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.

Sentences to ponder

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from: Restoring Sanctuary: A New Operating System for Trauma-Informed Systems of Care by Sandra L. Bloom, Brian Farragher on adaptive vs. technical problems in helping relationships.

In human service delivery, we have a historical burden to carry in that there is a long-standing belief that in our line of work we are dealing with technical problems. A client carries a diagnosis, and that means we give him or her a medication or a specific behavioral plan and the client should respond. Technical problems generally lend themselves to cookbook kinds of solutions such as “Ten Easy Steps to Put Your Backyard Grill Together” or “The Proper Procedure for Filling XYZ Form.”

But in reality, the problems we are dealing with are generally adaptive problems, problems that have never been solved before. We may have solved a problem like this one before but not this one. This is a different client. This is a different day, a different year. The people involved in delivering the new response are different. There are always different variables that make this problem different from the last one. Every story is a different story; every reenactment is a different reenactment.

Because our work is so complex and outcomes are so uncertain, we yearn for technical problems; as a result, we often treat adaptive problems as if they were technical problems.

This is not meant to suggest that addiction is a adaptive. However, many of the behavioral, social, cognitive, emotional, psychiatric and spiritual barriers we face are adaptive.

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Is rehab “outdated, expensive and deadly”?

This article, calling rehab “outdated, expensive and deadly” is wrong about some important things and right about some important things.

What it gets wrong

On medication assisted treatment (MAT):

  • It overstates the effectiveness of buprenorphine. If the medication “eliminates” and is so “effective”, you think they’d have better outcomes than this (Which is not an outlier and was spun as proof of buprenorphine’s effectiveness).
  • It gives false comfort about the protective effects of these medications against death by overdose.
    • While the study he linked to did find death rate 50% higher for people receiving only psychosocial support vs. methadone, he failed to acknowledge a few other points of interest.
      • First, who thinks psychosocial support is an adequate intervention for opioid addiction?
      • Second, 47.5% of all overdose deaths were people currently enrolled in methadone treatment.
    • I’ve blogged before that the death rate for people in MAT. It’s still very high. See here, here and here for just a few examples.
    • There’s no argument 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, hereherehere and here.)
  • It give a false impression that MAT is unavailable to most people with opioid addiction.

While he paints maintenance assisted treatment with a broad positive brush, he paints abstinence-based treatment with a broad negative brush. In doing so, he fails to mention that there is a model, in which residential treatment is one element, that has far superior outcomes to other approaches. This model is the gold standard and is used with addicted pilots and health professionals. (Yes, there are questions about about how differences in recovery capital and motivation might influence outcomes. But, it’s worth mentioning, isn’t it? Isn’t it reasonable to believe there’s a lot that can be learned from these programs?)

GotEthicsNewWhat it gets right

  1. Treatment for opioid addiction that amounts to little more than detoxification—getting the patient to 30 days abstinent—and not following that care with robust recovery monitoring and support is dangerous.
  2. There are a lot of phony success rates touted—in abstinence-based treatment and MAT.
  3. Exorbitant fees for residential and inpatient treatment are common.
  4. Charging large sums of money for inadequate care and making misleading success claims amounts to financial exploitation.
  5. There is too little consistency and accountability in all forms of treatment—abstinence-based and MAT. There is a lot of bad care out there.
  6. The opioid crisis is drawing attention and money to addiction treatment. As a field, the cost of failure will be huge and will set us back decades.
  7. The length of treatment is driven by funding rather than patient need or a gold standard of care—in abstinence-based treatment and MAT.
  8. Most programs do not provide good informed-consent—in abstinence-based treatment and MAT.

The writer doesn’t say this, but an implication of his arguments is that too many services focus on recovery initiation and too few focus on recovery maintenance.

The gold standard model includes eight, ten or fourteen elements (depending on how you count them). Offering just a few of these elements is common practice. That practice is inadequate, possibly dangerous and any marginally informed professional should know better.

What to do about it?

