field has struggled with defining recovery at least as long and as fiercely as it has with defining addiction: Since we can’t even agree on whether it’s a disease, a learning disorder or a criminal choice, it becomes even harder to figure out what it means when we say someone has overcome an addiction problem.”

But are “we” really unable to agree that addiction is a disease? Who’s “we”?

It’s not unlike suggestions that there’s wide disagreement on climate change.

“Since we can’t even agree on whether it’s a diseasea learning disorder or a criminal choice, it becomes even harder to figure out what it means when we say someone has overcome an addiction problem.” “. . . just so you know, the consensus has not been met among scientists on this issue. Or that CO2 actually plays a part in this global warming phenomenon as they’ve come up with somehow.”
Health organizations that call addiction a disease or illness:

  • American Society of Addiction Medicine
  • American Medical Association
  • American Psychiatric Association
  • American Hospital Association
  • American Public Health Association
  • National Association of Social Workers
  • American College of Physicians
  • National Institute of Health
  • National Alliance on Mental Illness
  • World Health Organization
Scientific organizations that recognize human caused climate change:

  • American Association for the Advancement of Science
  • American Astronomical Society
  • American Chemical Society
  • American Geophysical Union
  • American Institute of Physics
  • American Meteorological Society
  • American Physical Society
  • Federation of American Scientists
  • Geological Society of America
  • National Center for Atmospheric Research
  • National Oceanic and Atmospheric Administration
Health organizations that dispute the dispute the disease model:

  • I can’t find any. If you have some that are similar in stature to those above, send them to me.
Scientific organizations that dispute human caused climate change:

  • None, according to Wikipedia.

To be sure, there are people who don’t accept the disease model, some very smart people, but they represent a small minority of the experts. (The frequent casting as David vs. Goliath should be a clue.) And, if you look at their arguments, you’ll find other motives (I’m not suggesting nefarious motives) like protecting stigmatizationdefending free will from “attacks”, discrediting AA and advancing psychodynamic approaches, resisting stigma and emphasizing environmental factors.

Attending to some of their concerns makes the disease model and treatment stronger, not weaker. Lots of diseases have failed to do things like adequately acknowledge environmental factors. And, one takeaway from these critics is the importance of being careful about who we characterize as having a disease/disorder explicitly or implicitly (by characterizing them as being in recovery).

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Why Does Alcoholics Anonymous Work?

This video addresses two important questions:

  1. Can evidence be trusted if it’s not from a randomized controlled trial?
  2. Does Alcoholics Anonymous involvement really help alcoholics stay sober? Or, do AA attenders just stay sober because they are more motivated than non-attenders to stay sober?

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“Growing a Healing Forest is a mentality”

(Source: landscapevoice.com)

(Source: landscapevoice.com)

“What’s called for in this metaphor is treating the soil — creating a Healing Forest within which the health of the individual, family, neighborhood, community, and beyond are simultaneously elevated. The Healing Forest is a community in recovery.”

Derek Wolfe, a recent University of Michigan grad (soon to be a medical student), just posted an ambitous series of articles on Ann Arbor, MI as a “healing forest.”

Lunch-Room-Ann-Arbor-2015-1

He profiles several elements/contributors to Ann Arbor’s recovery readiness. Here’s my favorite:

Just a short walk from Zingerman’s Deli in Kerrytown sits The Lunch Room, a popular vegan restaurant in Ann Arbor. Co-owner Phillis Engelbert, formerly a community organizer before moving into the restaurant business, has worked like Weinzweig [Zingerman’s co-founder] to cultivate an inclusive culture and positive workplace, which may explain why 11 out of 27 of her employees are in recovery.

“Well I think with the first (employee in recovery), it probably was just building that personal relationship,” Engelbert said. “But then everyone who came after, the word was out: Lunch Room will support you. Or you know, there’s no stigma here. Or like, if you need to go to court dates, they’ll give you time off. Or if you end up going to a court date and you get thrown in jail for a couple days and then come back out, you won’t lose your job. Or like, they’ll celebrate your sobriety anniversaries. Or, just whatever, they’ll understand and there won’t be a stigma.”

