Author Archives: Jason Schwartz

About Jason Schwartz

Jason Schwartz, LMSW, ACSW, CADC, CCS, is the Clinical Director of Dawn Farm, overseeing treatment services for its two residential treatment sites, sub-acute detox, outpatient treatment services & detention-based juvenile treatment program. Jason is also an adjunct faculty at Eastern Michigan University’s School of Social Work and School of Leadership and Counseling. Jason blogs at www.addictionrecoverynews.com and has been published in Addiction Professional magazine and in a monograph Recovery-oriented Supervision with the Addiction Technology Transfer Center. Jason serves on the advisory boards of Eastern Michigan University’s School of Social Work and School of Leadership and Counseling. Jason also serves as a board member for the Livonia Save Our Youth Task Force, a substance abuse prevention coalition in his home community.

Addiction is disordered learning AND much more.

I’ve had a lot lot requests to respond to this recent piece in the NY Times.

A Personal Narrative or Universal Model?

drug-addictionThe piece is interesting and well written, but it focuses on the experience of one person. I get the impression that she’s frustrated that most people would say that her experience with heroin means she has the disease of opioid addiction. She does not believe she has a disease and doesn’t want to be shoehorned into that model. So, she’s created an alternative narrative to explain her experience.

That’s a fine thing. She may not have had the disease of addiction. In her case, it may have been a result of disordered learning, self-medication and become something akin to a love relationship with the relief that heroin provided. I can imagine it’d  be frustrating to be shoehorned into a model that doesn’t fit one’s experience.

The problem is that she constructs a model of understanding addiction from her personal experience—an experience that seems fairly atypical—and then uses it to try to disprove the disease model and shoehorn people with addiction into her model.

If it was intended to be something memoir-ish, that would be one thing. However, the article also seems to be trying to promulgate this model as the way the addiction should be understood generally.

Addiction as a Category

It’s important to point out that I don’t believe the author uses the same definition of addiction I do. I limit the term addiction to people with chronic and high severity substance use problems characterized by loss of control—not all people with drug problems are addicts.

In a previous post, I took a long look the categorization of substance use problems. In that post, I made the case for addiction as a different kind of problem from less severe substance use problems rather than a more severe version of the same problem.

Dependence was far from perfect. This is not an argument for a return to the abuse/dependence model. (Though I will argue that we should return to conceptualizing as addiction as a different kind of problem from low to moderate SUDs, rather than a different severity.)

Let’s start by stating that addiction/alcoholism is the chronic form of the problem is primary and characterized by functional impairment, craving and loss of control over their use of the substance.

Problems with the categories of abuse and dependence include:

  • Dependence has often been thought of as interchangeable with addiction/alcoholism, but this is not the case.
  • Dependence criteria captured people who are not do not have the chronic form of the problem. 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.
  • Dependence criteria captured people who are not experiencing loss of control of their use of the substance.
  • The word dependence leads to overemphasis on physical dependence which, in the case of a pain patient, may not indicate a problem at all.
  • The word abuse is morally laden.
  • For me, there are serious questions about whether abuse should be considered a disorder at all.

Several of these problems are related to doing a poor job in distinguishing which kind of user the patient or subject is.

The abuse/dependence model fell short in distinguishing between kinds of users. Rather than taking a step forward in distinguishing between the kinds of users, the continuum approach implies that there is only one kind with different levels of severity.

In that post, I also pointed out that framing addiction as a more severe version of the same problem would undermine the disease model.

The continuum approach becomes especially troubling when you think about the idea of giving people with low severity SUDs and people with the disease of addiction the same diagnosis, only with different severity ratings.

There’s little doubt that large numbers of young people on college campuses meet diagnostic criteria for an alcohol use disorder under the DSM 5. I doubt anyone would argue that all of these young people have a disease process? Even a mild one?

This seems likely to undermine the acceptance of addiction as a disease. Not just by the public, but also by insurers and policy makers.

So, it’s not surprising that she’s using the broader definition of addiction when questioning the disease model.

Addiction as a Learning Disorder

I don’t at all disagree that addiction involves disordered learning.

However, I would disagree that addiction is only (or primarily) disordered learning. Addiction is disordered learning AND much more.

The idea that learning plays a role in addiction is not new. The American Society of Addiction Medicine definition of addiction includes the following. (Keep in mind that references to memory speak to learning.)

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors. Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.

