Category Archives: Controversies

…let us work together

The last couple of days’ posts, a recent conversation and some recent news (I’ll let you guess which story.) reminded me of this post. It’s from a couple of years ago and has a couple of minor updates.


 

“If you have come here to help me, then you are wasting your time… 
But if you have come because your liberation is bound up with mine, 
then let us work together.” – Lila Watson

Obviously, I’ve been thinking a lot about the buprenorphine maintenance, the NY Times series and the reactions since it was published. (See here, here, here, here, here, here, here & here.)

At Dawn Farm, we’ve often said that maintenance approaches are often rooted in the belief that opiate addicts can’t recover. Now, I’m the kind of person who tends to be uncomfortable making statements that claim to know the contents of another person’s mind. This week has made me much more comfortable with that statement. None of the responses have argued that maintenance is a great tool for achieving recovery. Several have referred to opiate addiction as a hopeless condition. All the arguments for it have been harm reduction arguments–that it’s associated with reduced use, overdose death, disease transmission, crime and incarceration. (The data is less compelling than many of them would have you believe.)

I want to make clear that I have no interest in getting between an addict and a maintenance treatment. All I want is a day when addicts are offered the same treatment that their doctors are offered–recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose. (However, the only choices these articles are worried about are buprenorphine and methadone. SAMHSA reports that, in 2012, about 23% of opiate addicts had a treatment plan that included medication assisted treatment, while 7% got long term residential. It’s worth noting a couple things. First, SAMHSA’s data set is generally limited to programs that get federal funding. Many of these use methadone, but few use buprenorphine. Buprenorphine had $1.4 billion in US sales and was the number 28 drug in 2012. Second, that quarter of heroin addicts with medication assisted treatment in their treatment plans is only those who actually had medication in their plan–23% doesn’t represent everyone who was offered medication, that number would likely be much higher. Third, their definition of long term residential is very loose and can include “transitional living arrangements such as halfway houses”. So, that 7% is inflated and very misleading. Finally, how many people get the treatment doctors get? I’d feel pretty safe guessing it’s a fraction of a percent. Why is there no hand wringing about access to this kind of care?)

However, when we have professionals, policy makers and researchers who don’t believe in the capacity of patients to recover, the kind of help they are going to offer is going to be unhelpful. They’ll focus on risk factors for overdose like “compromised tolerance”. Of course, decreased tolerance is associated with overdose. Then again, social interaction is associated with transmission of many illnesses. Should we discourage social lives?

One has to wonder if the experts interviewed for these articles know any addicts in full recovery–people who are fully re-engaged in family life, community life, vocations, education, faith communities, etc. If so, do they think of the people they know as belonging to some special category that makes them different from other addicts? (When I teach about addiction and bring up the outcomes for health professionals, many students argue that they are a different kind of addict and better outcomes are to be expected.)

While I don’t want to take choices away from addicts, there’s a big part of me that wants these “experts” to leave us alone. We don’t need your “help.” (A kind of help you would never offer a sick peer.)

malcolmxbirthday16x9

That sentiment brings to mind this Malcolm X story:

Several times in his autobiography, Malcolm X brings up the encounter he had with “one little blonde co-ed” who stepped in, then out, of his life not long after hearing him speak at her New England college. “I’d never seen anyone I ever spoke before more affected than this little white girl,” he wrote. So greatly did this speech affect the young woman that she actually flew to New York and tracked Malcolm down inside a Muslim restaurant he frequented in Harlem. “Her clothes, her carriage, her accent,” he wrote, “all showed Deep South breeding and money.” After introducing herself, she confronted Malcolm and his associates with this question: “Don’t you believe there are any good white people?” He said to her: “People’s deeds I believe in, Miss, not their words.”

She then exclaimed: “What can I do?” Malcolm said: “Nothing.” A moment later she burst into tears, ran out and along Lenox Avenue, and disappeared by taxi into the world.

I can relate to his sentiment that the most helpful thing others can do is leave us alone. (“Other” can be a pretty ugly word, no?) Then, when I’m a little less emotional, I’m left to consider my own cognitive biases and creeping certitude. I have to think about the contributions of people like Dr. Silkworth, Sister Ignatia, George Vaillant, etc.

We also need to be watchful for ideological resistance to innovations that could help others find recovery.

Malcolm X had a similar experience to this too:

In a later chapter, he wrote: “I regret that I told her she could do ‘nothing.’ I wish now that I knew her name, or where I could telephone her, and tell her what I tell white people now when they present themselves as being sincere, and ask me, one way or another, the same thing that she asked.”

