“He’d still be alive”

CANADA TORONTO FILM FESTIVALMuch has been said this week about the death of Phillip Seymour Hoffman.

I’ve heard two recurring themes. First, that he might still be alive if he had been “treated with an evidence-based” treatment, like buprenorphine. Second, that he might still be alive if he hadn’t been inculcated with the disease model, which purportedly fosters learned helplessness.

The buprenorphine argument

I know nothing of the treatment he received and most of these people admit that they don’t either.

Let’s assume, for a moment, that their assumptions are correct.

One problems is that most of these writers fail to deal with the issue of falling buprenorphine compliance ratesThis recent study of 6 month study found a dropout rate of 76% for those without chronic pain and described the compliance rates as consistent with other studies.

Early studies of buprenorphine reported outstanding compliance rates. Those numbers need to be viewed with suspicion and one should wonder whether the promulgation of those numbers is a success of science or marketing.

Their premise seems to be that people prescribed buprenorphine don’t OD. I don’t doubt that people currently taking buprenorhine are at lower risk for OD. However, I’m not aware of any good studies of survival rates that consider real world compliance rates.

Now, we learn that buprenorphine was reportedly found in his apartment. I have no idea whether it was prescribed to him or whether he bought it on the street. If it was prescribed to him, it suggests that prescribing the drug may not have the protective properties that advocates claim. If he bought it on the street, it points to the issue of diversion, which raises questions about patient compliance with the drug.

Besides, this was someone who had maintained some sort of remission for 23 years, had been in relapse for one year and had only one, brief detox episode during that period of time. Seems a little rash to assume that that path that had worked for 23 years would be a bad path to try to get him back to.

The disease argument

There’s ample evidence that addiction is a disease and, kind of like the climate change debate, though there is a noisy group of dissenters with high visibility, there is widespread agreement among experts that it’s a brain disease characterized by loss of control.

One of the most common arguments to question the disease model is the existence of natural recovery–that fact that large numbers of “addicts” recovery without any help.

The quotation marks in the previous sentence signal my response. Vietnam vets who returned with heroin problems are a frequently cited example. Most came back to the states and quit heroin on their own. Reports indicate that only 5% to 12% were unable to quit or moderate.

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.

It’s worth noting that this can cut in both directions. There’s a tendency to respond to problem users (people who drink too much, but are not alcoholics.) and dependent non-addicts (most pain patients or these returning vets) as though they are addicts. This results in bad treatment for those people, bad research and it manufactures resentment toward treatment, mutual aid groups and recovery advocates.

We run into the same problem when recovery advocates (who I love and generally agree with) report that there are 23 million Americans in recovery. These kinds of statements tend to be based on surveys asking people something to effect of, “Have you previously had a problem with drugs or alcohol and no longer have one?” That kind of question is going to get a lot of false-positives for what we think of as recovery. It’s a little like asking people if they once had a chronic cough and no longer have one, then inferring that all of those people are in recovery from TB.

We know that relatively large numbers of young adults will meet criteria for alcohol dependence but that something like 60% of them will mature out as they hit milestones like graduating from college, starting a career or starting a family. Are these people addicts in recovery? Or, were they people with a problem of an entirely different kindan acute alcohol problem rather than the chronic brain disease of addiction?

We need to do a better job distinguishing addiction/alcoholism from dependence and look at improving DSM criteria to help with this distinction. Loss of control, over an extended period of time that returns after periods of abstinence is the key to me. Addicts/alcoholics are not people making poor decisions about their drug and alcohol use, they are people who have lost the ability to make execute decisions related to drug and alcohol use.

It’s apples and oranges and these statements about the prevalence of recovery do real damage to the cause. People with addiction shouldn’t be treated with expectations constructed around the experience and pathways of people who do not have the same disease. AND, people who do not have addiction should not be subjected to treatments for people who do have the disease.

A better argument

I’ve spent a lot of time on this blog responding to arguments that pharmacological treatments are better than drug-free treatment. And, I’ll admit that I feel defensive when I hear treatment being attacked. However, when I step back, I have to admit that there’s a lot of bad treatment out there. With and without medications.

These arguments about drug-free vs. drug maintenance miss one really big and really important point. Whichever kind of treatment a person ends up receiving, there’s a really good chance that they will not get the long term monitoring and support that is appropriate for a life-threatening and chronic disease.

Two models that have outstanding outcomes are treatment programs for health professionals and programs for pilots. Both have long term success rates in 90% range. Both of them happen to be drug-free, but the point I want to focus on is that they both provide intensive long term monitoring and support with rapid re-intervention in the event of relapse.

Shouldn’t we have a system that monitored Philip Seymour Hoffman in the same way we monitor people with heart disease? One other example that comes to mind is my dentist. I mean, I don’t even get cavities–there’s nothing urgent going on in my mouth. BUT, my dentist corners me into scheduling another appointment before I leave the office and they start calling and texting me to remind me AND even ask me to reply that I will make my appointment.

