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.

Zombie statistic contributed to opioid crisis

Back in February, I shared an article from JAMA, reviewing the role of Joint Commission’s pain standards in the current opioid epidemic and some of the lessons learned.

The fourth lesson was this:

Fourth, carefully review the primary literature on issues of critical importance and do not simply repeat the claims of experts in previous articles. The 1980 letter to the editor by Porter and Jick suggesting that addiction is rare in patients treated with narcotics has been cited almost 1000 times. Yet the report is so brief, methodologically vague, and unlikely to be generalizable to recent medical practice that its finding should never have been disseminated without cautionary notes and calls for research.

Now, the New England Journal of Medicine, the journal that published the 1980 letter, has published a review of its impact.

The prescribing of strong opioids such as oxycodone has increased dramatically in the United States and Canada over the past two decades.1 From 1999 through 2015, more than 183,000 deaths from prescription opioids were reported in the United States,2 and millions of Americans are now addicted to opioids. The crisis arose in part because physicians were told that the risk of addiction was low when opioids were prescribed for chronic pain. A one-paragraph letter that was published in the Journal in 19803 was widely invoked in support of this claim, even though no evidence was provided by the correspondents (see Section 1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org).

The authors reviewed the number of citations for this letter

We identified 608 citations of the index publication and noted a sizable increase after the introduction of OxyContin (a long-acting formulation of oxycodone) in 1995 (Figure 1)

Not only was it cited hundreds and hundreds of times, it was also misrepresented more than 80% of the time.

So . . . what was the impact of this letter?

In conclusion, we found that a five-sentence letter published in the Journal in 1980 was heavily and uncritically cited as evidence that addiction was rare with long-term opioid therapy. We believe that this citation pattern contributed to the North American opioid crisis by helping to shape a narrative that allayed prescribers’ concerns about the risk of addiction associated with long-term opioid therapy.

Their advice?

Our findings highlight the potential consequences of inaccurate citation and underscore the need for diligence when citing previously published studies.

This is why, in this blog, I’m always looking for sources and I try to share information from the actual study rather than press releases or abstracts. It’s always astonishing how often the actual study does not resemble the impression you’d get from other papers, press releases, and abstracts.

Be selective with your trust and verify. There are a lot of “zombie statistics” out there.

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OTC Naloxone in Michigan

Naloxone is not enough, but it is important.

From the press release:

Gov. Rick Snyder today authorized the Michigan Department of Health and Human Services to issue a standing order pre-authorizing the distribution of naloxone by pharmacists to eligible individuals.

“Naloxone is a tool in the fight against opioid addiction that can save lives immediately and we need to make sure all residents statewide have access, both in rural areas and urban centers,” Gov. Snyder said. “Our entire state has been affected by this horrible epidemic. I have said that state government will use all possible resources to reverse the course of the opioid crisis. This is one more action that demonstrates our full commitment to addressing the problem.”

Naloxone is a fast-acting medication that reverses opioid overdose. Pharmacies that obtain the standing order will be able to dispense naloxone to those at risk of an opioid-related overdose, as well as family members, friends, or other persons who may be able to assist a person at risk of an overdose. Currently, naloxone is only available to be administered by law enforcement or other first responders.

“As we continue our fight against opioid addiction, this order makes naloxone more accessible for those most likely to need it,” said Dr. Eden Wells, chief medical executive of MDHHS. “This is a vital step in reducing deaths related to opioid addiction in Michigan. By allowing for shorter response times in emergency situations, we can help save lives.”

States nationwide have experienced a dramatic increase in the number of opioid-related overdoses in recent years. In Michigan, the number of heroin-related overdose deaths increased from 1.1 per 100,000 residents in 2007 to 6.8 per 100,000 residents in 2015. Opioids, including heroin and prescription drugs, accounted for 473 deaths in 2007; in 2015, that number increased to 1,275.

