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.

The risks of the biological model


Bill White reacts to a special addiction-focused supplement in the journal Nature with hope and caution:

We should not forget the untoward effects of earlier biological models of addiction.  Such a view rose within the early twentieth century eugenics movement on the heels of the American temperance movement’s proclamation “Drunkards beget drunkards.” The eugenics movement promoted the prolonged sequestration (e.g., inebriate colonies, psychiatric state hospitals) of people addicted to alcohol and other drugs (AOD) and their inclusion in mandatory sterilization laws . . .

B0005204 Neurons in the brainHe goes on to cite researchers/advocates who have sounded warning bells. Among them, is this:

In 1998, Dr. Barry Brown also voiced concern that characterizing addiction as a “chronic relapsing disorder” rendered addiction a “no-fault condition” in which continued drug use was neither the responsibility of the drug user nor the addiction treatment professional.  His concern was that such an understanding could potentially lead to social, therapeutic, and personal pessimism related to the prospects of addiction recovery in spite of clinical and community studies revealing substantial rates of long-term addiction recovery.

He also gets into the risks of a model that emphasizes the loss of free-will and responsibility (Note that impaired free-will does not mean no free-will.). Please take the time to read the whole thing.

I’m a believer that addiction is a real disease, and I don’t use that term as a metaphor. However, I share his concerns.

Here are just a few of the concerns I’ve shared about the potential harms of a narrow biological view that frames the disease as a chemistry problem.

This isn’t, in any way, meant to suggest that this we should pull back from this model, that these concerns  will all come to pass or that my concerns don’t cut both ways. (“Medicalization” of chronic disease care has simultaneously brought dramatic improvements to patient care, while also frequently failing to improve health and recognize social determinants.)

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Reviewing the evidence-base

what-do-they-know_largeThe Atlantic summarizes a recently published attempt to assess the evidence-base.

No one is entirely clear on how Brian Nosek pulled it off, including Nosek himself. Over the last three years, the psychologist from the University of Virginia persuaded some 270 of his peers to channel their free time intorepeating 100 published psychological experiments to see if they could get the same results a second time around. There would be no glory, no empirical eurekas, no breaking of fresh ground. Instead, this initiative—the Reproducibility Project—would be the first big systematic attempt to answer questions that have been vexing psychologists for years, if not decades. What proportion of results in their field are reliable?

A few signs hinted that the reliable proportion might be unnervingly small. Psychology has been recently rocked by several high-profile controversies, including: the publication of studies that documented impossible effects like precognition, failures to replicate the results of classic textbook experiments, and some prominent cases of outright fraud.

The findings were not pretty.

As such, the results of the Reproducibility Project, published today in Science, have been hotly anticipated.

They make for grim reading. Although 97 percent of the 100 studies originally reported statistically significant results, just 36 percent of the replications did.

And, this doesn’t even consider whether the study and coverage of it even speak to the outcomes that patients and their families want.

Does this mean we should ignore research? No. But, it does mean we should be very careful consumers of it. And, we should probably be skeptical of those whose express excessive certitude on the basis of their evidence-base, especially when they discount experiential knowledge.

There is some good news, and some bad news coming from all of this.

On the positive side:

A 1997 US law mandated the registry’s creation, requiring researchers from 2000 to record their trial methods and outcome measures before collecting data. The study found that in a sample of 55 large trials testing heart-disease treatments, 57% of those published before 2000 reported positive effects from the treatments. But that figure plunged to just 8% in studies that were conducted after 2000. Study author Veronica Irvin, a health scientist at Oregon State University in Corvallis, says this suggests that registering clinical studies is leading to more rigorous research.

The downside? From education advocate, Parker Palmer:

. . . when measurable, short-term outcomes become the only or primary standard for assessing our efforts, the upshot is as pathetic as it is predictable: we take on smaller and smaller tasks—the only kind that yield instantly visible results—and abandon the large, impossible but vital jobs we are here to do.

We must judge ourselves by a higher standard than effectiveness, the standard called faithfulness. Are we faithful to the community on which we depend, to doing what we can in response to its pressing needs?

Palmer’s concerns point to to the potential for increasingly narrow definitions of effectiveness that may not speak to the real world needs of patients. Particularly, in the case of complex diseases with social, emotional and environmental factors.

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Sentences to ponder

wpid-wp-1406109969456.jpegFrom Jamie Holmes in the NY Times:

Presenting ignorance as less extensive than it is, knowledge as more solid and more stable, and discovery as neater also leads students to misunderstand the interplay between answers and questions.

People tend to think of not knowing as something to be wiped out or overcome, as if ignorance were simply the absence of knowledge. But answers don’t merely resolve questions; they provoke new ones.

(Hat tip: Debra Jay)

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Drug crimes and incarceration reform

fenceA very smart interview with Senator Corey Booker on criminal justice reform and the role of drug crimes in incarceration rates:

One concern I’ve heard from activists and academics is that there’s a conventional wisdom forming that the reason our prison population is so huge is because of nonviolent offenders. Even President Obama, during his big criminal justice speech in July, said, “Over the last few decades we’ve also locked up more and more nonviolent drug offenders than ever before, for longer than ever before, and that is the real reason our prison population is so high.” When I heard that, I just thought, “That’s not true.”

