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.

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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.

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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.

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Legalization + regulation + capitalism = ?

For all that argue, “Let’s just legalize and regulate. Look at tobacco and alcohol.”, John Oliver illuminates just how difficult it is to regulate tobacco. (NSFW)

BTW – I’ve made it clear on this blog that I oppose incarceration for possession, so this is not an argument for the drug war.

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Why wasn’t my love enough?

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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it will not always be so

minimalwall-hope-10-78-1“The chronicity of addiction is really a kind of fatalism writ large. If an addict knows in his heart he is going to use someday, why not today? But if a thin reed of hope appears, the possibility that it will not always be so, things change. You live another day and then get up and do it again. Hope is oxygen to someone who is suffocating on despair.”–David Carr

[Thanks Janice]

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12 step groups and meds

SAMHSA-recovery-definitionFrom Melissa Petro on After Party Chat:

I’m hardly an AA advocate; I don’t even do the program anymore. But what Cherkis claims simply wasn’t my experience. Sure, there are individual members who have their own beliefs and experiences about prescription medication—and, yes, some of them have gone on to establish facilities in the name of 12 step—but “We are not doctors” is the official party line. This is what I learned as a member of the program. Never was I taught, nor did I believe, that it was my right to police another person’s sobriety. In this day and age, given the proliferation of prescription medication, including medicine for pain, most 12-steppers I know don’t even think about sticking their noses in another person’s medicine cabinet.

 

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