As part of their final recommendations, Gov. Snyder’s Prescription Drug and Opioid Abuse Task Force found that naloxone is a safe and lifesaving drug that should be more accessible. In 2016, Public Act 383 was passed giving the chief medical executive authority to issue a standing order that does not identify a patient for the purpose of dispensing naloxone. To dispense naloxone under the standing order, pharmacies must register with MDHHS online at www.michigan.gov/naloxone.

When obtaining naloxone from a pharmacy, individuals will be provided with the steps for responding to an opioid overdose as well as important information about where to go for treatment services. Pharmacies will be required to keep track of the amount of naloxone dispensed and will report these numbers to MDHHS on a quarterly basis.

It’s going to take a little while for pharmacies to get registered and get rolling.

It’s my understanding that the order was written in a way that allows for it to be covered by insurance, including Medicaid.

Meijer has already been selling it OTC and may get things rolling more quickly than the others with insurance coverage.

Here is a flyer to help get the word around.

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Sentences to ponder

photo credit: sarcasmo

From the ATTC/NIATx blog (emphasis mine):

Today public health leaders think using marijuana together with alcohol increases the risk for impaired driving. Tomorrow leaders of multinational corporations will think selling marijuana together with alcohol – and tobacco – increases the opportunity for enhanced profits.

One hundred and forty years ago the invention of machines for rolling tobacco cigarettes radically reduced production costs and prices. That triggered consolidation from regional companies to multinationals, and shifted tobacco consumption from cigars to cigarettes and from men to also women. Now the spread of legalization is radically reducing production costs and prices, rapidly increasing firm size, shifting the favored product forms, and shifting consumption from weekend to daily patterns of use.

I do not expect marijuana legalization to match the public health catastrophe wrought by the tobacco industry. But I expect the dynamic energy of the free market to exploit fully the profit potential of this new (to private industry) dependence-inducing intoxicant, and innovation will carry the markets and consumption to places we would have a hard time imagining today.

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What will mental health look like under the Trump administration?

This will be interesting to watch.

President Trump’s pick to run federal mental health services has called for a bold reordering of priorities — shifting money away from education and support services and toward a more aggressive treatment of patients with severe psychiatric disorders.

The proposal has some psychiatrists — a generally liberal bunch — cheering despite their distrust of the Trump administration.

But it’s also sparked concern among other health professionals, who worry that the administration will put too much emphasis on medicating and hospitalizing patients, and remove supports that might help them integrate successfully into society.

It would seem that there is plenty of room to discuss whether efforts to deinstitutionalize mental health have left us without some of the care we need. (For example, there’s a persistent shortage of psychiatric beds.) On the other hand,

She will be the first to assume the title of assistant secretary for mental health and substance abuse — a near-cabinet position which reports directly to Health and Human Services Secretary Tom Price. Congress created the post to bring order to a scattered system; this is the first time mental health and substance abuse have received such a weighty emphasis in D.C.

“We’ve never had someone coordinating the fragmented mental health services in this country,” said clinical psychologist Xavier Amador, who has written several books for patients with mental illness.  . . .

McCance-Katz, a psychiatrist who specializes in opioid abuse, hasn’t spoken publicly since her nomination, and declined to talk to STAT. But she has had a long career in mental health, and her writings — as well as a fact sheet put out by the Department of Health and Human Services — give insight into her priorities. Among them:

  • Increase the number of inpatient beds for patients experiencing serious psychiatric symptoms.

  • Reconfigure health privacy laws to give families access to information about patients who are severely mentally ill.

  • Reevaluate federal funding for suicide hotlines and programs that train patients with psychiatric disorders to help their peers.

The article does a good job providing an overview of the politics involved, including criticism from politicians and the recovery vs. medical model tensions.

Read the rest here.

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Recovery Celebrities?

gut-check-image2A couple of days ago, I had a chance to catch up with a friend and recovery advocate. Turns out we share a concern about the emergence of a kind of celebrity culture within recovery advocacy efforts.