Alex Haley, in the autobiography’s epilogue (Malcolm X had since been assassinated), recounted a statement Malcolm made to Gordon Parks that revealed how affected he was by his encounter with the blonde coed: “Well, I’ve lived to regret that incident. In many parts of the African continent I saw white students helping black people. Something like this kills a lot of argument. . . . I guess a man’s entitled to make a fool of himself if he’s ready to pay the cost. It cost me twelve years.”

Malcolm X realized, too late, that there was plenty this “little blonde coed” could have done, that his response to her was inconsistent with what he, his associates, and his followers wanted to accomplish.

Bill White wrote about the things that have allowed practitioners to avoid the cultural traps in working with addicts:

Four things have allowed addiction treatment practitioners to shun the cultural contempt with which alcoholics and addicts have long been held:

  1. personal experiences of recovery and/or relationships with people in sustained recovery,
  2. addiction-specific professional education,
  3. the capacity to enter into relationships with alcoholics and addicts from a position of moral equality and emotional authenticity (willingness to experience a “kinship of common suffering” regardless of recovery status), and
  4. clinical supervision by those possessing specialized knowledge about addiction, treatment and recovery processes.

We must make sure that these qualities and conditions are not lost in the rush to integrate addiction treatment and other service systems.

I don’t know how to engage these experts who may know a lot about the illness, but they often appear to be blind to the fact that full recovery already exists in every community across the country. It’s especially tough when the field is so fractured, there’s so much money to be made, and external forces (like the Affordable Care Act) are going to be pushing addicts toward primary care for their treatment.

As far as Dawn Farm goes, I heard something last week that cast us in a new light for me.

We are unapologetically rooted in culture.
If you want to join us, and you’re not part of that culture,
you need to find ways to respect, honor and celebrate that culture.”  – Dan Floyd

We’ve talked a lot about the concept of cultural competence and that professional helpers need to deliberately develop similar competencies when working with addicts and the recovering community. I still believe this is true. But, at Dawn Farm, we go beyond mere competence. We are rooted in the culture of recovery, and we help non-recovering staff (more than half of our staff) find ways to respect, honor and celebrate that culture.

This puts us out of the mainstream among professional helpers and “experts” on addiction, but we wouldn’t change a thing.

The question is how to develop this kind of competence in these researchers, policy makers and experts. It would seem that recovery advocacy would be an important way to do this. However, drug manufacturers have ingratiated themselves with recovery advocacy organizations and the organizations have tried to ingratiate themselves with experts. As a result, they’ve waded into supporting medication assisted recovery, but have done little to challenge the therapeutic nihilism that PHARMA nurtures and is a theme in the public comments of these experts.

In the meantime, this brings me back to the quote I opened this post with.

“If you have come here to help me, then you are wasting your time… 
But if you have come because your liberation is bound up with mine, 
then let us work together.” – Lila Watson

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The adjacent possible and hope

I heard a radio show this morning about where ideas come from.

They interviewed a guy who wrote a book and gave a TED talk on the topic.

During the interview he discussed the concept of the adjacent possible and it’s importance in forming new ideas. During the interview, he described it as the building blocks of new ideas. Without the right building blocks, any innovation is not possible. He described it another way in a WSJ article:

The adjacent possible is a kind of shadow future, hovering on the edges of the present state of things, a map of all the ways in which the present can reinvent itself.

The strange and beautiful truth about the adjacent possible is that its boundaries grow as you explore them. Each new combination opens up the possibility of other new combinations. Think of it as a house that magically expands with each door you open. You begin in a room with four doors, each leading to a new room that you haven’t visited yet. Once you open one of those doors and stroll into that room, three new doors appear, each leading to a brand-new room that you couldn’t have reached from your original starting point. Keep opening new doors and eventually you’ll have built a palace.

During the interview, he pointed out that it doesn’t matter how smart one is, it was not possible to invent a microwave in 1650, because the building blocks, the adjacent possible, just wasn’t there.

One factor is that the physical building blocks did not exist. The other factor is that the imaginative/inspiration building blocks did not exist.

This reminded me of a metaphor Bill White once used when talking about hope-engendering relationships offering kindling for hope.

I think this helps explain the resistance some recovery advocates have to interventions focused on something other than drug-free recovery. There’s a sense of how precious this adjacent possible is, and how easy it is to imagine a world where drug-free recovery is not possible because the adjacent possible has been lost.

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2014’s top posts: #2

“He’d still be alive”

CANADA TORONTO FILM FESTIVALMuch has been said this week about the death of Phillip Seymour Hoffman.

