Shame, methadone and recovery

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The Boston Globe has an article on the shame that successful methadone patients carry.

It makes me sad to hear of anyone doing the deal feeling shame about being a recovering addict.

People with opioid addiction ought to have access to methadone, if that’s what they want. Without shame.

They also ought to have access to the gold standard for addiction treatment—the same care that an opioid addicted health professional gets.

They also ought to get accurate information about the various pros and cons of each approach.

For example, they ought to know that the gold standard demands a lot of the patient, and existing models have relied on using the health professional’s license as a contingency to maintain compliance with these demands. They also ought to know that the approach hasn’t been studied on the general population of opioid addicts because no one has been willing to invest in it.

They also ought to know that despite all of the arguments that research proves “methadone maintenance is the most effective treatment for opioid addiction”, the evidence base for methadone focuses on reduced drug use, reduced OD, reduced criminal activity and reduced disease transmission.

Bill White, a researcher and methadone advocate, summarizes the evidence this way:

As a professional field, we know a great deal about what methadone maintenance treatment can eliminate from the lives of patients, but we know very little from the standpoint of science about what it adds. In fact, we know very little about the stages and styles of long-term medication-assisted recovery.

This lack of quality of life evidence is exemplified by the Boston Globe article:

They come to this methadone clinic . . . at around 6 in the morning — a time set aside for working men and women to get doses before heading to their jobs. About 400 of the 4,000 patients here work full time.

10% work full time?

In the article, a successful patient points to the dosing line that forms after the employed patients have gone to work.

Josh, 29, gestured at the line of men and women waiting outside. Workers’ hour had passed. Some of the people there now looked broken and wasted, like the stereotype that persists even though we’re constantly hearing that addiction can strike anyone.

“Would you want those people in your house when you’re not home?” asked Josh, who installs central air. “Hell, no. People don’t see the flip side — the dental assistants, the lawyers, the doctors.”

I don’t want to interfere with access to maintenance and I don’t want methadone patients living with shame. At the same time, all the advocacy for maintenance treatments misses that there are real reasons for the persistent skepticism about them. When a lot of people look at the population of patients, they don’t see an outcome that they’d want for themselves or loved ones.

via Shame of methadone use clouds heroin addicts’ recovery – Metro – The Boston Globe.

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Treatment Works, IF . . .

ROSC-modified Treatment Works Poster

Courtesy of Bill White. Visit williamwhitepapers.com

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Drug money

From the Forbes list of the richest U.S. families:

SacklersThe richest newcomer to Forbes 2015 list of America’s Richest Families comes in at a stunning $14 billion. The Sackler family, which owns Stamford, Conn.-based Purdue Pharma, flew under the radar when Forbes launched its initial list of wealthiest families in July 2014, but this year they crack the top-20, edging out storied families like the Busches, Mellons and Rockefellers.

How did the Sacklers build the 16th-largest fortune in the country? The short answer: making the most popular and controversial opioid of the 21st century — OxyContin.

It’s worth noting that this wealth was amassed with a drug whose marketing resulted in $635,000,000 of fines and lawsuits are still pending. The total cost of fines and lawsuits is expected to reach $1,000,000,000. In pure financial terms, it still looks like a pretty good deal. That seems like a problem, no?

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Why wasn’t my love enough?

This post was a followup to Seth Mnookin’s review of Hari’s book. It highlights one of the harms of misunderstanding addiction as a product of lack of connection, purpose and enriching environments.
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grief by maryn0503

grief by maryn0503

Yesterday, I posted a link to Seth Mnookin’s review of Chasing the Scream. Mnookin has been open about his addiction recovery for a long time.

In 1999, his mother wrote a piece about her experiences during his years of using. She does a great job illuminating the secret suffering of many loved ones. It’s actually a powerful rebuttal to Hari’s notion that a lack of love and enriching environments are the cause of addiction.

Our fears about Seth absorbed the family’s energies. My husband and I were often preoccupied. It was hard to concentrate, it was hard to sleep, it was hard to pay attention to our other children. We were exhausted, and though we tried to continue family activities, it was often an effort, and they could see this. We became stricter with them, wondering if we had been too lenient with Seth, and also less demanding, thinking that any behavior short of drug use was not worth correcting. They had their own fears for Seth’s safety. Once, when our younger son was in high school, my husband left a message for him to call. He needed to change a plan about the car, but our son could only imagine one reason for his father to call him at school: Seth had died.