The neurobiology of addiction encompasses more than the neurochemistry of reward.1 The frontal cortex of the brain and underlying white matter connections between the frontal cortex and circuits of reward, motivation and memory are fundamental in the manifestations of altered impulse control, altered judgment, and the dysfunctional pursuit of rewards (which is often experienced by the affected person as a desire to “be normal”) seen in addiction–despite cumulative adverse consequences experienced from engagement in substance use and other addictive behaviors. The frontal lobes are important in inhibiting impulsivity and in assisting individuals to appropriately delay gratification. When persons with addiction manifest problems in deferring gratification, there is a neurological locus of these problems in the frontal cortex. Frontal lobe morphology, connectivity and functioning are still in the process of maturation during adolescence and young adulthood, and early exposure to substance use is another significant factor in the development of addiction. Many neuroscientists believe that developmental morphology is the basis that makes early-life exposure to substances such an important factor.

. . .

In addiction there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviors despite mounting concerns expressed by significant others in their lives; and display an apparent lack of appreciation of the magnitude of cumulative problems and complications. The still developing frontal lobes of adolescents may both compound these deficits in executive functioning and predispose youngsters to engage in “high risk” behaviors, including engaging in alcohol or other drug use. The profound drive or craving to use substances or engage in apparently rewarding behaviors, which is seen in many patients with addiction, underscores the compulsive or avolitional aspect of this disease. This is the connection with “powerlessness” over addiction and “unmanageability” of life, as is described in Step 1 of 12 Steps programs.

Is addiction a disorder of learning? Yes. But, it’s also a disorder of genetics, motivation, reward and stress.

 

Dirk Hason has written eloquently on the convergence of thinking of addiction as a learning disorder and muddying the distinctions between problem use and addiction.

For harm reductionists, addiction is sometimes viewed as a learning disorder. This semantic construction seems to hold out the possibility of learning to drink or use drugs moderately after using them addictively. The fact that some non-alcoholics drink too much and ought to cut back, just as some recreational drug users need to ease up, is certainly a public health issue—but one that is distinct in almost every way from the issue of biochemical addiction. By concentrating on the fuzziest part of the spectrum, where problem drinking merges into alcoholism, we’ve introduced fuzzy thinking with regard to at least some of the existing addiction research base. And that doesn’t help anybody find common ground.

Addiction as Love and Self-medication

Addiction as an unhealthy form of attachment or love is also not a new idea. Stanton Peele, a gadfly and long time critic of the disease model wrote the following:

An addiction may involve any attachment or sensation that grows to such proportions that it damages a person’s life. Addictions, no matter to what, follow certain common patterns. We first made clear in Love and Addiction [published in 1975] that addiction— the single-minded grasping of a magic-seeming object or involvement; the loss of control, perspective, and priorities—is not limited to drug and alcohol addictions. When a person becomes addicted, it is not to a chemical but to an experience. Anything that a person finds sufficiently consuming and that seems to remedy deficiencies in the person’s life can serve as an addiction. The addictive potential of a substance or other involvement lies primarily in the meaning it has for a person.

Theories of addiction as a form of self-medication have been about for decades. These theories frame addiction as secondary to another problem which may be social, psychological, environmental or physical in nature.

However, addiction is widely accepted as a primary disease among professional societies.

Further, addiction’s (I’m referring to severe and chronic substance use problems.) onset, course and response to treatment is often affected by social, environmental, psychological and physical problems, but it generally does not fade away when those problems are addressed.

Multiple Mechanisms

The more we learn about addiction, the more we find that there are multiple mechanisms involved. In a 2011 post, I wrote the following (keep in mind that this is abstract speculation rather than a concrete theory):

Or, maybe there are several neurological mechanisms (reward pathway, memory circuits, risk evaluation, self-regulation, stress responses, etc.) and some people may have 2, others may have 6.  Some factors may be associated with a more chronic form, others may be associated with a more severe loss of control and overall severity may be associated with the number of factors the person has. (Some might be primary to addiction, others secondary.)

There are probably a lot more than 6 but, for the sake of argument, let’s stick with 6. So, is it possible that the author had 1, or 2 or 3 of these mechanisms (ones involving memory, attachment and learning) while most people with addiction (chronic and severe) suffer from 5 or 6?

Could this provide a way to view her model as true for her (and some others) and the disease model as true for most people with addiction? I think it might. And, maybe it could also shed some light on a portion of that segment of young, heavy users who mature out.

It’s not that she’s wrong. It’s just that she’s zooming in on one part of a larger story to the exclusion of the rest of what we know.