I’ve heard two recurring themes. First, that he might still be alive if he had been “treated with an evidence-based” treatment, like buprenorphine. Second, that he might still be alive if he hadn’t been inculcated with the disease model, which purportedly fosters learned helplessness.

The buprenorphine argument

I know nothing of the treatment he received and most of these people admit that they don’t either.

Let’s assume, for a moment, that their assumptions are correct.

One problems is that most of these writers fail to deal with the issue of falling buprenorphine compliance ratesThis recent study of 6 month study found a dropout rate of 76% for those without chronic pain and described the compliance rates as consistent with other studies.

Early studies of buprenorphine reported outstanding compliance rates. Those numbers need to be viewed with suspicion and one should wonder whether the promulgation of those numbers is a success of science or marketing.

Their premise seems to be that people prescribed buprenorphine don’t OD. I don’t doubt that people currently taking buprenorhine are at lower risk for OD. However, I’m not aware of any good studies of survival rates that consider real world compliance rates.

Now, we learn that buprenorphine was reportedly found in his apartment. I have no idea whether it was prescribed to him or whether he bought it on the street. If it was prescribed to him, it suggests that prescribing the drug may not have the protective properties that advocates claim. If he bought it on the street, it points to the issue of diversion, which raises questions about patient compliance with the drug.

Besides, this was someone who had maintained some sort of remission for 23 years, had been in relapse for one year and had only one, brief detox episode during that period of time. Seems a little rash to assume that that path that had worked for 23 years would be a bad path to try to get him back to.

The disease argument

There’s ample evidence that addiction is a disease and, kind of like the climate change debate, though there is a noisy group of dissenters with high visibility, there is widespread agreement among experts that it’s a brain disease characterized by loss of control.

One of the most common arguments to question the disease model is the existence of natural recovery–that fact that large numbers of “addicts” recovery without any help.

The quotation marks in the previous sentence signal my response. Vietnam vets who returned with heroin problems are a frequently cited example. Most came back to the states and quit heroin on their own. Reports indicate that only 5% to 12% were unable to quit or moderate.

Hmmmm. That range….5 to 12 percent…why, that’s similar to estimates of the portion of the population that experiences addiction to alcohol or other drugs.

To me, the other important lesson is that opiate dependence and opiate addiction are not the same thing. Hospitals and doctors treating patients for pain recreate this experiment on a daily basis. They prescribe opiates to patients, often producing opiate dependence. However, all but a small minority will never develop drug seeking behavior once their pain is resolved and they are detoxed.

My problem with all the references to these vets and addiction, is that I suspect most of them were dependent and not addicted.

So…it certainly has something to offer us about how addictions develops (Or, more specifically, how it does not develop.), but not how it’s resolved.

Why is it so frequently cited and presented without any attempt to distinguish between dependence and addiction? Probably because it fits the preferred narrative of the writer.

It’s worth noting that this can cut in both directions. There’s a tendency to respond to problem users (people who drink too much, but are not alcoholics.) and dependent non-addicts (most pain patients or these returning vets) as though they are addicts. This results in bad treatment for those people, bad research and it manufactures resentment toward treatment, mutual aid groups and recovery advocates.

We run into the same problem when recovery advocates (who I love and generally agree with) report that there are 23 million Americans in recovery. These kinds of statements tend to be based on surveys asking people something to effect of, “Have you previously had a problem with drugs or alcohol and no longer have one?” That kind of question is going to get a lot of false-positives for what we think of as recovery. It’s a little like asking people if they once had a chronic cough and no longer have one, then inferring that all of those people are in recovery from TB.

We know that relatively large numbers of young adults will meet criteria for alcohol dependence but that something like 60% of them will mature out as they hit milestones like graduating from college, starting a career or starting a family. Are these people addicts in recovery? Or, were they people with a problem of an entirely different kindan acute alcohol problem rather than the chronic brain disease of addiction?

We need to do a better job distinguishing addiction/alcoholism from dependence and look at improving DSM criteria to help with this distinction. Loss of control, over an extended period of time that returns after periods of abstinence is the key to me. Addicts/alcoholics are not people making poor decisions about their drug and alcohol use, they are people who have lost the ability to make execute decisions related to drug and alcohol use.

It’s apples and oranges and these statements about the prevalence of recovery do real damage to the cause. People with addiction shouldn’t be treated with expectations constructed around the experience and pathways of people who do not have the same disease. AND, people who do not have addiction should not be subjected to treatments for people who do have the disease.