But removing stigma in a workplace can’t just be an effort from top leadership. The mentality must make its way into the minds of every employee. One of the ways in which Engelbert is able to maintain a stigma-free culture and family atmosphere is through a careful hiring process.

Removing stigma in a workplace can’t just be an effort from top leadership. The mentality must make its way into the minds of every employee.

“I’m also really really careful about who I hire because I don’t want to wreck (the inclusive, stigma-free culture),” Engelbert explained. “So I tell people when they’re interviewing, I say, ‘We have people here from all walks of life. We have people here of different income backgrounds, education levels, prison history, lesbian, gay, trans, whatever. You have to be happy about that or you can’t work here. Like you have to look at that as a positive and help us embrace all that or this isn’t the place for you.’”

The result of Engelbert’s efforts is an environment in which recovery is able to be discussed openly among the staff. Conversations about recovery occur often at The Lunch Room.

“Everyday. All the time. It’s just like talking about the weather,” Engelbert said.

One Lunch Room employee put it this way: “It’s nice to be open about (recovery), have a boss that understands and just not have like a drug-fueled kitchen environment ’cause that’s just not what I want to be around.”

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The “rat park” guy

Bruce Alexander A Global Historical View Of Addiction And The Future Of Addiction Treatment FEADSeveral recent books have attempted to refute the disease model of addiction over the last few years. (See here, here, here and here for some examples.)

All of these books cite Bruce Alexander’s “rat park” experiments as important evidence that addiction is not a brain disease.

If you’ve ever been curious about Bruce Alexander, here’s your chance to watch a talk he gave earlier this year.

Is the disease model really in doubt?

I believe that there is no serious scientific disagreement about the matter.

Here are a couple of talks that explain the disease model.

First, NIDA Director Norak Volkow:

Second, Kevin McCauley in our own education series:

 

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Does “stigma reduction” miss the point?

missing the point

A provocative interrogation of stigma reduction campaigns:

Once we declared a war on stigma, I knew we were screwed. Like poverty, racism, drugs, terror and obesity before it—fighting stigma ensures that we will likely make little progress. Instead of doing anything about the things actually killing drug addicts and alcoholics, we focus on something vague and unbeatable. It’s like fighting smoke.

Forget stigma, let’s focus on what’s actually decimating care for mentally ill and addicted persons—corporate greed. Some health care is lucrative. Hospitals usually have some great digs for these golden geese. The hospitals in my area show off their outpatient surgery recovery suites . . .

Treatment of the addicted and mentally ill will never be a money maker, nor should it have to be. I would love to see a beautiful new psych ward in the ads for my local hospital, but apparently this is not a demographic with disposable income—nor is this a group of people with a voice. This leads to efforts at reducing stigma. This would make a lot of sense if the thing blocking change in these massive healthcare systems was a misunderstanding of mental illness or addiction, or an active antipathy toward helping these people. I do not think this is the case. I just think it’s irrelevant.

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Does rehab kill?

“Rehab kills people,” Willenbring said

Dr. Willenbring is right that bad and/or inadequate rehab is dangerous. HOWEVER, this is true of a lot of treatments. For example, an inadequate course of antibiotics is dangerous.

So, what does good treatment look like? He suggests it comes in the form of medication.

Another way to identify what good treatment looks like is to ask one question can cut through a lot of confusion about treatment options—“What kind of treatment do addicted doctors get?” This question avoids arguments about treatment models, evidence-based practices and the effectiveness of 12 step groups. It moves past what physicians recommend for people like you (or your loved one) and what they actually do for people like themselves.

Fortunately, a few days after Dr. Willenbring’s comments were published, the NY Times published an article on a doctor with addiction who was arrested for diverting medication. What kind of treatment did she get?

She was allowed to attend a rehabilitation program while still seeing patients.

Rehab? It doesn’t say what kind of rehab but, rehab?  Really?