When I heard this story, I tried to imagine our younger son getting the message — the blood drains from his cheeks as he leaves the classroom and walks to the office. How many halls does he pass through, clutching his books, thinking his brother is dead? How much time passes before he hears his father’s calm, everyday voice? I had tried so hard to protect my children, and I couldn’t even protect them from each other.

Everyone seemed to have better parenting skills than I did — anyone whose child was not using drugs, anyone whose child could call home without imagining disaster. Leafing through the book review section of the Sunday Times, I happened upon the advertisement for a novel, “Cloud Nine.” Even the reviewer’s words accused me, proclaiming that “the strength of family ties can ultimately set things right.” So why couldn’t my love set things right? Why wasn’t my love enough to save my son?

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“unintentionally comical” – Johann Hari’s Chasing the Scream

stop with the factsSeth Mnookin reviews Chasing the Scream and finds its review of the science troubling. (Previous post on Hari here.)

The first tip-off that Hari might be in over his head comes when he describes how “a small band of dissident scientists” had uncovered the answers he was looking for after working “almost unnoticed, for several decades.” Hari starts with Gabor Mate, a Hungarian-born Canadian physician whose theories about how the roots of addiction (and lots of other things to boot) can almost always be found in childhood trauma are, in fact, quite well known. To support his portrayal of Mate as a fringe renegade, Hari acts as if a rigid, deterministic model of addiction as a purely physical disease is almost universally accepted; if anything, the opposite is true. Even more problematic is Hari’s wholesale acceptance of Mate’s reductionistic approach when, in fact, there’s a significant body of work demonstrating its shortcomings.

The next researcher to benefit from Hari’s credulousness is Bruce Alexander, a Canadian psychologist who believes that drugs are not the cause of drug addiction. Alexander is best known for his “Rat Park” experiments in the 1970s, which were designed to demonstrate that rats in stimulating, social environments would not become addicted to morphine while rats in cramped, metal cages would. Hari explains why Alexander’s views have not been universally embraced by making the preposterous assertion that “when we think about recovery from addiction, we see it through only one lens — the individual.”

A few pages later, Hari is talking to a Welsh psychiatrist named John Marks, who is a proponent of providing prescription narcotics to addicts. Hari supports Marks’s claims by referring to “research published in the Proceedings of the Royal College of Physicians of Edinburgh” but then buries in the notes the fact that it was Marks himself who was the author of that research. Sometimes, Hari’s unquestioning acceptance of what these researchers say is unintentionally comical: At one point, he quotes Alexander explaining that drug addicts don’t get clean because they would rather spend their time doing “exciting things like rob stores and hang around with hookers.”

Read Mnookin’s entire review here.

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We all wish love was enough

fear_false_evidence_appearing_realMore on Johann Hari, a post from earlier this year.

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This article, claiming to have discovered the long suppressed cause of addiction, has been making the rounds and has been recommended by a lot of people.

Like a lot of things, it contains some truth but is not the Truth.

People generally bring up rat park and returning Vietnam vets to advance 2 arguments.

  1. That you can’t catch addiction by just being exposed to the drug.
  2. That environment is the real problem. If you put people in bad environments, they’ll look like addicts. If you enrich addicts’ environments, they’ll stop being addicted.

I whole-heartedly agree with argument #1. You can expose 100 people to drugs like cocaine and heroin and a relatively small minority will develop chronic problems–5 to 23, depending on the study you look at. So, even if the outlier studies were true, we’re still talking about 77% not becoming addicted.

Every field has its goofballs, but in my two decades in the field I have not heard any serious practitioners or researchers argue that simple exposure (even to large doses over an extended period) causes addiction.

Argument #2 is much weaker. It’s my understanding that follow-up studies with rats have failed to reproduce these findings and suggested genetic factors were important. The strongest statement you can make about environment is that it is a risk factor, but not anything approaching a cause.

As for returning Vietnam vets, this is from a post I wrote a few years ago:

These stories often ignore the fact that:

“. . . there was that other cohort, that 5 to 12 per cent of the servicemen in the study, for whom it did not go that way at all. This group of former users could not seem to shake it, except with great difficulty.”

Hmmmm. That range….5 to 12 percent…why, that’s similar to estimates of the portion of the population that experiences addiction to alcohol or other drugs.

To me, the other important lesson is that opiate dependence and opiate addiction are not the same thing. Hospitals and doctors treating patients for pain recreate this experiment on a daily basis. They prescribe opiates to patients, often producing opiate dependence. However, all but a small minority will never develop drug seeking behavior once their pain is resolved and they are detoxed.

My problem with all the references to these vets and addiction, is that I suspect most of them were dependent and not addicted.