A better argument

I’ve spent a lot of time on this blog responding to arguments that pharmacological treatments are better than drug-free treatment. And, I’ll admit that I feel defensive when I hear treatment being attacked. However, when I step back, I have to admit that there’s a lot of bad treatment out there. With and without medications.

These arguments about drug-free vs. drug maintenance miss one really big and really important point. Whichever kind of treatment a person ends up receiving, there’s a really good chance that they will not get the long term monitoring and support that is appropriate for a life-threatening and chronic disease.

Two models that have outstanding outcomes are treatment programs for health professionals and programs for pilots. Both have long term success rates in 90% range. Both of them happen to be drug-free, but the point I want to focus on is that they both provide intensive long term monitoring and support with rapid re-intervention in the event of relapse.

Shouldn’t we have a system that monitored Philip Seymour Hoffman in the same way we monitor people with heart disease? One other example that comes to mind is my dentist. I mean, I don’t even get cavities–there’s nothing urgent going on in my mouth. BUT, my dentist corners me into scheduling another appointment before I leave the office and they start calling and texting me to remind me AND even ask me to reply that I will make my appointment.

If my dentist can deploy the strategies to promote continuity of care, why can’t addiction treatment programs?

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2014’s Top Posts: #3

Recovery MAINTENANCE

imagesThere’s a lot of commentary out there on Philip Seymour Hoffman’s death. Some of it’s good, some is bad and there’s a lot in between. Much of it has focused overdose prevention and some of it has focused on a need for evidence-based treatments.

Anna David puts her finger on something very important. [emphasis mine]

Let’s explain that this isn’t a problem that goes away once you get shipped off to rehab or even get a sponsor—that this is a lifelong affliction for many of us. There seems to be this misconception that people are hope-to-die addicts and then get hit by some sort of magical sunlight of the spirit and are transported into another existence where the problem goes away.

[NOTE – I know almost nothing of Hoffman or the treatment he received from his doctors or anyone else. My comments should be considered commentary on the issues involved rather than the specifics of Hoffman or the help he received.]

What I haven’t heard discussed much is his reported relapse a year or so ago. How could that have been prevented?

From what I understand, this is someone who had been in remission for 23 years. And, it sounds like his relapse began in a physician’s office when he was prescribed an opiate for pain.

  • What’s the evidence-base around treating pain in someone who has been abstinent for 23 years?
  • What are the evidence-based practices around how professional helpers should monitor and support the recovery of a patient who has been sober for decades?
  • What are the behaviors associated with recovery maintenance over decades through pain and difficult life experiences?

20090101-new-yearCould the outcome have been different if some sort of recovery checkup had been performed by his primary care physician or the doctor who treated his pain?

If he had been in remission from some other life-threatening chronic disease, wouldn’t his doctors have watched for a symptoms of a recurrence? Or,  given serious consideration to contraindications for the use of particular medications with a history of that chronic disease?

What if he had been asked questions like:

  • How’s your recovery going?
  • Have you had any relapses? Cravings?
  • How did you initiate your recovery?
  • How have you maintained your recovery?
  • Have there been changes in the habits associated with your recovery maintenance? (Meetings, readings, sponsor, social network, etc.)
  • How’s your mood been?
  • What do your family and friends who support your recovery say about this?

Also, if it’s determined that a high risk treatment (like prescribing opiates to someone with a history of opiate addiction) is needed, what kind of relapse prevention plan was put into place? What kind of monitoring and support?

There are two issues here. One is the lack of research, training and support that physicians get around treating addiction and supporting recovery.

The second issue is the role of the patient.

I listened to a talk by Dr. Kevin McCauley this morning in which he addressed objections to the disease model. One of the objections was that the disease model lets addicts off the hook. His response was that, given the cultural context, there were grounds for this concern. BUT, the contextual problem was with the treatment of diseases rather than classifying addiction as a disease. He pointed out that our medical model positions the patient as a passive recipient of medical intervention. As long as the role of the patient is to be passive, this concern has merit. He suggests we need to expect and facilitate patients playing an active role in their recovery and wellness.

So…this was someone who had been in remission for decades. He clearly had a responsibility to maintain his recovery. At the same time, the medical and/or treatment system has a responsibility to monitor and support his recovery.

I happen to have celebrated 23 years of recovery several months ago. I’m still actively engaged in behaviors to maintain my recovery. (Much like I’m actively engaged in behaviors to keep my cholesterol low.)

In 23 years, has a doctor or nurse EVER asked me how my recovery is going? No. Have they ever evaluated my recovery in ANY way? No.