It seems like a good time to revisit a post from Bill White that addresses the topic. The post focuses on anonymity and advocacy, examining the changing cultural context for anonymity and its functions.

On anonymity as a spiritual principle [emphasis mine]:

When AA literature speaks of anonymity as a “spiritual principle,” it does so out of a profound understanding of the importance of self-transcendence as the vehicle for sobriety and serenity. You can hear people depicting AA as a “selfish program” to mean that the alcoholic must get sober for self and not for others, but you find a quite different orientation on the issue of anonymity. The “spiritual substance” of anonymity according to AA’s core literature is not selfishness but “sacrifice.” (AA, 1952/1981, p. 184). What is sacrificed in AA (and in acts of heroism) are one’s “natural desires for personal distinction,” which in AA are eschewed in favor of “humility, expressed by anonymity” (AA, 1952/1981, p. 87). Applying this understanding, one could see how an AA or NA member choosing public recovery advocacy could technically meet the letter of Tradition Eleven (not disclosing AA affiliation at the level of press), but violate the pervading spirit of the Traditions (Tradition Twelve). This could occur when advocacy is used as a stage for assertion of self (flowing from ego / narcissism / pride and the desire for personal recognition) rather than as a platform for acts of service, which flow from remorse, gratitude, humility, and a commitment to service. (2013)

He closes with a call for a gut check on our advocacy efforts:

There is a purity—perhaps even a nobility—to recovery advocacy when it meets the heroism criteria. There is a zone of service and connection to community within advocacy work, and I think we must do a regular gut check to make sure we remain within that zone and not drift into advocacy as an assertion of ego. The intensity of camera lights, the proffered microphone, and seeing our published words and images can be as intoxicating and destructive as any drug if we allow ourselves to be seduced by them. If we shift our focus from the power of the message to our power as a messenger, we risk, like Icarus of myth, flying towards the sun and our own self-destruction. To avoid that, we have to speak as a community of recovering people and avoid becoming recovery celebrities—even on the smallest of stages. We must stay closely connected to diverse communities of recovery and speak publicly not as an individual or representative of one path of recovery, but on behalf of all people in recovery. The fact that no one is fully qualified to do that helps us maintain a sense of humility even as we embrace the very real importance of the work to be done. The spirit of anonymity—that suppression of self-centeredness—can be respected when we speak by embracing the wonderful varieties of recovery experience rather than as individuals competing for attention and superiority. (2013)

We stand on the shoulders of others

I’m grateful for Bill’s reminder. Personally, I’m bothered be some of the slogans coming out of the newest generation of advocates. “Silent no more”, “I am not anonymous” and “The silence ends” are just a few examples.

First of all, anonymity, as practiced within communities of recovery, never demanded silence. All one needs to do is read AA’s chapter on the 12th tradition, published in 1952.

When opportunities to be helpful came along, he found he could talk easily about A.A. to almost anyone. These quiet disclosures helped him to lose his fear of the alcoholic stigma, and spread the news of A.A.’s existence in his community. Many a new man and woman came to A.A. because of such conversations. Though not in the strict letter of anonymity, such communications were well within its spirit.

But it became apparent that the word-of-mouth method was too limited. Our work, as such, needed to be publicized. The A.A. groups would have to reach quickly as many despairing alcoholics as they could. Consequently, many groups began to hold meetings which were open to interested friends and the public, so that the average citizen could see for himself just what A.A. was all about. The response to these meetings was warmly sympathetic. Soon, groups began to receive requests for A.A. speakers to appear before civic organizations, church groups, and medical societies. Provided anonymity was maintained on these platforms, and reporters present were cautioned against the use of names or pictures, the result was fine.

We may not have organized recovering people into a national advocacy movement, but we’ve never been silent. As a community, we haven’t cowered in shame. Communities of recovery are so frequently painted as “secretive”, with all of it’s pejorative connotations–implying shame, hiding, cultishness, etc. Why are we reinforcing this?