More reading

 

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Senate sits on opioid investigation report

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The Senate Finance Committee has buried an investigative report on financial ties between drug manufacturers and medical organizations that were setting guidelines for opioid use.

In 2012, the chair and ranking member of the Senate Finance Committee, Max Baucus (D-Mont.) and Chuck Grassley (R-Iowa), launched an investigation into financial ties between drug manufacturers and medical organizations that were setting guidelines for opioid use. When the investigation began, the federal government had already reported that opioid overdoses were killing more people each year than car accidents. Many staffers working for Baucus considered his home state of Montana to be ground zero for the epidemic of opioid addiction.

The committee focused on the American Pain Foundation, the Center for Practical Bioethics, and five other organizations. It also targeted three leading opioid makers: Purdue Pharma (OxyContin), Endo Pharmaceuticals (Percocet), and Johnson & Johnson (Duragesic). The committee demanded to see documents and get answers to its questions.

Over the course of many months, congressional investigators collected and analyzed a mountain of material. These documents, and the report that was drafted from them almost a year later, have never seen the light of day. Instead, they remain sealed in the Senate Finance Committee’s office.

The work is done. Why would they not release it? Read the rest here. Then, contact your senator.

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Pharma’s incentive problem

money-pillsHarvard Business Review examines the ways in which Pharma’s employee and business unit incentives contributes to the opioid crisis. It’s not as piercing as one might home, but it’s interesting food for thought.

Here’s one portion:

It isn’t news that rewarding sales volume rather than public health outcomes is a problem in the pharmaceutical industry. In fact, this is the root of nearly all the mistrust that clouds the industry’s operations, relationships, and reputation. The memory of hefty legal settlements for improper marketing and obfuscation of safety risks lingers, the biggest being GlaxoSmithKline’s 2012 $3 billion penalty over the marketing of antidepressants and a safety issue for a diabetes drug.

But there are ways that employee compensation around outcomes could change that. For one, it could instantly align each sales rep, and other commercial employees, with their customers — and with the patient. Suddenly doctors and pharmaceutical employees could be working to the same defined outcome goal for patients.

So, for example, part of the incentive compensation for the commercial team could be tied to real outcomes in patients in their territories. Certain territories will be more challenging — for instance socio-economic factors, diet, education, and behaviors like smoking could vary from area to area. Adjusting for that, a sales rep could have higher compensation potential for working in such areas and generating results.

Legally, salespeople can only talk about outcomes if they are approved in the drug’s label by the Food and Drug Administration — another reason to have more outcomes data determined in the testing phase. But commercial employees also could work to help improve outcomes through community outreach.

This reimagination of the sales rep as a health outcomes advocate would require some different skills and a new collaboration with health providers and insurers. Strategically, however, it could transform the value of the frontline sales force. Rather fighting for doctor time, the sales force could be a grassroots, public health army working and advocating for optimal health outcome in patients and the community. The opioid story, after all, might have been different if bonuses incentivized value instead of volume.

It’s hard to imagine this kind of transformation of values in this business. I’m not holding my breath. It seems like it would take payer or regulatory intervention.

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Medical management of chronic disease is a mess

Push_vs_Pull_MarketingSenator Ron Wyden, with a focus on seniors, examines the problems Americans face with medical management of chronic diseases.

The struggles that people with chronic illness face are manifold. One problem is coordinating care. It’s hard enough for somebody who’s perfectly healthy to assemble medical records for a new doctor; consider how difficult it must be for an elderly woman who recently suffered a heart attack. Think about her journeying to a doctor appointment across town in the middle of the day. Or filling a hard-to-find prescription and adding it to an already-daunting battery of pills.

America’s health care system tells millions of seniors they’re on their own when it comes to managing their chronic illnesses. The result is a full-time job and far too many chances for dangerous errors and missteps.

Today, Medicare inexplicably charges older Americans a copay just to coordinate care among all their doctors. Doesn’t it defy common sense for seniors to pay extra for care coordination that holds costs down? In my view, this charge should be junked, and care coordination should begin right after seniors receive their free physical provided by the Affordable Care Act. This is one of many commonsense changes to Medicare that could improve the lives and health of seniors with chronic diseases, many of whom have stories all too familiar to every American family.

As Seth Mnookin shared last week, coordination of care is a huge problem. And, as Sen. Wyden’s article suggests, there’s little reason to believe care coordination would be much better if addiction treatment were housed within a doctor’s office.

