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.

New wave of overdoses and a place to learn about the problem & solutions

“We are increasingly seeing signs of what appears to be a return to the epidemic levels of 10 years ago, when fentanyl-related drug overdoses were blamed for 236 excess drug deaths,” Washtenaw County Medical Examiner Dr. Jeffrey Jentzen said in a statement.

5802a0a2-c647-4a0c-b05b-031506e3eddeIt just so happens that MAADAC’s Spring Conference is focused on the opioid epidemic. Speakers include:

  • Keynote by Joseph Rannazzisi, DEA Office of Diversion Control (The first time I saw one of his colleagues present, I was not at all looking forward to it. I learned a lot. It was really good and Mr. Rannazzisi is supposed to be even better.)
  • Update on Managing Treatment Options for Expectant Mothers by Dr. Carl Christensen
  • Grief After Death by Overdose: Working with Survivors by Tana Bridge, Ph.D., LMSW, CTC-S
  • Supporting Recovery on Campus by Matt Statman, LMSW, CAADC
  • Lessons Learned in Building a Technology Oriented Delivery System by Kristen Senters, MA, CAADC

1 Comment

Filed under Uncategorized

Sentences to ponder

From Jennifer Matesa:

image

Look at this picture. This is how some people taper off Suboxone. They cut the dissolvable films into little bitty pieces. The company that makes Suboxone does not advise doing this, because they say they can’t guarantee the drug is evenly distributed throughout the film, but guess what?—I think it’s because they don’t want people to taper off it. I’ve talked to Tim Baxter, M.D., global medical director of Reckitt Benckiser, manufacturer of Suboxone. In two separate interviews he told me, “We don’t promote detox.” They want you to stay on this drug.

 

1 Comment

Filed under Uncategorized

AA, evidence and Glaser

SecondOpinion400Science writer John Horgan takes a look at the Gabrielle Glaser Atlantic article that’s gotten so much attention.

Here’s his overview:

The addiction-treatment industry is a racket, which cries out for critical investigation. But Glaser’s article is embarrassingly shallow and one-sided. She cherry-picks data and anecdotes to make A.A. look bad and alternatives look good.

Here’s some detail on her cherry-picking:

Here’s an example of how Glaser misrepresents sources: She quotes a 2006 report by the Cochrane Collaboration on A.A. and other twelve-step programs (so-called because they are based on A.A.’s recommendations for maintaining sobriety).Cochrane Collaboration is a terrific source of independent analyses of health-related issues, but for the most part its work does not support Glaser’s thesis.

She quotes Cochrane’s conclusion that “no experimental studies unequivocally demonstrated the effectiveness of AA or [12-step] approaches for reducing alcohol dependence or problems.” She neglects to mention that the 2006 report also examined studies comparing twelve-step programs to other treatment methods. The result? “Severity of addiction and drinking consequence did not seem to be differentially influenced by [twelve-step programs] versus comparison treatment interventions,” Cochrane states, “and no conclusive differences in treatment drop out rates were reported.”

Glaser faults the zero-tolerance tenet of A.A. and touts programs that seek reduction rather than elimination of drinking. But a 2012 Cochrane evaluation found no rigorous studies of so-called “managed alcohol programs.” The report states: “The lack of evidence does not allow for a conclusion regarding the efficacy of [managed alcohol programs] on their own, or as compared to brief intervention, moderate drinking, no intervention or 12-step variants.”

Glaser is also keen on pharmaceutical treatments, particularly those involving naltrexone, which blocks opioid receptors and is more commonly used to counter opioid addiction. Glaser reports that after taking naltrexone herself for ten days, she “no longer looked forward to a glass of wine with dinner,” and she lost two pounds to boot.

Glaser cites other personal testimonials and studies that supposedly demonstrate naltrexone’s effectiveness. Actually, the evidence is, at best, mixed. A 2010 Cochrane analysis of 50 studies involving 7,793 subjects concluded that “more patients who took naltrexone were able to reduce the amount and frequency of drinking than those who took an identical appearing, but inert substance.” The effect was hardly overwhelming. “On average,” the Cochrane report noted, “one out of nine patients was helped by naltrexone.” Even that modest effect was not supported by a double-blind study reported in the New England Journal of Medicine in 2001. Those authors found no difference between naltrexone and placebos for treating “chronic, severe alcohol dependence.”

