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.

Harm reduction and recovery advocacy

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If you have a couple of minutes, check out Chris Budnick’s interview with Kevin McCauley.

The whole conversation is great, but 24:15 to 25:50 really leapt out at me.

Kevin shares his mom’s reaction to learning of his addiction and harm reduction as a “deeply humane response” to what is often perceived as a “set of unsolvable conditions.”

Kevin, we’re also glad you didn’t end up in Holland shooting drugs for the rest of your life.

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Methadone accounts for 19.7% of Minnesota’s opioid deaths

methadone-is-helping-minnesota-addicts-but-leaving-its-own-dangerous-trail-star-tribune

From the Star Tribune:

As opioid overdose deaths have spiked in Minnesota — from 54 in 2000 to 355 last year — so has the number of methadone clinics and patients. Across the state, 16 clinics now treat some 6,700 addicts.

But methadone deaths have risen in tandem. Minnesota is on pace for more than 70 this year, up from just five in 2000, according to a Star Tribune review of death certificate data through September.

An expert offers a defense:

Even so, Dr. Charles Reznikoff of Hennepin County Medical Center said the state’s opioid death toll would be far worse if methadone weren’t available. The addiction specialist said HCMC’s outpatient methadone clinic sees 300 patients a day — more than its emergency department.

“For every patient who dies [taking methadone], there are five who are saved,” he said.

The solution?

One solution could be greater use of Suboxone, a newer opioid treatment that isn’t addictive and comes with fewer federal restrictions.

Isn’t addictive?

BTW – We recently took a closer look at a meta-analysis used to support Suboxone.

BTW2 – We also recently posted on the business of Suboxone.

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Amen.

calendarThe headline says it all:

How We Got Here: Treating Addiction In 28 Days

More:

She says the late Daniel Anderson was one of the primary architects of the “Minnesota model,” which became the prevailing treatment protocol for addiction specialists. At a state hospital in Minnesota in the 1950s, Anderson saw alcoholics living in locked wards, leaving only to be put to work on a farm.

To find a path for them to get sober and leave the hospital, he came up with the 28-day model.

Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers, has studied the model’s history. He says the month-long standard comes from the notion that when “someone is suffering from addiction — and in the days that this began, we’re pretty much talking about alcoholism — it made sense to people that it took about four weeks to stabilize somebody.”

And then, Ventrell says, “It became the norm because the insurance industry was willing to pay for that period of time.”

Now the model has spread to treatment for opioid addiction, even though recovering from addiction to those powerful drugs may require a different method.

Hazelden was brave and correct to admit that their model was inadequate. Unfortunately, adding maintenance medications to a 28 day program doesn’t address the real problem.

However, there is a model that works and the key difference is that it provides treatment of an appropriate quality, intensity and duration followed by years of assertive recovery monitoring and support. (And, we can work on adaptations that get more voluntary participation and don’t cost too much.)

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Don’t Run! Call 911!

Spread the word!

911-good-samaritan

Printable flyer available here.

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“nothing was quite like Suboxone”

There have been a couple of news stories about buprenorphine over the last couple of days.

The first article looks at the business of pain medication, medications to treat side effects of pain medication and medications to treat addiction to pain medication.

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Opioid prescriptions alone have skyrocketed from 112 million in 1992 to nearly 249 million in 2015, the latest year for which numbers are available, and America’s dependence on the drugs has reached crisis levels. Millions are addicted to or abusing prescription painkillers such as OxyContin, Vicodin and Percocet. Statistics from the Centers for Disease Control and Prevention show that, from 1999 to 2014, more than 165,000 people died in the United States from prescription-opioid overdoses, which have contributed to a startling increase in early mortality among whites, particularly women — a devastating toll that has hit hardest in small towns and rural areas.

The pharmaceutical industry’s response has been more drugs. The opioid market — now worth nearly $10 billion a year in sales in the United States — has expanded to include a growing universe of medications aimed at treating secondary effects rather than controlling pain.

There’s Suboxone, financed and promoted by the U.S. government as a safer alternative to methadone for those trying to break their dependence on opioids. There’s naloxone, the emergency injection and nasal spray carried by first responders to treat overdoses. And now there’s Relistor, the drug based on Moss’s work, and a competitor, Movantik, for constipation.

In colorful charts designed to entice investors, numerous pharmaceutical makers tout the “expansion opportunity” that exists in the “opioid use disorders population.”