If my dentist can deploy the strategies to promote continuity of care, why can’t addiction treatment programs?

UPDATE

This is my April 16th post, after new details were revealed about his exposure to Suboxone.

The latest on Phillip Seymour Hoffman

imagesAfter all the speculation that Phillip Seymour Hoffman could have been saved if he had been placed on Suboxone, we have one more bit of information. Not only did he have the drug in his apartment, he had enough exposure to recommend it to a fellow addict.

Sometime last year, he met Mr. Hoffman through mutual friends. They were kindred spirits, he said, both private people. He avoided questions about whether the two used drugs together. But he said they talked and exchanged text messages about their addictions, with Mr. Hoffman urging Mr. Aaron to try Suboxone, a controversial prescription painkiller used to treat heroin addiction. The messages ended last fall, when the two men fell out of touch, Mr. Aaron said. Then, at the beginning of February, Mr. Hoffman died of an overdose of multiple drugs.

I’m not arguing that the drug killed him. Just that the arguments that “abstinence-based/12 step domination” in the treatment industry killed him is a bogus argument.

11 Comments

Filed under Controversies, Research, Treatment

11 responses to ““He’d still be alive”

  1. I absolutely agree that addiction is in part the result of physiological changes in the brain in response to drug use, alongside genetic factors that may also contribute to addiction. However to call addiction a disease, for me at least, is misleading. A disease is something which stems from one dysfunctional aspect of the body; above I have mentioned two which contribute to addiction.

    The problem with this is that people expect a single ‘cure’ for that ‘disease’, when as you have pointed out yourself there isn’t one single ‘cure’. An even bigger issue with the disease model is that by and large it completely ignores social structural and economic factors and their contribution to the likelihood of developing addiction, as well as the role they play in recovery.

    Addiction or dependence check ups from a GP are an excellent idea I must agree, but social risk factors should also be identified. At the same time improving social circumstances for those in poverty would go a long way to preventing people from engaging in the use of high risk substances in the first place. Addiction isn’t just a matter of what’s inside us, but what’s outside us as well.

    • Thanks for reading and commenting. A disease model does not have to preclude attention to environmental factors. It’s widely accepted that disease vulnerability, onset, progression and response to treatment is influenced by things like stress, population density, pollution, nutrition, access to care, etc.

      Patient prognosis with any chronic illness is going to be influenced by the characteristics and severity of the illness, but possibly even more important are the other problems that the patient has. The more problems, the worse the prognosis.

      Thanks again. I appreciate your thoughts.

  2. Jason, this is one of the most well written pieces that I have seen on this topic and it is timely with the unfortunate passing of Phillip Seymour Hoffman. I have long felt that professionals and the public struggle with understanding the differences between dependence and addiction as well as how best to respond to both from a treatment perspective. I think you articulate the problem well. We are taught very early on in social work courses about the need for follow-up or maintenance as part of this strategy of practice that is guided by the problem solving approach. I wonder how the overload and stresses to our various systems of care impact our ability to focus the attention that we should on maintenance and follow-up? Do we need further education as professionals and a society about the different levels of or impact of substance abuse? Do we need better protocols and systems for monitoring how folks are doing in addressing their abuse, dependence, or addiction, so we can identify and assist with relapse earlier as well as spot those folks who may first register at an abuse or dependence level, but may move into a place of addiction? Do we need to build our capacity or get creative somehow in helping our systems be able to successfully monitor and attend to maintenance and follow-up? Or is the reality that we need to address it all? I think your perspective kicks us all in the butt by starting the conversation about the major difference between dependence and addiction, need to approach the two differently, and necessity of doing better follow-up and maintenance with people fighting this terrible disease of addiction. I know that some folks will raise the point about why do we wait until a celebrity passes away to deal with an every day problem facing our society and communities, but I think anytime there is an opportunity to talk about a major social problem, raise awareness, and begin addressing it in concrete ways, something positive can come from tragedies such as this one. I appreciate you bringing these issues into the public consciousness. – shane

  3. Janice R. Baker, LMSW, CAADC

    Jason, I have not heard such thoroughness on this subject from even the “expert” SA talking heads on TV. (Maybe they need to get you up there.) You said a lot of things I have been thinking about related to this overdose death. I have been working with SA clients for only 8 years, but I so related to your take on this.

  4. jen lindsey cooper

    Wow! Great article Jason! I learn so much reading your blog. Thank you!
    Jen

  5. chuck gehrke

    Thanks. All very well stated and so true. It is too bad more discussions regarding addiction and addicts can’t have the same balance, absence of a disrespectful tone regarding those who might disagree with the writer, and non-judgmental attitude towards the addict.

  6. Thank you so much Jason for your insight in providing such a well written article and your thoughtful response. I have learned alot. This further helps me to continue to understand what at times can be a very daunting disease. And Dr Gehrke as always your statement can’t be more emphasized.

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