Do they want to check my cholesterol every so often. Like clockwork.

This is a critical failure of the system and the evidence-base. And, we don’t just fail people with decades of recovery. Even more so, we fail people with 90 days, 6 months, a year, 5 years, etc. Then we blame the approach that helped them stabilize and initiate their recovery when the real problem was that we never helped them maintain their recovery. (Then, too often, our solution is to insist that they get into that passive patient role, just take their meds and let the experts do their work.)

via Another Senseless Overdose.

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Filed under Controversies, Policy, Treatment

2014’s top posts: #5

He died from heroin (addiction)

Phil Hoffman . . . did not die from an overdose of heroin — he died from heroin. We should stop implying that if he’d just taken the proper amount then everything would have been fine.

via Aaron Sorkin: Philip Seymour Hoffman and Drug Addiction

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Top posts of 2014: #12

Abstinence—The Only Way to Beat Addiction?

StrawmanWhat killed Philip Seymour Hoffman? According to Anne Fletcher, it wasn’t the doctor who prescribed him the pain medication that began his relapse, it wasn’t the prescribers of the combination of meds found in his body, it wasn’t his discontinuing the behaviors that maintained his recovery for 23 years, it wasn’t a drug dealer, and it wasn’t addiction itself.

According to her it was 12 step groups for promulgating an alleged myth:

This is exactly what happened when Amy Winehouse, Heath Ledger, Corey Monteith, and most recently, Phillip Seymour Hoffman were found dead and alone. Scores of people most of us never hear about suffer a similar fate every year.

Why does this keep happening? One of the answers is that many people struggling with drug and alcohol problems have been “scared straight” into believing that abstinence is the only way out of addiction and that, once you are abstinent, a short-lived or even single incident of drinking or drugging again is a relapse. “If you use again,” you’re told, “you’ll pick up right where you left off.” Once “off the wagon,” standard practice with traditional 12-step approaches is to have you start counting abstinent days all over again, and you’re left with a sense that you’ve lost your accrued sober time.

She’s describing a theory often referred to as the “abstinence violation effect”. The argument is that the “one drink away from a drunk” message in 12 step groups is harmful and makes relapses worse than they might have been.

One problem. The theory is not supported by research. (See here and here. It hasn’t even held up with other behaviors.)

Two things are important here.

  • First, many people experience problems with drugs and alcohol without ever developing an addiction. Most of these people will stop and moderate on their own. These people are not addicts and their experience does not have anything to teach us about recovery from addiction.
  • Second, loss of control is the defining characteristic of addiction. The “one drink away from a drunk” message is a colloquial way of describing this feature of addiction.

Further, she characterizes AA as opposing moderation for problem drinkers, when AA literature itself says, “If anyone who is showing inability to control his drinking can do the right- about-face and drink like a gentleman, our hats are off to him.” 12 step groups believe that real alcoholics will be incapable of moderate drinking, but they are clear that they have no problem with people moderating, if they are able. This is a straw man.

We’re left to wonder why a best selling author and NY Times reporter would attack 12 step groups with a straw man argument and a long discredited theory.

via Abstinence—The Only Way to Beat Addiction? Part 1 | Psychology Today.

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Urban myths exposed

1242257784-vaillantPoints blog is back with a great interview with George Vaillant.

Here’s one of the questions and his response:

2. What do you think a bunch of alcohol and drug historians might find particularly interesting about your book?

The value of the Grant study to the history of alcoholism is the number of urban myths that it exposes, and for this reason it received the biennial Jellinek prize for the best research in alcoholism in the world.

The first urban myth exposed is that depression causes alcoholism. Our prospective study shows beyond a doubt that alcoholism causes depression.

Second, alcoholics have unhappy childhoods due to their parents’ alcoholism; unhappy childhoods without a history of alcoholism do not lead to alcoholism. Therefore, the relationship between childhood and alcoholism appears to be genetic.

The third urban myth exposed is that AA is only for a few alcoholics and drugs are more useful. There are no two-year or longer studies of Naltrexone, Antabuse, or Acamprosate that have been shown to be effective, nor has long-term follow-up of cognitive behavioral therapy proved to be effective. On the other hand, when we followed, over 60 years, our sample of roughly 150 alcoholics, the men who made complete recovery—that’s an average of 19 years of abstinence—as contrasted to those men who remained chronically alcoholic until they died, the men who “recovered” went to 30 times more AA meetings than the men who remained chronically ill. Like outgrowing adolescence, it takes a long time to learn to put up with AA, but when you do, it works.

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