A sad fact is, for far too many people, their choices are inadequate medication-free treatment or inadequate medications assisted treatment (MAT). Given these choices, for a lot of people, inadequate MAT is probably less bad than inadequate medication-free treatment.

I write frequently about the gold standard of care—the care that addicted doctors receive. They have outstanding outcomes. (I’ve even suggested that abstinence vs. MAT arguments may be a distraction from focusing on the need for long term recovery management.)

A lot of people express doubt about whether than model can be adapted to meet the needs of other people with addiction.

All of these concerns have merit. Yet, we don’t really know because we haven’t tried.

I believe we should put effort into adapting and delivering the gold standard to all people with opioid addiction.

Where we can’t offer the gold standard to patients, we should at least tell them it exists, but it’s too expensive or there are no providers. (But, not necessarily at the expense of anything else.) Where can offer some, but not all, elements of the gold standard, we should share that information too.

Critics of abstinence-based treatment are right that there has been too little meaningful informed consent.

People with addiction should be told about the treatments that exist, and the evidence for them. When discussing the evidence for an approach, they ought to be informed about the extent to which the evidence aligns with their goals.

Then, they should be told about the treatments that are available to them. And, they ought to be told why some treatments aren’t available to them—not covered, too expensive, no provider available, policy barriers, etc.

Then, they should be free to choose the treatment they prefer. And, within reason, they should be free to change their mind.

 

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Update. FULL 911 Good Samaritan Legislation in Michigan

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Good news!!!

There are 2 bills in the Michigan House of Representatives Criminal Justice Committee that would would provide immunity from criminal charges for people all ages who are seeking emergency medical assistance for themselves or friends as a result of a drug overdose from any illicit drug.

Rep. Pscholka’s bill, House Bill 5649, provides immunity from possession penalties in certain circumstances.

Rep. Singh’s bill, House Bill 5650, provides immunity from use penalties in certain circumstances.

These bills expand upon last years House Bill 4843 by removing limitations based on age and type of drug.

The House Criminal Justice Committee will be taking up these bills on Tuesday, May 17, 2016 at 9:00 AM in Room 327, House Office Building, Lansing, MI.

Contact the House Criminal Justice Committee to let them know you support these bills.

Background

The Facts

Keep these facts in mind:

  • Overdose is now the leading cause of accidental death in the U.S. Most of these overdose deaths are due to opioids.
  • If help arrives in time, overdoses can be safely and quickly reversed with a squirt of naloxone up the patient’s nose.
  • More than half of all overdoses occur in the presence of other people, usually other drug users.
  • Too often, people do not call 911 in a timely manner due to fear of arrest for possession of drugs.

A First Step

At the urging of parents who have lost children to overdose, the Michigan legislature made some good first steps last year. They enacted laws that increased access to naloxone, the drug that reverses overdoses.

On October 13, 2014, Public Acts 311, 312, 313 and 314 of 2014 were signed into law.

These acts will:

  • Allow Narcan to be prescribed to friends and family of heroin addicts, so it’s readily available in the event of an overdose.
  • Protect a person administering Narcan in good faith to be immune from criminal prosecution or professional sanctions.
  • Require emergency medical personnel to carry the drug in their vehicles and be trained in how to administer it.
  • Require the state Department of Community Health to complete annual reports of opioid-related overdose deaths.

Another Step

Last summer, Michigan Rep. Al Pscholka (R-Stevensville) introduced House Bill 4843, a bipartisan measure, that would create Good Samaritan protections for individuals under the age of 21 who seek medical attention for themselves or another person believed to have overdosed. However, the Good Samaritan protections are limited to the illegal possession of prescription drugs (in quantities consistent with personal use) for people under the age of 21.

Last December the Governor signed the Good Samaritan Bill, House Bill 4843, into law.