She didn’t want to go to the New York Health Committee for Physician Health, a program funded by the American Medical Association to identify and treat doctors with mental health or drug problems, she says, “because I didn’t want anybody to find out.”

Nobody wants to admit defeat or weakness; but only doctors (and airline pilots) thought to have drug problems have such rigorous drug-testing programs, according to Terrance M. Bedient, the director of the Committee for Physician Health. Some lose their livelihoods temporarily, some permanently.

. . .

“I saw people with less privilege, less education, treated the same way I was,” she says. “The judge in my case understood addiction so well. It’s a disease.”

And that is what many in the addiction field think we should remember: not that Dr. Karcher didn’t have advantages — she did — but that she got the kind of treatment that more substance abusers should get. Physicians in New York State have some of the best outcomes in the country, according to Brad Lamm.

“It’s not that they’re better people or better addicts,” he says.

They don’t get specific about the kind of rehab Dr. Karcher got, but what kind of rehab do doctors usually get?

Physicians’ Health Programs (PHPs) do not provide substance abuse treatment. Under authority from state licensing boards, state laws, and contractual agreements, they promote early detection, assessment, evaluation, and referral to abstinence-oriented (usually) residential treatment for 60 to 90 days. This is followed by 12-step-oriented outpatient treatment. Physicians then receive randomly scheduled urine monitoring, with status reports issued to employers, insurers, and state licensing boards for (usually) 5 or more years.

Does this care kill them?

A sample of 904 physicians consecutively admitted to 16 state Physicians’ Health Programs (PHPs) was studied for 5 years or longer to characterize the outcomes of this episode of care and to explore the elements of these programs that could improve the care of other addicted populations. The study consisted of two phases: the first characterized the PHPs and their system of care management, while the second described the outcomes of the study sample as revealed in the PHP records. 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. At post-treatment follow-up 72% of the physicians were continuing to practice medicine. 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.

It’s worth noting that there is other evidence for the use of residential. (See here, here and here.) But, let’s stay focused on the PHP approach.

Is there another approach that rivals the outcomes found in PHPs?

Back to Willenbring:

. . . adding that the model for the 28-day rehab, Minnesota’s Hazelden Foundation, began offering buprenorphine maintenance itself in 2012 after a series of patient deaths immediately after treatment. Hazelden’s medical director, Dr. Marvin Seppala, told me when the rehab announced the change that using these medications is “the responsible thing to do” because of their potential to save lives.

That was 4 years ago. A year in, they were teasing pretty impressive early outcomes and promised more outcomes studies were to come. 4 years is a long time to keep the world waiting. However, they just posted that they expect to publish their outcomes next year. We’ll have to wait and see what they end up reporting.

To be sure, some people have good outcomes with medication assisted treatment. At the same time, it’s not as simple and obvious as the article suggests. First, the evidence doesn’t match the hype. (See here, here, herehere and here.) Second, while the inadequacy of many residential/inpatient treatment programs has gotten a lot of attention, medication assisted treatment has its share of problems. (See this recent photo essay on Boston’s “methadone mile” and this recent article on problems with buprenorphine in northeast Tennessee.)

 

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Update 7/26/2016. FULL 911 Good Samaritan Legislation in Michigan

ambulanceblur-2

Great news!!

Both 911 Good Samaritan Bills have made it out of the Michigan Senate Judiciary Committee.

Now is the time to contact your State Senator and ask her/him to vote yes on these bills.

Find the contact info for your State Senator here.

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(The rest of this post was originally posted 5/12/2016. It is provided here for background.)

Good news!!!

There are 2 bills in the Michigan House of Representatives Criminal Justice Committee that would would provide immunity from criminal charges for people all ages who are seeking emergency medical assistance for themselves or friends as a result of a drug overdose from any illicit drug.

Rep. Pscholka’s bill, House Bill 5649, provides immunity from possession penalties in certain circumstances.

Rep. Singh’s bill, House Bill 5650, provides immunity from use penalties in certain circumstances.

These bills expand upon last years House Bill 4843 by removing limitations based on age and type of drug.

