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.

“Legalize Pot, But Don’t Normalize It”

A typically thought provoking take from Tyler Cowan:

I propose that cities and suburbs restrict the sale and usage of marijuana to the same areas we use for garbage disposal and other “zoned out of sight” enterprises. We needn’t throw anyone in jail: If people or businesses violate these strictures, keep hitting them with the equivalent of parking tickets or injunctions, much as you would for an out-of-place repair shop.

It should be possible to visit Colorado without knowing that marijuana is legal there. If someone is determined to ingest it, they can either drive to an industrial zone or order it online, and smoke it at home or up away in the mountains.

You might wonder why we should be so worried about public marijuana use. To put it bluntly, I see intelligence as one of the ultimate scarcities when it comes to making the world a better place, and smoking marijuana does not make people smarter.

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The treatment hustle makes Last Week Tonight

This weekend, John Oliver spent nearly 2o minutes describing several of the treatment industry’s biggest hustles.

CaptureIs this a sign of the times?

Maybe, but it’s not new.

In Recovery Rising, Bill White describes the business landscape in the 1980s:

The trend of private insurance companies paying for the treatment of alcoholism and subsequently other addictions unleashed an unprecedented wave of institutional profiteering. In addition to the proliferation of addiction treatment units in hospitals, private, free-standing treatment programs grew at record pace in the 1980s. It was a predator’s ball. People with little knowledge of addiction recovery entered the business of addiction treatment as an investment to make money and sucked every dollar possible out of these new businesses. The operational assessment philosophy was, “If you have the insurance, you have the disease.” The admonition to staff was, “If you can’t find it (substance use disorder diagnosis), you haven’t looked hard enough.” Inappropriate admissions and re-admissions, inappropriate lengths of stay, inadequate treatment, and insufficient post-treatment monitoring and support (the latter not reimbursed by insurance companies) were pervasive. It was only a question of time before it would all collapse. And when it did, it was once again those suffering from alcohol and other drug problems, their families, and local communities who were most injured.

In another paper, he described the scene at the beginning of the 20th century:

The field’s public reputation had been wounded by highly publicized breaches of ethical conduct. Newspaper exposés charged incompetence and fraud
in the field’s clinical and business practices. Allegations abounded of inadequate care, patient abuses, sleazy marketing practices, and the financial exploitation of patients and families. Muckraking investigations of the bottled addiction “cures” exposed products secretly loaded with alcohol, opium, morphine, and cocaine.

Bill ended that paper with the following thoughts:

We must both aggressively monitor the ecosystem within which we operate and take a more activist role within that ecosystem. We must get ourselves clinically and ethically re-centered. We must take a highly splintered field and find a way to speak with one voice. And we must rebirth a new generation of leaders who can carry our mission of serving the still suffering addict into the 21st century. If we fail to meet these challenges, we may be doomed to repeat an episode in history little known to today’s providers of addiction treatment. And that lack of knowledge is perhaps itself a source of great vulnerability. As the great comedic scholar Lily Tomlin once suggested, “Maybe if we listened, history wouldn’t keep repeating itself.”

Those words were written in 1999, after the field had collapsed from the 1980s boom. They are probably more important today than they were then.

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Blue Care Network of Michigan tests new opioid treatment with 2 mental health facilities

Why is BCN launching these pilots?

“Cost is one factor. We also look at quality of life. Our goal is to help people stay well,” said Beecroft, a psychiatrist, geriatrician and substance abuse specialist. “We have looked at return on investment and if you just treat the individual, you get 2-1 investment return. You spend $10,000 on treatment, and the overall medical spend return is $20,000.”

“Quality of life”? That’s very encouraging, but I’m a naturally skeptical sort.

Let’s see what they are planning.

Beecroft said Blue Care came up with the CLIMB program. CLIMB stands for community-based, life-changing, individualize, medically assigned and evidenced-based treatment. It is intended to add several components to how Maplegrove and Pine Rest treat opioid abuse patients. He said there will be more attention to post-acute care treatment and follow-up.

“We will be looking at how best to use recovery coaches, case managers from the plan, visiting and social workers to the home,” he said.

Bulat said she and other addiction specialist experts help Blue Care refine its CLIMB program. “They have the pilot now to track and see what we are doing to encourage others (providers) to do the same,” she said.

That kind of long-term and person-in-environment approach sounds like it could be a very good thing.

Hats off to Dr. Bulat (a friend of the Farm), BCN and Maplegrove. I wish them success.

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Congress is hyperfocused on opioids. Is it focusing enough on addiction?

There’s actually an interesting discussion happening in congress right now:

A question some lawmakers and journalists often ask is whether Congress is too closely targeting opioids, as the epidemic is a problem of polydrug misuse. Bloomberg’s editorial board warned “lawmakers need to take benzodiazepines seriously, before it’s too late.” (Overdose deaths associated with benzodiazepines are fewer than opioids, but still eight times what it was in 1999.)