So…it certainly has something to offer us about how addictions develops (Or, more specifically, how it does not develop.), but not how it’s resolved.

Why is it so frequently cited and presented without any attempt to distinguish between dependence and addiction? Probably because it fits the preferred narrative of the writer.

So. . . rat park and returning Vietnam vets are not quite what he describes. Let’s continue.

I do appreciate the article’s call for compassion and I am a believer that purpose, meaning and connection are important elements of stable recovery. However, as I continue reading the article, I am reminded of Ralph Waldo Emerson:

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.

mencken-complex-problemHe says that addiction that begins with  prescribed pain medication “virtually never happens.” Well, it’s hard to pin down exactly how often it happens, due to chicken and egg questions related to how many pain patients have pre-existing substance use problems. However, reported estimates range from  “from 2.8% (Cowan et al., 2003) to 50% ( Saper et al., 2004).”

What about the Portugal miracle? We’ll a few things to keep in mind. First, the decriminalization approach is focused on getting addicts into treatment. Housing and treatment may be addressed, but it’s clear the focus is on treatment. Second, Portugal was starting from the position of a terrible heroin problem. They’ve gone from 1% addicted to 0.5% addicted. That’s great, but to provide a little context, the National Survey on Drug Use and Health pegs current heroin users at 0.1% of the U.S. population.

So . . . the article doesn’t tell the whole story, it oversimplifies some very complex issues and presents us with straw man arguments. (Who says that anyone who uses heroin is going to get hooked for life? [Note that he had to go back to a commercial from the 1980s and that a search for the reported text of the commercial only produces references to his article.] Or, that behavioral, environmental, social and other factors are unimportant in the development, course and recovery from addiction?)

I also worry about the implied message that we just love them enough, they’ll get well. I see countless families that provide housing, jobs, connection and love–only with watch their loved one slip further and further into addiction.

Addiction is a complex problem. Multiple factors influence it’s development, course and resolution. This is always the case with chronic disease. There’s a cultural narrative out there that addiction is not a disease, that it is rational, that it’s a product of environment, that it’s a learning disorder, that framing it as a disease is a foundation for violating individual liberties and that recovery needs to be redefined. Intended, or not, stories like this are part of that narrative.

I don’t engage in ad hominem arguments, but, while we’re on the topic of narratives, it would seem strange to not point out that this author has a history of playing fast and loose to advance a narrative.

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Hari and the truth


Johann Hari is getting a new wave of attention after a recent TED talk. I’m not surprised he’s getting so much attention. He’s a great story teller with a compelling narrative.

However, while is narrative does contain some important truths, he’s just plain wrong about the cause of addiction.

Over the next few days I will repost some previous posts on his book and articles.

First, I’ll bottom-line his thesis.

  • Do lack of purpose and connection cause addiction? No.
  • Are purpose and connection important? Yes.
  • Could lack of purpose and connection influence the onset and course of addiction? Yes.
  • Are creating purpose and connection important elements in facilitating recovery for many addicts? Yes.
  • Do lack of purpose and connection cause addiction? No.

Hari has a history of playing fast and loose to advance a narrative. I’ll point out just one of those today, his discussion of Portugal.

Hari:

In the year 2000, Portugal had one of the worst drug problems in Europe. One percent of the population was addicted to heroin, which is kind of mind-blowing, and every year, they tried the American way more and more. They punished people and stigmatized them and shamed them more, and every year, the problem got worse. And one day, the Prime Minister and the leader of the opposition got together, and basically said, look, we can’t go on with a country where we’re having ever more people becoming heroin addicts.

What really happened:

Hannah Laqueur, a rising young scholar at UC Berkeley, asks a novel question in her analysis of Portugal: Is there any evidence that the 2001 law actually was a radical move from criminalization to decriminalization of drug use? Looking at the 8 years of data prior to the law, she found that the average population of people in prison for simple drug possession was about 21. Not 21% of prisoners but 21 people in a nation of 10 million!. Prior to the elimination of prison sentences in 2001, drug possession convictions accounted for just 0.3% of Portugal’s prison population.

The 2001 law’s removal of incarceration as a penalty was thus simply a formalization of longstanding criminal justice policy. Looking at drug use indicators before and after 2001 and attributing any change to the “radical decriminalization” is thus wrong-headed because no such change occurred.

Not as dramatic, huh?

Why would a journalist make such a mistake? Probably because the truth doesn’t fit with his narrative. And, this is the pattern in Hari’s book–he cherry-picks and massages evidence to support his narrative.

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