Indivior, a specialty pharmaceutical company listed on the London Stock Exchange, sees “around 2.5m potential patients, the majority of whom are addicted to prescription painkillers,” as opposed to illicit drugs such as heroin. Another company, New Jersey-based Braeburn Pharmaceuticals, highlights “growth drivers” for the market, noting that millions of additional Americans not yet identified are also likely to be dependent on opioid painkillers.

Analysts estimate that each of these submarkets — addiction, overdose and side effects — is worth at least $1 billion a year in sales. These economics, experts say, work against efforts to end the epidemic.

If opioid addiction disappeared tomorrow, it would wipe billions of dollars from the drug companies’ bottom lines.

The second story is that 35 states (plus Washington DC) are suing Reckitt Benckiser for engaging in a variety of “deceptive and unconscionable” practices, including using “feared-based messaging” and “sham science” to keep generics out of the market by killing the tablet form of the drug so that they would be the sole purveyor of a patent protected version of the drug.

The plaintiffs in the lawsuit say Reckitt Benckiser took product hopping to a nefarious new level by using “feared-based messaging” and “sham science” to illegally subvert the market for Suboxone tablets while aggressively promoting its new film variation, which was introduced in 2010 and is under patent until 2023.

“The circumstances alleged in this case are particularly egregious in that, in the midst of an epidemic of opioid abuse and addiction… consumers and taxpayers have had to pay more for a drug that may help to mitigate some of the problem,” said George Jepsen, the attorney general of Connecticut, in a statement announcing the suit.

. . .

Patent expiration is a conundrum faced by all drug makers and ordinarily it wouldn’t be a terribly big deal for a global monolith like Reckitt Benckiser—which generated more than $2.5 billion in revenue during the first half of 2016 through its ownership of popular brands like Lysol disinfectant, Mucinex cold medicine, and Durex condoms.

But nothing was quite like Suboxone, a blend of the painkiller buprenorphine and the opiate blocker naloxone.

. . .

By the time it lost its monopoly, Suboxone accounted for 85 percent of all spending on medication-assisted treatment in the U.S.—almost all of it subsidized by taxpayers—and Reckitt Benckiser was sitting on the pharmaceutical equivalent of a goldmine.

That’s when it got creative.

The plaintiffs accuse the company of undermining the market for generics through a “multi-step scheme” that began in 2010 with an aggressive effort to get prescribers to stop dispensing its own Suboxone tablets and replace them with the new film version.

Over the next two years, Reckitt Benckiser allegedly compensated doctors for being advocates of the drug, lobbied legislators on the benefits of Suboxone film, and penalized employees for not meeting sales targets for the new drug. It also raised the price of its tablets, making them more expensive than the newer film version, even though the pills are cheaper to make.

In September 2012, with generics getting closer to approval, Reckitt Benckiser announced its intention to take tablet versions of its drug off the market on the grounds that the pills posed a safety threat to children who might inadvertently eat them. On the same day it filed a “Citizen’s Petition” with the Food and Drug Administration calling on the agency to postpone approval of generics in the interest of public safety.

The company based its child-safety claims on a single study it had paid for itself.

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Too expensive? (2016)

Discrimination1

I frequently point to health professional recovery programs when discussing the effectiveness of drug-free treatment when it’s delivered in the appropriate dose, frequency and duration. They have stellar outcomes. (More details here.)

The programs were abstinence-based, requiring physicians to abstain from any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Tests rapidly identified any return to substance use, leading to swift and significant consequences. Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. … The unique PHP care management included close linkages to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous and the use of residential and outpatient treatment programs that were selected for their excellence.

I generally get three counter-arguments:

  1. That health professionals have more recovery capital and are more likely to recover than other addicts.
  2. That the threat of license suspension/revocation provides a unique combination of carrot and stick. We’ll never get that kind of engagement with regular people.
  3. That treating everyone in this manner would be too expensive—we’ve made a decision, as a culture, that we’re willing to invest this time and capital into addicted doctors but we can’t do it for everyone.

I want to respond to these arguments in this post.

1. “Health professionals have more recovery capital and are more likely to recover than other addicts.”

There may be ways in which health professionals are unique in terms of recovery capital. This may be true. However, they also face a unique set of barriers when initiating recovery. A study of physician recovery programs (this excludes health professionals other than physicians) found high rates of opioid addiction (35%), high rates of combined alcohol and drug problems (31%) and high rates of psychiatric problems (48%). In addition, 74% were not self-referred.

Further, health professionals confront easy access to drugs and with this ease of access to prescription drugs, they often develop tolerance levels that dwarf those of street addicts.