“I am not anonymous” seems dismissive of anonymity as a spiritual principle.

The issue isn’t advocacy. The first wave of this advocacy movement was much more respectful of tradition and the people who blazed the trail for building a recovering community capable of engaging in this level of advocacy. They made the case for “advocacy with anonymity” rather than dismissing it as quaint.

There’s nothing wrong with evolving. There’s nothing wrong with questioning the confines of tradition. We don’t have to be bound by tradition, but we should respect the traditions, principles and values that brought us this far.

I hope this movement grows, matures and succeeds in reducing stigma and improving access to help of adequate quality, intensity and duration.

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Design, Rebranding and Cannabis

Design/creative blog 99U looks at rebranding efforts in the cannabis industry:

In the last few months, Christopher Simmons, creative director for MINE, has designed branding and packaging for several dispensaries in San Francisco, including BASA, Dutchman’s Flat, Petra, and Prophet.

“With Prophet, the question was: How do you get away from the dominant paradigm in the industry, which is still holding on to that Bob Marley stoner culture? Because that’s not where the market’s going,” he says. “When I design packaging for these premium brands, I don’t ask if it’s going to look good in a head shop; I want to know if I could reasonably expect to see this at a Whole Foods or a Starbucks.”

Simmons’ work for Prophet’s flower features a sophisticated, bold, sans serif typeface and masculine color palette on a canister that mimics chewing tobacco tins. On the other end of the spectrum, his work for Petra mints is aimed at women, who generally prefer edibles to smoking. Each color hints at a flavor, and each pattern draws inspiration from a country where the plant is indigenous: A Moroccan pattern is paired with mint, and an Indian pattern is paired with mango.

As we move toward legalization, and experienced marketing firms are charged with growing sales, how will it change the culture and what will it look like? What regulations on marketing and sales will be needed?

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Maybe prohibition is the way to go?

For years I’ve been writing comments like this about drug policy:

Any drug policy will have problems, probably serious problems. The important questions are:

  • Which problems are we most unwilling to live with?
  • Which problems are we most willing to tolerate?
  • What strategies will help us achieve these goals while maintaining concern for all problems?

Of course, of equal importance is our willingness to regularly re-assess policy to improve our response and address unanticipated problems.

These are really hard questions.

And, it’s been frustrating to read lots of people treating it as though there are simple and obvious answers.

The intersections of addiction, capitalism, medicine, crime, and government, with all their variations, limitations and flaws make this a very difficult problem. We tend to underestimate the existence of unintended consequences and overestimate our influence.

It’s good to see a pretty influential writer at Vox interrogate his own beliefs and assumptions.

By the time I began as a drug policy reporter in 2010, I was all in on legalizing every drug, from marijuana to heroin and cocaine.

It all seemed so obvious to me. Prohibition had failed. Over the past decade, millions of Americans had been arrested and, in many of these cases, locked up for drugs. The government spent tens of billions of dollars a year on anti-drug policies — not just on policing and arresting people and potentially ruining their lives, but also on foreign operations in which armed forces raided and destroyed people’s farms, ruining their livings. Over four decades, the price tag for waging the drug war added up to more than $1 trillion.

. . .

Then I began reporting on the opioid epidemic. I saw friends of family members die to drug overdoses. I spoke to drug users who couldn’t shake off years of addiction, which often began with legal prescription medications. I talked to doctors, prosecutors, and experts about how the crisis really began when big pharmaceutical companies pushed for doctors and the government to embrace their drugs.

. . .

Looking at this crisis, it slowly but surely dawned on me: Maybe full legalization isn’t the right answer to the war on drugs. Maybe the US just can’t handle regulating these potentially deadly substances in a legal environment. Maybe some form of prohibition — albeit a less stringent kind than what we have today — is the way to go.

Read the whole thing here.

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