A piece in New York magazine offers similar criticisms and actually interviews experts who have done actual research on 12 step groups and 12 step facilitation:

. . . throughout the piece, Glaser is simply ignoring a decade’s worth of science.

“No, that’s not true,” said Dr. John Kelly, a clinical psychologist and addiction specialist at Massachusetts General Hospital and Harvard Medical School, when I ran Glaser’s argument by him. “There’s quite a bit of evidence now, actually, that’s shown that AA works.” Kelly has a front-row view of the current generation of research: Alongside Dr. Marica Ferri, the original report’s lead author, and Dr. Keith Humphreys of Stanford, he’s currently at work updating the Cochrane Collaboration guidelines (he said they expect to publish their results in August).

Kelly said that in recent years, researchers have begun ramping up rigorous research on what are known as “12-step facilitation” (TSF) programs, which are “clinical interventions designed to link people with AA.” Dr. Lee Ann Kaskutas, a senior scientist at the Alcohol Research Group who has conducted TSF studies, explained that while these programs take on different forms, they’re generally oriented toward preparing participants for the (potentially weird-seeming, especially at first) culture and philosophy of 12-step programs like AA. By randomly assigning a group of study participants to either TSF programs or standard treatment, researchers can overcome some of the self-selection issues inherent to studying AA “in the wild” (that is, it could be that people who choose to go to AA are simply more motivated to kick their addiction).

The data from these sorts of studies, argued Kelly, Kaskutas, and other researchers with whom I spoke, suggest that it outperforms many alternatives. “They show about a 10 to 20 percent advantage over more standard treatment like cognitive behavioral therapy in terms of days abstinent, and typically also what we find is that when people are engaged in a 12-step-oriented treatment and go to AA, they have about 30 percent to 50 percent higher rates of continuous abstinence,” said Kelly.

In an interview about her article, Glaser tries to deflect criticism by misrepresenting her own written criticism of 12 step groups and 12 step facilitation by stating she was really only criticizing 12 step facilitation and not 12 step groups. Even it it were true, this is a problem:

In an email and phone call, Glaser said that TSF programs are not the same thing as AA and the two can’t be compared. But this argument doesn’t quite hold up: For one thing, the Cochrane report she herself cites in her piece relied in part on a review of TSF studies, so it doesn’t make sense for TSF studies to be acceptable to her when they support her argument and unacceptable when they don’t. For another, Kelly, Katsukas, and Humphreys, while acknowledging that TSF programs and AA are not exactly the same thing, all said that the available evidence suggests that it’s the 12-step programs themselves that are likely the primary cause of the effects being observed (the National Institutes of Health, given the many studies into TSF programs it has sponsored, would appear to agree).

In the midst of all this, the New York Times highlights a recent study. The study founds that alcoholics attending AA did better than those who did not and then tried to determine whether this was because those who attended AA were more motivated–whether they did better and attended AA because they were more motivated rather than doing better because of AA. The NY Times article summarizes the findings this way:

Not everyone will comply with treatment. But, among those who do, are they made better off? That’s a question worth answering.

The Humphreys study does so and tells us that A.A. helps alcoholics, apart from the fact that it may attract a more motivated group of individuals. With that established, the next step is to encourage even more to take advantage of its benefits.

Horgan concluded his piece with this thought:

But as psychologists Hal Arkowitz and Scott Lilienfeld noted in Scientific American in 2011, given “the wide availability of meetings and the lack of expense, A.A. is worth considering for many problem drinkers.” [Italics added.] If all treatments are as effective as each other, cost should be the determining factor. Judged by that criterion, no treatment beats A.A., because A.A. is free.

6 Comments

Filed under Uncategorized

Cold water for miracle meds

ice-bucket-challenge-2Keith Humphreys pours cold water on the miracle drug hype:

Like everyone else, I constantly see headlines that the cure for some dread disease has been discovered. On those occasions when journalists interview me about such stories, I have a habit of dispensing cold water. For example, a few years ago, a small clinical trial seemed to show that anti-depressants helped meth-addicted people to stop using drugs. This is what I said to an excellent health reporter, Erin Allday, about the findings:

“There have been quite a few bombs pharmacologically…those earlier experiences have taught me to be cautious now.”