Well, look, the drug war certainly has driven an explosion in incarceration, and drug crimes do make up a very large percentage of what we have. But again, we’ve been doling out harsher and harsher penalties for all crimes.

I’ve seen research that says only 17 percent of the inmates in state prisons are there for drug charges. Just 17 percent! Whereas 50 percent or so are there for crimes that are classified as violent. Does that mean talking about the problem in the way Congress has been talking about it puts a pretty low ceiling on how much of a reduction in the prison population we can achieve?

Right, but there’s some other data that we should talk about. Michelle Alexander [author of The New Jim Crow] talks about how much marijuana arrests have fueled the explosion in arrests in our country. Her point is that we end up sending so many young people, particularly young African-Americans and Latinos, into the system. And what happens once you get a felony conviction? Now you are entering this American caste system where you can’t get a job, you can’t get a loan, you can’t get a Pell grant, you can’t get public housing. And then those people often feel that they have no other options, so they go back and commit crime again. And again, and again. And what we saw in Newark, through a Rutgers study, was that about 84 percent of our murder victims had been arrested before an average of 10 times.

Victims?

Victims. So what I’m saying is that, because of these low-level drug crimes, people get stuck in this world that eventually turns violent. So I’m very concerned about how we’re treating the drug war. And while I definitely want to deal with a more expansive view of who should be eligible for a lot of this legislation, please understand that the drug war has really fueled so much of our problem. The drug war has been a war where the direct casualties have primarily been America’s poor; America’s minorities; and often, unfortunately, America’s vulnerable, in terms of people with disease and addiction and mental health.

There is some debate around the Michelle Alexander book—there are people who say she overstates the role of the drug war in the mass incarceration boom. And there is data that says the percentage of drug offenders in the prison population peaked in like, 1990, at 22 percent. So even when it was at the highest it has ever been, 4 out of 5 people in prison were there for offenses that didn’t involve drugs. That’s something I hear from folks who are worried that the focus is too much on drug crimes right now.

I guess I’m not into the tyranny of the “or”— either this or that. This system is broken along many, many dimensions. And to ignore the crisis of America’s drug policies and the devastating impact it’s having in America is a very significant problem. That’s not to say there’s not a problem with high mandatory minimums as a whole—which have shifted our whole criminal justice system from courts and judges to prosecutorial discretion. But the situation is bad all over.

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half-measures are not enough

PathsBill White provides a great summary of a recent review of research on opioid addiction, treatment and recovery.

Bottom line:

  • opioid addiction is deadly
  • opioid addicts can recover
  • treatment that’s long enough and intense enough is associated with better outcomes

Unfortunately, most opioid addicts seeking treatment never get offered care that meets these criteria.

Read the rest here.

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Shame, methadone and recovery

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The Boston Globe has an article on the shame that successful methadone patients carry.

It makes me sad to hear of anyone doing the deal feeling shame about being a recovering addict.

People with opioid addiction ought to have access to methadone, if that’s what they want. Without shame.

They also ought to have access to the gold standard for addiction treatment—the same care that an opioid addicted health professional gets.

They also ought to get accurate information about the various pros and cons of each approach.

For example, they ought to know that the gold standard demands a lot of the patient, and existing models have relied on using the health professional’s license as a contingency to maintain compliance with these demands. They also ought to know that the approach hasn’t been studied on the general population of opioid addicts because no one has been willing to invest in it.

They also ought to know that despite all of the arguments that research proves “methadone maintenance is the most effective treatment for opioid addiction”, the evidence base for methadone focuses on reduced drug use, reduced OD, reduced criminal activity and reduced disease transmission.

Bill White, a researcher and methadone advocate, summarizes the evidence this way:

As a professional field, we know a great deal about what methadone maintenance treatment can eliminate from the lives of patients, but we know very little from the standpoint of science about what it adds. In fact, we know very little about the stages and styles of long-term medication-assisted recovery.

This lack of quality of life evidence is exemplified by the Boston Globe article:

They come to this methadone clinic . . . at around 6 in the morning — a time set aside for working men and women to get doses before heading to their jobs. About 400 of the 4,000 patients here work full time.

10% work full time?

In the article, a successful patient points to the dosing line that forms after the employed patients have gone to work.

Josh, 29, gestured at the line of men and women waiting outside. Workers’ hour had passed. Some of the people there now looked broken and wasted, like the stereotype that persists even though we’re constantly hearing that addiction can strike anyone.

“Would you want those people in your house when you’re not home?” asked Josh, who installs central air. “Hell, no. People don’t see the flip side — the dental assistants, the lawyers, the doctors.”

I don’t want to interfere with access to maintenance and I don’t want methadone patients living with shame. At the same time, all the advocacy for maintenance treatments misses that there are real reasons for the persistent skepticism about them. When a lot of people look at the population of patients, they don’t see an outcome that they’d want for themselves or loved ones.

via Shame of methadone use clouds heroin addicts’ recovery – Metro – The Boston Globe.

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Treatment Works, IF . . .

ROSC-modified Treatment Works Poster

Courtesy of Bill White. Visit williamwhitepapers.com

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