911 Good Samaritan Laws

NARCAN-KITThe Drug Policy Alliance provides a really good summary of 911 Good Samaritan laws:

Accidental overdose deaths are now the leading cause of accidental death in the United States, exceeding even motor vehicle accidents among people ages 25 to 64. Many of these deaths are preventable if emergency medical assistance is summoned, but people using drugs or alcohol illegally often fear arrest if they call 911,  even in cases where they need emergency medical assistance for a friend or family member at the scene of a suspected overdose.The best way to encourage overdose witnesses to seek medical helpis to exempt them from arrest and prosecution for minor drug and alcohol law violations, an approach often referred to as Good Samaritan 911.

The chance of surviving an overdose, like that of surviving a heart attack, depends greatly on how fast one receives medical assistance. Witnesses to heart attacks rarely think twice about calling 911, but witnesses to an overdose often hesitate to call for help or, in many cases, simply don’t make the call. In fact, research confirms the most common reason people cite for not calling 911 is fear of police involvement.

It’s important to know that this is not a liberal vs. conservative or Republican vs. Democrat issue. Some of the reddest and the bluest states in the country have passed 911 Good Samaritan laws.

Twenty states and the District of Columbia have enacted policies to provide limited immunity from arrest or prosecution for minor drug law violations for people who summon help at the scene of an overdose. New Mexico was the first state to pass such a policy and has been joined in recent years by Alaska, California, ColoradoConnecticut, Delaware, Florida, Georgia, Illinois, LouisianaMaryland, Massachusetts, Minnesota, New Jersey, New York, North Carolina, Rhode Island, Vermont, Washington and Wisconsin.

Further, these laws don’t protect dangerous or predatory criminals.

Good Samaritan laws do not protect people from arrest for other offenses, such as selling or trafficking drugs, or driving while drugged. These policies protect only the caller and overdose victim from arrest and/or prosecution for simple drug possession, possession of paraphernalia, and/or being under the influence.

The Bad News

An overdose is a major medical crisis, right? It’s not unlike a heart attack.

Here’s what happens when someone has a heart attack41KSA2GA12L._SX300_

  1. A person has a heart attack at the grocery store and . . .
  2.  . . . thank goodness, the store has an automatic defibrillator.
  3. Someone has been trained to use the defibrillator and performs the rescue.
  4. Someone else calls 911 to make sure the patient gets all the care they need.
  5. The patient is taken to the emergency department and medically stabilized.
  6. Once stabilized, the patient gets transferred to care that will address the cause of the heart attack and/or care that will prevent future heart attacks.
  7. The patient’s treatment plan will generally include lifestyle changes. (Diet, exercise, etc.)
  8. Then, the patient gets follow-up care that might include:
    • follow up appointments with specialists,
    • periodic tests to monitor for indicators of a recurrence,
    • self-monitoring (blood pressure), and
    • monitoring by the patient’ primary care physician.
  9. If problems recur or there are indications of a potential recurrence, the care plan will be re-evaluated and the patient will get whatever care they need.

Here’s what happens when someone ODs and is rescuednarcan

  1. A person overdoses and . . .
  2.  . . . thank goodness, the someone has naloxone.
  3. The person has been trained to use naloxone and performs the rescue.

Maybe, if they are lucky, these steps happen.

  1. Someone else calls 911 to make sure the patient gets all the care they need.
  2. The patient is taken to the emergency department and medically stabilized.

Naloxone is not enough.

We’d never tolerate cardiac patients being sent home without the proper care. Why should people with an addiction be treated any differently?

The good news

The good news is that there are models that work.

The Gold Standard

A male doctor writes on a patients chart.The best example of what should happen is the the kind of care that opioid addicted doctors, nurses, pilots and lawyers get. They all have low relapse rates and return to work at very high rates.

Here’s what would happen if one of them overdosed at work (or if it was known to their employer):

First, the recovery planning begins with some important assumptions:

  • abstinence is the goal;
  • full recovery with a return to full functioning is the expectation;
  • addiction is a chronic illness and recovery requires long term treatment, support and monitoring; and
  • for recovery to be durable, the addict must be an active participant in treatment and recovery maintenance.