Being skeptical about miracle cures is simply playing the odds.

Then, he reports research on the the latest medical marijuana “miracle”:

You may have heard for example dramatic anecdotes “proving” that high-CBD marijuana cures seizures in children. Sounds great, but as more data were gathered by neurologist Dr. Kevin Chapman “the miracle” took a beating:

Dr. Chapman’s study, which involved a review of the health records of 75 children who took CBD, found that 33% of them had their seizures drop by more than half. However, 44% of the children experienced adverse effects after taking CBD, including increased seizures. Of the 30 patients whose records included the results of brain-wave tests, a less subjective measure of seizure activity, only three showed improvements in those exams.

“It really wasn’t the high numbers we were hoping for,” Dr. Chapman said.

No one who understands medicine will be surprised by this result.

4 Comments

Filed under Uncategorized

Naloxone is not enough – updated

 

This is a repost from earlier in the week that has been updated to include an exchange with a commenter that touches upon some important themes in responding to OD and opiate addiction.

================

NARCAN-KITFrom USA Today:

Fulcher [an emergency room physician at Sts. Mary & Elizabeth Hospital in Louisville, Ky.]says he generally supports giving greater access to naloxone, which at one point his ER administered so often doctors felt like they were running a drive-through OD clinic. But he says new laws “totally ignore” the overall problem of addiction and may communicate an underlying acceptance of intravenous heroin use. “Politicians will feel like they’ve dealt with the problem,” Fulcher says.

There’s a comment on Join Together that suggests this is a straw man, that no one says naloxone is enough. There’s some truth to this.

At the same time, how much action are we hearing about to increase access to treatment of an appropriate quality, intensity and duration?

UPDATE:
A commenter expressed concern about Dr. Fulcher’s concern that we “may communicate an underlying acceptance of intravenous heroin use.” In her comment she cited a reseacher (and harm reduction activist) Peter Davidson. The exchange touched upon some important themes. Below is my lightly edited response.

That line made me cringe too. However, not knowing anything about him, I’m willing to give him the benefit of the doubt.

First, you didn’t include an important line from that quote, “‘Politicians will feel like they’ve dealt with the problem,’ Fulcher says.” This changes the context considerably. It makes it sound less like a concern about increased drug use and more like a concern about political indifference.

Second, he’s an ED physician and his reference to ERs feeling like “drive-through OD clinics” suggest he’s witnessing what we see in our community–an OD, naloxone reversal, brief visit to the ED with (at best) a passive referral to treatment, and ODing again, sometimes fatally. It becomes normalized and is not treated like a near fatal event/symptom of a life-threatening illness with a high mortality rate.

Finally, he’s not saying we need less naloxone. He’s saying we need naloxone-plus–that we need naloxone plus addiction treatment.

Given that, I’m willing to interpret his statement as a poorly worded expression of concern about professional and social indifference to non-fatal OD.

It’s interesting. After your comment I looked to read more on Peter Davidson. I see that he created odgame.org.

While I’m not crazy about the style of it, what really bothered me was the content of the game. If you call 911, the game continues for 3 turns (unless you do something to kill the person). However, if you give the person naloxone, it’s game over, with a pat on the back and instructions to:

“If you can’t stay with them, try and leave them with someone else. If that isn’t an option either, at least try and leave them in a public place so there’s a chance some passer-by might notice if they lose consciousness again.”

I think this is exactly what Fulcher was pushing back against. No mention of getting medical help. No mention of treatment. No hope for recovery. No using this as a window of opportunity to intervene. Mission accomplished and we can feel good about ourselves.

Can you imagine instructing people to use an automated defibrillator on someone who has a heart attack and the care ending there with a congratulations? Or worse, leave them in a public place?