Two pieces of folk wisdom may also be relevant:

  • “Doctors make the worst patients.”
  • “I’ve never met anyone too dumb for recovery, but I’ve met plenty of people who were too smart.”

So…they may have unique advantages, but they also have unique barriers. If there is a difference, is there reason to believe it’s stark enough to it wouldn’t work for other addicts?

2. “Heath professionals are uniquely motivated because of the threat of license suspension/revocation.”

This is probably the strongest counter-argument.

Health professionals place incredibly high value on their profession. They often put enormous time, effort and money into becoming a health professional, but it’s more than that. Their profession often becomes integral to their identity and is a key source of meaning and purpose. In health professional recovery programs, we’ve constructed a system that uses this incredibly powerful element of the addict’s life to initiate and maintain their recovery. And, it’s not just threats. They offer a path to returning to work in a pretty expeditious time-frame, they provide peer support, they develop contracts with employers that provide both support and monitoring.

What would happen if we constructed systems that identified and used (not through coercion or manipulation) elements of the addict’s life that are integral to their identity and are a key sources of meaning and purpose? Debra Jay has developed one model of recovery support that seeks to do exactly this. (Interestingly, she’s had to develop a model that doesn’t require professionally directed services, because it’s not covered by insurance and many families may not be able to afford it.)

What else could be done? We don’t know. Because, as a system, we haven’t tried.

I recently blogged on the issue of coercion and health professional recovery programs and said this:

. . . it is our experience that attracting people to the front door is pretty easy if you have an attractive back door. In our case, this includes:

  • safe, affordable and stable sober housing;
  • opportunities for stable employment with advancement opportunities;
  • a large, welcoming and energetic recovering community (with lots of opioid addicts in long term recovery);
  • two local collegiate recovery programs that support a path to college degrees; and
  • lots of recovery role models providing support and demonstrating that all of this is do-able.

If we can create systems that provide this kind of back door and integrate long term recovery monitoring and support, I think it could go a very long way toward overcoming the long-term-voluntary-engagement-without-coercion issue.

. . .

I’m not suggesting that we’ll have relapse rates as low as 22% over 5 years. I’m also not suggesting that it’d be easy to keep people engaged for 5 years. But, what’s possible? Huge improvements, I’d imagine. But, we don’t know, because we haven’t tried.

Imagine that we tried and engaged in continuous improvement for 10 years. How far could we go?

3. “Treating everyone in this manner would be too expensive.”

So, then, what is provided and what might it cost to replicate it?

First, what is provided:

The first phase of formal addiction treatment for two thirds of these physicians (69%) was residential care often for 90 days. The remaining 31% began treatment in an intensive day treatment setting. The participants at this stage usually received multiple intensive sessions of group, individual, and family counseling as well as an introduction to an abstinence-oriented lifestyle through required attendance at Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Caduceus meetings (a collegial support association for recovering health professionals) and other mutual-aide community groups. Frequent status reports on treatment progress were required by most PHPs.

Use of pharmacotherapy as a component of treatment for SUDs was rare. Very few of the treatment programs or the medical directors of the PHPs used any of the available maintenance or antagonist medications.

After completion of initial formal addiction treatment, all PHPs developed a continuing care contract with the identified physician consisting of support, counseling, and monitoring for usually 5 years. Most PHPs (95%) also required frequent participation in AA, NA, or other self-help groups and verification of attendance at personal counseling and/or Caduceus meetings.

Physicians were tested randomly throughout the course of their PHP care, typically being subject to testing 5 of 7 days a week.

Physicians were typically tested an average of four times per month in the first year of their contracts for a total of about 48 tests in the year. By the fifth year, the average frequency of testing was about 20 tests per year.

How much would this cost to replicate? The following is based on Dawn Farm’s fees and costs.

  • $16,800 – 120 days of residential treatment plus unlimited aftercare groups
  • $5460 – 364 drug screens over 5 years ($15 per screen. 2x per week for first 2 years, 1x per week for years 3-5.)
  • $10,000 – 100 outpatient group sessions ($25) and 100 outpatient individual sessions ($75)
  • $5000 – 5 years of recovery support and monitoring from a Recovery Support Specialist with a caseload of 40 (A former head of Michigan’s monitoring program reports that their Case Managers have approximately 150 cases each.)
  • Total = $37,260

Now, this does not include one important element—a workplace monitor and a career employer making contract compliance a condition of employment. However, we offer transitional housing to clients for up to two years.