Signpost along the road to recovery.The recovery plan is likely to include the following:

  • Formal treatment. The first phase of formal addiction treatment for most of these professionals is residential care ranging from 30 to 90 days.
  • Supportive services. Supportive services used by these professionals includes AA or NA 12-step groups, aftercare groups from their formal treatment programs, and follow-up from case managers.
  • Long-term support and monitoring. After completion of initial formal addiction treatment, they develop a continuing care contract consisting of support, counseling, and monitoring for usually 2 to 5 years.
  • Drug testing. Regular testing for 2 to 5 years, usually with more frequent testing at the start and reduced testing following periods of stable negative drug test results.
  • Dealing with relapse. Relapses are usually addressed by a combination of increased intensity of care and monitoring and by immediately informing family and colleagues of the physician to enlist their support.

Other options

Buprenorphine (Suboxone) and methadone have been shown to reduce drug use, overdose risk, criminal activity and disease transmission.

Some people are able to stabilize and live normal lives on these medications but, at this point, there is no research demonstrating its effectiveness with quality of life indicators like employment.

Many people hope to use these drugs as an interim step toward abstinence. However, there is no established model for successfully transitioning buprenorphine and methadone patients to abstinence. A large federally-funded study attempting to do this reported, “near universal relapse.”

Another option is an injectable drug called Vivitrol. It is injected once per month and can protect against overdose. Unfortunately, it’s very expensive.

Which to choose?

Hope Traffic SignThe gold standard offers a path to full recovery, but it does demand a lot of structure, effort and lifestyle changes.

Many professionals prefer drug maintenance as a goal. It’s an easier plan to implement and many professionals are not confident that their patients are capable of drug-free recovery. (Look for professionals that are optimistic and believe in you ability to achieve full recovery.)

However, most patients and families, for a wide variety of reasons, prefer abstinence as a goal–the most common reason is that they want their life back the way it was before they became addicted.

Patients not sticking with the treatment plan is the biggest barrier to success with both approaches.

It’s harder than it should be

Getting the gold standard for yourself or a family member is likely to be very difficult. But, there are steps you can take to improve the odds.

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Bad behavior isn’t limited to Pharma

-Miracle_Cure!-_Health_Fraud_Scams_(8528312890)Yesterday, it was suggested that I post about the abuses in the residential treatment and sober housing industries, suggesting that readers might get the impression that drug-free treatment is good while medication-assisted treatment is bad.

The reader had a point–there’s no shortage of exploitative and shady behavior among these providers. In fact, at Dawn Farm, we go out of our way to distinguish ourselves from the rest of the industry.

I probably haven’t posted a whole lot about it because the problem is not quite as visible in Michigan. Some areas, parts of Florida and California in particular, have become hubs of exploitative and shoddy addiction services.

Earlier this year, the Palm Beach Post did an investigative series on the problem in their area. It’s REALLY bad. And, while the problem might be worse in  some areas, it is everywhere.

The problem is that people are usually seeking treatment in the midst of a crisis–they are willing to do almost anything for their loved one. Too many programs offer false hope and exploit that desperation.

Things to look out for include:

  • claims of absurdly high recovery rates;
  • exorbitant fees (higher fees are not an indicator of better services);
  • lack of transparency in fees;
  • no-refund policies for prepaid and unused days in the event of early discharge or leaving against staff advice;
  • lack of professionalism;
  • short term programs for high severity problems;
  • a treatment culture that resembles a boot camp or a spa;
  • the absence of meaningful and appealing long term follow-up care;
  • low retention rates; and
  • doesn’t offer family programming/support.

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Meet the unicorns

unicorns-e1445611915468After yesterday’s post, we need a little hope and a reminder that people with opioid addiction can achieve full recovery.

Some local people in recovery from opioid addiction were growing frustrated with media representations of opioid addiction that suggest full abstinence-based recovery is not a realistic goal.

They decided to start The Unicorn Project and  I’ve helped them with a website.

Media reports and comments from “experts” give the impression that opioid addiction (heroin, vicodin, etc.) is a near hopeless condition and that the only hope is maintenance on other opioids (buprenorphine and methadone).