3 Comments

Filed under Uncategorized

Naloxone is not enough

NARCAN-KITFrom USA Today:

Fulcher [an emergency room physician at Sts. Mary & Elizabeth Hospital in Louisville, Ky.]says he generally supports giving greater access to naloxone, which at one point his ER administered so often doctors felt like they were running a drive-through OD clinic. But he says new laws “totally ignore” the overall problem of addiction and may communicate an underlying acceptance of intravenous heroin use. “Politicians will feel like they’ve dealt with the problem,” Fulcher says.

There’s a comment on Join Together that suggests this is a straw man, that no one says naloxone is enough. There’s some truth to this.

At the same time, how much action are we hearing about to increase access to treatment of an appropriate quality, intensity and duration?

UPDATE:
A commenter expressed concern about Dr. Fulcher’s concern that we “may communicate an underlying acceptance of intravenous heroin use.” In her comment she cited a reseacher (and harm reduction activist) Peter Davidson. The exchange touched upon some important themes. Below is my response.

That line made me cringe too. However, not knowing anything about him, I’m willing to give him the benefit of the doubt.

First, you didn’t include an important line from that quote, “‘Politicians will feel like they’ve dealt with the problem,’ Fulcher says.” This changes the context considerably. It makes it sound less like a concern about increased drug use and more like a concern about political indifference.

Second, he’s an ED physician and his reference to ERs feeling like “drive-through OD clinics” suggest he’s witnessing what we see in our community–an OD, naloxone reversal, brief visit to the ED with (at best) a passive referral to treatment, and ODing again, sometimes fatally. It becomes normalized and is not treated like a near fatal event/symptom of a life-threatening illness with a high mortality rate.

Finally, he’s not saying we need less naloxone. He’s saying we need naloxone-plus–that we need naloxone plus addiction treatment.

Given that, I’m willing to interpret his statement as a poorly worded expression of concern about professional and social indifference to non-fatal OD.

It’s interesting. After your comment I looked to read more on Peter Davidson. I see that he created odgame.org.

While I’m not crazy about the style of it, what really bothered me was the content of the game. If you call 911, the game continues for 3 turns (unless you do something to kill the person). However, if you give the person naloxone, it’s game over, with a pat on the back and instructions to:

“If you can’t stay with them, try and leave them with someone else. If that isn’t an option either, at least try and leave them in a public place so there’s a chance some passer-by might notice if they lose consciousness again.”

I think this is exactly what Fulcher was pushing back against. No mention of getting medical help. No mention of treatment. No hope for recovery. No using this as a window of opportunity to intervene. Mission accomplished and we can feel good about ourselves.

Can you imagine instructing people to use an automated defibrillator on someone who has a heart attack and the care ending there with a congratulations? Or worse, leave them in a public place?

4 Comments

Filed under Uncategorized

Why so irrational about AA?

AA isn't the only way to recover, but no reasonable person can say it's ineffective.

AA isn’t the only way to recover, but no reasonable person can say it’s ineffective.

Gabrielle Glaser has gotten another AA bashing article published and it’s getting a lot of attention. Of course she doesn’t really offer a tangible alternative.

I’m not going to write another piece rebutting it, but I’ll point you to a few relevant posts.

First, in New York magazine, Jesse Singal dismantles Glaser’s arguments.

As with any story about a complicated social-science issue, there are aspects of Glaser’s argument with which one could easily quibble. For one thing, she repeatedly conflates and switches between discussing AA, a program that, whatever one thinks about it, is clearly defined and has been studied, in one form or another, for decades, and the broader world of for-profit addiction-recovery programs, which is indeed an underregulated Wild West of snake-oil salesman offering treatments that haven’t been sufficiently tested in clinical settings. Her argument also leans too heavily on the work of Lance Dodes, a former Harvard Medical School psychiatrist. He has estimated, as Glaser puts it, that “AA’s actual success rate [is] somewhere between 5 and 8 percent,” but this is a very controversial figure among addiction researchers. (I should admit here that I recently passed along this number much too credulously.)

But on Glaser’s central claim that there’s no rigorous scientific evidence that AA and other 12-step programs work, there’s no quibbling: It’s wrong.

Next, one of my previous posts lays out the evidence for the use of 12 step groups.

Then, here are some of my responses to Dodes.

Finally, some posts on addiction treatment and recovery being made a front in the culture wars, including a response to a previous Glaser article.

8 Comments

Filed under Uncategorized