The House Criminal Justice Committee will be taking up these bills on Tuesday, May 17, 2016 at 9:00 AM in Room 327, House Office Building, Lansing, MI.

Contact the House Criminal Justice Committee to let them know you support these bills.

Background

The Facts

Keep these facts in mind:

  • Overdose is now the leading cause of accidental death in the U.S. Most of these overdose deaths are due to opioids.
  • If help arrives in time, overdoses can be safely and quickly reversed with a squirt of naloxone up the patient’s nose.
  • More than half of all overdoses occur in the presence of other people, usually other drug users.
  • Too often, people do not call 911 in a timely manner due to fear of arrest for possession of drugs.

A First Step

At the urging of parents who have lost children to overdose, the Michigan legislature made some good first steps last year. They enacted laws that increased access to naloxone, the drug that reverses overdoses.

On October 13, 2014, Public Acts 311, 312, 313 and 314 of 2014 were signed into law.

These acts will:

  • Allow Narcan to be prescribed to friends and family of heroin addicts, so it’s readily available in the event of an overdose.
  • Protect a person administering Narcan in good faith to be immune from criminal prosecution or professional sanctions.
  • Require emergency medical personnel to carry the drug in their vehicles and be trained in how to administer it.
  • Require the state Department of Community Health to complete annual reports of opioid-related overdose deaths.

Another Step

Last summer, Michigan Rep. Al Pscholka (R-Stevensville) introduced House Bill 4843, a bipartisan measure, that would create Good Samaritan protections for individuals under the age of 21 who seek medical attention for themselves or another person believed to have overdosed. However, the Good Samaritan protections are limited to the illegal possession of prescription drugs (in quantities consistent with personal use) for people under the age of 21.

Last December the Governor signed the Good Samaritan Bill, House Bill 4843, into law.

911 Good Samaritan Laws

NARCAN-KITThe Drug Policy Alliance provides a really good summary of 911 Good Samaritan laws:

Accidental overdose deaths are now the leading cause of accidental death in the United States, exceeding even motor vehicle accidents among people ages 25 to 64. Many of these deaths are preventable if emergency medical assistance is summoned, but people using drugs or alcohol illegally often fear arrest if they call 911,  even in cases where they need emergency medical assistance for a friend or family member at the scene of a suspected overdose.The best way to encourage overdose witnesses to seek medical helpis to exempt them from arrest and prosecution for minor drug and alcohol law violations, an approach often referred to as Good Samaritan 911.

The chance of surviving an overdose, like that of surviving a heart attack, depends greatly on how fast one receives medical assistance. Witnesses to heart attacks rarely think twice about calling 911, but witnesses to an overdose often hesitate to call for help or, in many cases, simply don’t make the call. In fact, research confirms the most common reason people cite for not calling 911 is fear of police involvement.

It’s important to know that this is not a liberal vs. conservative or Republican vs. Democrat issue. Some of the reddest and the bluest states in the country have passed 911 Good Samaritan laws.

Twenty states and the District of Columbia have enacted policies to provide limited immunity from arrest or prosecution for minor drug law violations for people who summon help at the scene of an overdose. New Mexico was the first state to pass such a policy and has been joined in recent years by Alaska, California, ColoradoConnecticut, Delaware, Florida, Georgia, Illinois, LouisianaMaryland, Massachusetts, Minnesota, New Jersey, New York, North Carolina, Rhode Island, Vermont, Washington and Wisconsin.

Further, these laws don’t protect dangerous or predatory criminals.

Good Samaritan laws do not protect people from arrest for other offenses, such as selling or trafficking drugs, or driving while drugged. These policies protect only the caller and overdose victim from arrest and/or prosecution for simple drug possession, possession of paraphernalia, and/or being under the influence.

The Bad News

An overdose is a major medical crisis, right? It’s not unlike a heart attack.