Some of these reports acknowledge that there are people who achieve drug-free recovery, but imply that they are extremely rare. It almost sounds like everyone’s heard of them, but no one’s seen one–like unicorns.

We know this isn’t true.

We want people to know that opioid addicts can achieve full recovery without opioid maintenance drugs. And, it’s not rare or unusual when people get the right kind of help.

We’re not here to argue that medications like buprenorphine and methadone are bad, or that our path to recovery or one form of treatment is better than another.

We just want people to know that drug-free recovery is a legitimate path to recovery, that many people already succeed with this path, and that more people could also succeed on this path—if they are offered the right kind of help.

Our evidence is us. We’re all in long-term recovery from opioid addiction.

All of us have been in full recovery for more than 5 years.

This is just a start. The current postings represent just a small fraction of the recovering opioid addicts in a single community. They have several more unicorns working on their stories.

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“heroin-assisted treatment, a science-based, compassionate approach”

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A photo-essay (trigger warning) seeks to document heroin-assisted “treatment” (my quotes) and humanize heroin addiction.

The author explains his intent:

Throughout the project, I’d spoken with the subjects about the purpose of the photo essay – to challenge the stereotypes of drug genre photography and to help spread awareness about heroin-assisted treatment.

He also describes the reality of what he witnessed:

I often explained to them that their photos would likely be published on the Internet – that police, future employers and others could learn they are heroin users. Despite the risks, the three subjects reiterated that they wanted to take part in the project because they, too, wanted to tell others about heroin-assisted treatment.

I’d been told that after enrolling in the heroin-assisted treatment study, some participants had reconnected with family members, found stable housing and gotten jobs. I hoped that I’d be able to take photos of Marie, Cheryl and Johnny in these types of settings.

However, I quickly learned that this wouldn’t be easy. Two of the three subjects didn’t engage in many other activities beyond self-injecting at the Crosstown clinic three times a day. Outside the clinic, much of their time was spent acquiring and using drugs.

This meant the moments I was able to capture ended up being far less varied than I’d anticipated.

Still, there were revealing moments, like when I managed to photograph Marie traveled across the city by bus to try to find her mother. It was Thanksgiving and she hadn’t seen her mother in over two years. I thought these particular photos might help the viewer understand Marie in a new way: even if people weren’t able to fully understand the depth of Marie’s suffering or the roots of her addiction, everyone knows what it’s like to want to spend the holidays with loved ones.

The greatest challenge I faced was determining how to document two of the subjects’ ongoing drug use outside of the heroin-assisted treatment study. I simply couldn’t ignore it because it was a major part of their day-to-day lives.

The images are pretty rough and heartbreaking, but he suggests he avoided anything sensational.

When the time came to choose the final photographs, I deliberately left out images that I suspected could be viewed as the most sensational or degrading.

This is described as last resort “treatment”. One can’t help but wonder what kind of care these people have been provided. Did they ever get compassionate, comprehensive, high quality treatment of adequate duration and intensity? Were they ever helped by people who believe in their capacity to recover? Were they ever exposed to a community of people who have recovered and enjoying full, satisfying lives?

Is this treatment? Or, palliative care for a treatable condition?

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What does clinical humility look like?

Bill White recently put out a thought-provoking call for addiction professionals and institutions to engage in self inventory and practice professional humility:

The challenges for each of us who work in this special service ministry and for the specialized industry of addiction treatment include conducting a regular inventory of clinical and administrative policies and practices to identify areas of inadvertent harm, altering conditions linked to such harm, making amends for such injuries, and developing mechanisms to prevent such injuries in the future.

He highlights an example I’d been meaning to share:

Chris Budnick, an addictions professional in North Carolina and founding Board Chair for Recovery Communities of North Carolina, Inc. (RCNC), recently responded to that question by preparing a formal letter of amends to the individuals, families, and communities he has served.

Chris’s reading of his letter is in the video above. The text can be read in Bill’s post here.

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