“I’m concerned that here in Congress we’re so focused on opiates as the drug de jure, if you will, and that in five years or so when this crisis ends or abates or tapers that we’re going to have a bunch of federal programs that are specifically aimed at a problem that may not be as significant,” said Sen. Lisa Murkowski (R-AK) in April.

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Effects of MAT on functional outcomes

Recovery from opioid addiction is also more than remission, with remission defined as the sustained cessation or deceleration of opioid and other drug use/problems to a subclinical level—no longer meeting diagnostic criteria for opioid dependence or another substance use disorder. Remission is about the subtraction of pathology; recovery is ultimately about the achievement of global (physical, emotional, relational, spiritual) health, social functioning, and quality of life in the community.

William White

I have frequently posted about the importance of research looking at the quality of life of treatment patients.

When you hear or read someone say something like, “this treatment approach is the most evidence-based,” we should follow-up with the question, “evidence-based for what outcome?”

Statements like this are frequently made about MAT and follow-up questions are rarely asked and answered.

Unfortunately, the evidence-base says very little about the quality of life of the research subjects. Most studies focus on measures like reduced days of illicit drug use, reduced criminal activity, reduced disease transmission, and reduced overdose rates. Of course, these are important outcomes, but they fall far short of the outcomes desired by most patients and families.

A recently published study looks at what they call “functional outcomes.” These include “cognitive (e.g., memory), physical (e.g., fatigue), occupational (e.g., return to work), social/behavioral (e.g., criminal activity), and neurological (e.g., balance) function.”

These are moving in the direction of quality of life measures. Good!

They did not conduct a study with patients, instead they reviewed existing research to see what can be learned.

So . . . how much research had anything to say about these kinds of measures?

A comprehensive search followed by 1411 full text publication screenings yielded 30 randomized controlled trials (RCTs) and 10 observational studies meeting inclusion criteria.

Only 40? That’s disappointing, but how useful were those 40?

Functional measures were primary outcomes in only six RCTs; it is unclear if the other trials, which were powered statistically to detect differences in illicit drug use or treatment retention, had adequate power to detect differences in functional effects.

They summarized findings addressing the following areas:

  • memory
  • attention
  • cognitive speed
  • vision
  • driving
  • employment
  • fatigue
  • insomnia
  • family functioning
  • psychological function
  • aggression
  • criminal activity
  • arrests and incarceration
  • legal status
  • stress

The researchers summarized their findings this way:

Several of the individual studies that compared OUD patients who received MAT to those who did not reported significant positive effects of MAT on functional outcomes. However, in several studies, MAT patients performed significantly worse than matched healthy controls. Because of the limited number and quality of the studies, the quality of evidence supporting significant differences is low or very low. The only exception is moderate quality evidence supporting a lower prevalence of fatigue with buprenorphine compared to methadone.

There are legitimate questions to be raised about the comparisons. For example, are healthy controls the right comparison group? Is placebo the right comparison group. We might also ask if the researchers’ standards for inclusion were too high.

Whatever opinions one holds on those questions, it seems pretty clear that there is a disconnect between the way the evidence is frequently discussed and what we can actually conclude from it.

This doesn’t mean MAT is bad or should not be available. It simply means the research doesn’t speak to outcomes most patients are seeking. We should acknowledge this when we discuss the evidence and researchers should seek answers to quality of life questions.

Here’s what I’ve said repeatedly in this blog:

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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Sentences to ponder

“We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive. . . . whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person’s life.”

Atul Gawande

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Overdose crisis? Or, addiction crisis?

British Columbia has long been cited as a model for North American drug policy and harm reduction implementation.

BC has established a Death Review Panel in response to the overdose crisis. The panel recently issued a report with 3 recommendations. The first recommendation to regulate recovery homes, which currently require only a simple inspection of the facility. (The other 2 were for more maintenance treatments and more harm reduction.)

The chair of the panel cited the abstinence orientation of houses as a concern.

A columnist at the Vancouver Sun pushes back against the argument that BC is suffering from insufficient harm reduction:

This is, after all, a city and a province that for nearly 20 years has been at the forefront of harm-reduction with needle exchange programs, safe injection sites, methadone and suboxone treatment programs, a prescription heroin program and, more recently, free naloxone kits, free-standing naloxone stations and training for first-responders and even teachers in how to use it as an antidote for fentanyl overdoses.

We’ve gone from crisis to crisis, each one sucking up incredible resources. Currently, a quarter of a million dollars a day goes into the Downtown Eastside alone for methadone treatment. This year, the B.C. government expects the number of British Columbians receiving replacement drug therapy to rise to 30,000 and then nearly double to 58,000 by 2020-21.

In 2006 when Vancouver updated its four pillars approach, it noted that there were 8,319 British Columbians being treated with methadone.

By 2020-21, the province also expects to be supplying 55,000 “free” take-home naloxone kits, up from 45,000 this year.

We keep hearing about an overdose crisis, but what we have is an addictions crisis. Solving it will require a lot more than simply reducing harm.

What’s needed is a recovery orientation. (Which does not rule out harm reduction.)

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