This is an urgent need in the lives of many people with addiction. There are efforts to improve this inside and outside of traditional medicine. We started a primary care project 5 years ago to get all residential clients connected to recovery-informed primary care and improve coordination of care. It hasn’t been perfect, but there’s a stark difference between today and 2010. If only we could extend that into the rest of their medical care—specialists and emergency medicine.

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A Systems Approach Is The Only Way To Address The Opioid Crisis

wp17a759ca_05_06Health Affairs has a great summary of a recent report on the opioid crisis.

It identifies “six key components to develop a system-wide community solution.”

  1. Recognize That Everyone In Your Community Has A Role To Play
  2. Work Together
  3. Work On Multiple Parts Of The System Simultaneously
  4. Be Unambiguous About The Risks Of Prescription Opioids
  5. Re-Train The Medical Community
  6. Recognize That Addiction Is A Chronic Disease, And Treat It Accordingly

Read the article for details.

The most striking thing is a table that identifies objectives, actions and actors. Nothing groundbreaking, but it does s really nice job of pulling together the multiple needs and systems in one place.

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Sentences to ponder

photo credit: sarcasmo

photo credit: sarcasmo

On the Stanford rape case [emphasis mine]:

When Brock Turner sexually assaulted the woman now famous for her seething court statement about the crime, at least two other men had also seen her lying unnaturally still behind a dumpster near a fraternity house on the Stanford University campus. But while much has been said in recent weeks about the lax sentence Turner received, little attention has been paid to the fact that what he did was way worse than a sexual attack on a drunk woman unable to consent. It was actually an assault on an overdose victim, one who was at risk of serious medical problems and even death if she didn’t get help fast.

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Another day, another recovery hustle

51T1SeT4LRL._SX345_BO1,204,203,200_HuffPo has a new article on ethically impaired treatment providers:

The opioid epidemic, which just added Prince to its list of victims, has shoved the addiction industry into the spotlight, and many here at the National Association of Addiction Treatment Providers conference worried aloud how the industry’s lax ethical standards would look in the new glare.

Nor is greater attention to ethics the providers’ only threat. Drug treatment is now big business, and a wave of consolidation is sweeping the industry, as private equity firms and publicly traded companies look to cash in on the surging rates of addiction. Federal regulators, meanwhile, are pushing to reform the very nature of the services offered by treatment centers.

How the addiction industry faces up to all these changes will help set the course of drug treatment for years to come.

It hits upon two themes from yesterday’s post. First, patient recruitment and expensive IOP:

Among the more abusive practices the NAATP is trying to root out is “patient brokering,” which several conference attendees told The Huffington Post should be more accurately thought of as “human trafficking.” Art VanDivier, chair of the NAATP’s Ethics Committee, said the going rate to steer a patient with Affordable Care Act coverage to a particular facility is now $7,000. That sounds like a lot of money, but the clinic can bill the insurer $15,000 to $30,000 for a month of treatment, charge for lucrative drug tests along the way, and then bill for eight or so weeks of intensive outpatient treatment.

It also discuss internet marketing concerns:

Another area of concern is the twist that online marketing has taken. Try it for yourself — hop over to Google and search for addiction treatment options in your area. Chances are good that most of the results you’ll get will have gamed their way onto the list, and none of them will actually be in your area. Third-party sites that present themselves as independent aggregators of information are often run by a single treatment center, and every phone number routes to it rather than to the various clinics the site purports to link to. “Closers” on the other end of the line are charged with persuading the family in crisis to send their loved one to that single center — even if they may be located far away. (Indeed, the distance can be sold as a positive, since removing the patient from negative influences can be beneficial.)

Unfortunately, the writer conflates 12 step facilitation (which is evidence-based) with these ethical failings, weirdness and zealotry.

UPDATE: It’s also unfortunate that they frame maintenance as the gold standard without any context. Of course, addicted physicians do not receive maintenance treatments, there’s a different gold standard for them.

UPDATE 2: It’s not enough to give the impression that people who believe residential and 12 step facilitation should be part of the continuum are weirdos and zealots. The author, while promoting his article, has now tweeted that “Industry leader says on the record he refuses to judge success ‘by who doesn’t die'”. It sounds like the guy was trying to make a point about quality of life, but it was a stupid comment nonetheless.

Who is this industry bigwig? Someone I never heard of and had to google. Turns out he’s the Director of Spiritual Care at Caron. “Industry leader.” smh

 

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