At less than $38,000 for the whole package, in the context of American healthcare spending, this does not seem to be an unsustainable burden and, in fact, is likely to be a very wise investment in pure financial terms. It’s in the same ballpark as inserting a stent–just the procedure, excluding continuing care, medications, etc. We implant 2,000,000 stents per year.

Imagine what would be possible if 2,000,000 addicts were given that opportunity. Imagine what we could learn.

 

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The gold standard and problem of coercion

i_love_evidence_based_medicine_key_chains-r33ff90ead6aa425ea368e31ca9ee70e5_x7j3z_8byvr_512I’ve written a lot on this blog about the gold standard model of treatment for addiction–health professional recovery programs.

Whenever I discuss the model, I get a lot of responses that could be placed into the category of, “Yeah, but they’re different. They’re doctors. And, besides, they’ve got a lot to lose.”

I’ve addressed the first part of that objection here.

Health professionals have more recovery capital and are more likely to recover than other addicts.

There may be ways in which health professionals are unique in terms of recovery capital. This may be true. However, they also face a unique set of barriers when initiating recovery. A study of physician recovery programs(this excludes health professionals other than physicians) found high rates of opioid addiction (35%), high rates of combined alcohol and drug problems (31%) and high rates of psychiatric problems (48%). In addition, 74% were not self-referred.

Further, health professionals confront easy access to drugs and with this ease of access to prescription drugs, they often develop tolerance levels that dwarf those of street addicts.

Two pieces of folk wisdom may also be relevant:

  • “Doctors make the worst patients.”
  • “I’ve never met anyone too dumb for recovery, but I’ve met plenty of people who were too smart.”

So…they may have unique advantages, but they also have unique barriers. If there is a difference, is there reason to believe it’s stark enough to it wouldn’t work for other addicts?

The second set of objections focus on coercion. (We’ll take away your medical license if you don’t do everything we tell you to do.)

Some of these objections argue that coercion is a critical element in the success of the model–that transferring the model to other patients without the element of coercion would not get us similar outcomes because coercion is such an important ingredient.

Other objections argue that the model is unethical because of the coercion. They point to alleged abuses by monitoring agencies. Many people with these objections seek to discredit the entire model. I’m not going to dive deep into these arguments in this post other than to make 3 statements: 1) It’s possible that monitoring agencies, assessment procedures and inclusion criteria may need to be improved in some states. 2) Where a professional’s impairment creates a public safety issue, it’s seems nearly impossible to avoid the threat of suspending/revoking their license. 3) While the model includes coercion, it also includes a lot of support and benefits–offering a path to returning/continuing to work (often quickly) and establishing support/monitoring systems in the workplace. There’s a stick, but there are also a lot of carrots.

It’s important to note that none of these objections question the actual outcomes of the model.

Is coercion necessary?

I recently had a conversation with a consultant in Washington state. They are shutting down a large facility used for involuntary treatment. (They have some sort of involuntary commitment law.) I think think she said the process was instigated by the expiration of a 99 year property lease agreement rather than some rejection of the model. Nevertheless, they are rethinking the model and wanted to hear about Dawn Farm. She was concerned about the issue of attraction to treatment. Over the course of the conversation, I told her that it is our experience that attracting people to the front door is pretty easy if you have an attractive back door. In our case, this includes:

  • safe, affordable and stable sober housing;
  • opportunities for stable employment with advancement opportunities;
  • a large, welcoming and energetic recovering community (with lots of opioid addicts in long term recovery);
  • two local collegiate recovery programs that support a path to college degrees; and
  • lots of recovery role models providing support and demonstrating that all of this is do-able.

If we can create systems that provide this kind of back door and integrate long term recovery monitoring and support, I think it could go a very long way toward overcoming the long-term-voluntary-engagement-without-coercion issue.

One interesting observation is that many of these “carrots”, like sober housing and employment opportunities, don’t seem to provide as strong a draw for people of higher socio-economic status. They have greater access to housing and employment opportunities. While material capital certainly makes achieving recovery easier in many ways, I wonder if, in this way, those with “lower recovery capital” might be easier to engage in these systems of long term recovery monitoring and support.

I’m not suggesting that we’ll have relapse rates as low as 22% over 5 years. I’m also not suggesting that it’d be easy to keep people engaged for 5 years. But, what’s possible? Huge improvements, I’d imagine. But, we don’t know, because we haven’t tried.

Imagine that we tried and engaged in continuous improvement for 10 years. How far could we go?

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