Here’s what happens when someone has a heart attack41KSA2GA12L._SX300_

  1. A person has a heart attack at the grocery store and . . .
  2.  . . . thank goodness, the store has an automatic defibrillator.
  3. Someone has been trained to use the defibrillator and performs the rescue.
  4. Someone else calls 911 to make sure the patient gets all the care they need.
  5. The patient is taken to the emergency department and medically stabilized.
  6. Once stabilized, the patient gets transferred to care that will address the cause of the heart attack and/or care that will prevent future heart attacks.
  7. The patient’s treatment plan will generally include lifestyle changes. (Diet, exercise, etc.)
  8. Then, the patient gets follow-up care that might include:
    • follow up appointments with specialists,
    • periodic tests to monitor for indicators of a recurrence,
    • self-monitoring (blood pressure), and
    • monitoring by the patient’ primary care physician.
  9. If problems recur or there are indications of a potential recurrence, the care plan will be re-evaluated and the patient will get whatever care they need.

Here’s what happens when someone ODs and is rescuednarcan

  1. A person overdoses and . . .
  2.  . . . thank goodness, the someone has naloxone.
  3. The person has been trained to use naloxone and performs the rescue.

Maybe, if they are lucky, these steps happen.

  1. Someone else calls 911 to make sure the patient gets all the care they need.
  2. The patient is taken to the emergency department and medically stabilized.

Naloxone is not enough.

We’d never tolerate cardiac patients being sent home without the proper care. Why should people with an addiction be treated any differently?

The good news

The good news is that there are models that work.

The Gold Standard

A male doctor writes on a patients chart.The best example of what should happen is the the kind of care that opioid addicted doctors, nurses, pilots and lawyers get. They all have low relapse rates and return to work at very high rates.

Here’s what would happen if one of them overdosed at work (or if it was known to their employer):

First, the recovery planning begins with some important assumptions:

  • abstinence is the goal;
  • full recovery with a return to full functioning is the expectation;
  • addiction is a chronic illness and recovery requires long term treatment, support and monitoring; and
  • for recovery to be durable, the addict must be an active participant in treatment and recovery maintenance.

Signpost along the road to recovery.The recovery plan is likely to include the following:

  • Formal treatment. The first phase of formal addiction treatment for most of these professionals is residential care ranging from 30 to 90 days.
  • Supportive services. Supportive services used by these professionals includes AA or NA 12-step groups, aftercare groups from their formal treatment programs, and follow-up from case managers.
  • Long-term support and monitoring. After completion of initial formal addiction treatment, they develop a continuing care contract consisting of support, counseling, and monitoring for usually 2 to 5 years.
  • Drug testing. Regular testing for 2 to 5 years, usually with more frequent testing at the start and reduced testing following periods of stable negative drug test results.
  • Dealing with relapse. Relapses are usually addressed by a combination of increased intensity of care and monitoring and by immediately informing family and colleagues of the physician to enlist their support.

Other options

Buprenorphine (Suboxone) and methadone have been shown to reduce drug use, overdose risk, criminal activity and disease transmission.

Some people are able to stabilize and live normal lives on these medications but, at this point, there is no research demonstrating its effectiveness with quality of life indicators like employment.

Many people hope to use these drugs as an interim step toward abstinence. However, there is no established model for successfully transitioning buprenorphine and methadone patients to abstinence. A large federally-funded study attempting to do this reported, “near universal relapse.”

Another option is an injectable drug called Vivitrol. It is injected once per month and can protect against overdose. Unfortunately, it’s very expensive.

Which to choose?

Hope Traffic SignThe gold standard offers a path to full recovery, but it does demand a lot of structure, effort and lifestyle changes.

Many professionals prefer drug maintenance as a goal. It’s an easier plan to implement and many professionals are not confident that their patients are capable of drug-free recovery. (Look for professionals that are optimistic and believe in you ability to achieve full recovery.)

However, most patients and families, for a wide variety of reasons, prefer abstinence as a goal–the most common reason is that they want their life back the way it was before they became addicted.

Patients not sticking with the treatment plan is the biggest barrier to success with both approaches.

It’s harder than it should be

Getting the gold standard for yourself or a family member is likely to be very difficult. But, there are steps you can take to improve the odds.

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