Category Archives: Policy

The golden age

Keith Humphreys argues we’re entering a golden age0524-Golden-Age-Runway-show for mental health care:

For most of U.S. history, employers did not provide adequate mental health benefits in the insurance packages they assembled for employees. This wasn’t a controversial policy: most labor unions were quite happy to trade “mental for dental” when they negotiated fringe benefits. But over time, more and more families who were being destroyed by a loved one’s schizophrenia or alcoholism or manic depression went through a second round of suffering when they discovered that their employer-based insurance wouldn’t pay for care.

These families made common cause with other advocates to mount a 12-year push for equal treatment, which culminated in the 2008 Wellstone-Domenici Mental Health Parity and Addiction Act. As a result of this law, the more than 100 million Americans who receive insurance through large employers are now guaranteed that their mental health-related benefits will be comparable to those for the treatment of other disorders.

Also in 2008, a major effort to reform Medicare passed, one that critically included a little-noticed mental health provision that just came into full effect this year. Since its creation, Medicare had covered 80% of all outpatient care except for mental health and addiction treatment, only 50% of which was covered. This extremely high co-payment effectively prevented many Medicare recipients from receiving mental health care. Today, however, the 50 million senior citizens and disabled persons who rely on Medicare enjoy the same level of coverage for outpatient psychiatric care as they do for all other types of medical treatment.

The 2010 Affordable Care Act is even more transformative. The law allows a parent to keep their children on family health insurance until the age of 26, thereby fully covering the age range in which almost all serious mental illnesses and addictions begin. Furthermore, the law defines insurance coverage for mental illness and addiction care as “essential health benefits.” As a result, both the Medicaid expansion and the private plans sold on health exchanges all cover care for psychiatric disorders at the same level as other diseases. The Department of Health and Human Services estimates that over 60 million Americans will receive improved mental health insurance coverage because of the provisions of the ACA.

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Filed under Mental Health, Policy

Hope, empowerment, capability, connection and purpose

Hopeworks Community recently listed his core beliefs related to his recovery from mental illness:

The idea was simple. There are a few core beliefs about recovery that make a difference. To the extent you are able to live them your recovery will be positively impacted.

My list of core beliefs was simple:

Life can get better.
I can help make it better.
I can learn the things I need to do to make it better.
I have support. People care about me and what I am doing.
What I do matters. It has meaning and purpose.


This rings very true for addiction recovery as well. Any practitioner or program that ignores these dimensions is inadequate. Some people will need no assistance with this kind of recovery–if we reduce their symptoms they can take care of all of this on their own without mutual aid or extended professional help. (I’m thinking of people with major depression or a problem drinker.) Others will more severe and chronic mental illness or substance use disorder will need lifelong professional and/or peer support. (Here, I’m thinking of an addict or chronic, debilitating mental illness.)

There’s a lot of pushback on this for addiction. Just this weekend, Anne Fletcher tweeted a dismissive reaction to a Bill White post about developing geographic communities of recovery.

Would she have the same reaction to a post about building communities of recovery for people with chronic and severe mental illness? Would she tweet a response that implies it’s overkill and these people (Who, together, are re-engaging in full family, occupational and community life.) need discover that there’s more to life and they need to get out of some growth-limiting bubble?

There’s been a whole new wave of these kinds of reactions recently. To me, they suggest a couple of beliefs:

  • The failure to acknowledge the different needs of people who have less severe or time-limited problems with alcohol and other drugs versus those with severe, chronic and debilitating addictions. Their reactions often focus on the experiences of the former, framing substance use disorders as a lifestyle choice.
  • The perception that recovery advocates (12 step recovery in particular) can’t tell the difference between these two groups and are bent on evangelizing every problem user into their one and only path to recovery while obstructing access to any treatment or recovery support that isn’t perfectly compatible.
  • That this perceived pattern of behavior undermines the legitimacy of mutual aid groups and the empirical evidence for the their effectiveness and their mechanisms of change.

Hopeworks Community closed with a thought that sums up recovery as a way of life.

But I know recovery is never a thing to have, but a way of doing.

Interesting that there is so much resistance to lifestyle change as an approach to managing addiction while there’s no dispute that lifestyle change is critical to successful management of other chronic illnesses and that peer support is important for successfully initiating and sustaining lifestyle change.

I don’t hear any of these reactions regarding people who join a gym, spend an hour there 5 days a week, start eating healthier, integrate being physically healthy into their identity and develop new social networks around these changes, like, say, a tennis league or a biking group. Why is that? We don’t hear that push back, and we’re not even talking about people who were occupationally, socially, emotionally and familially impaired. And, if some faction of these people exhibited evangelical zeal and insisted this was the only way to be healthy and that everyone needed to do this, would we be so dismissive of scholarly work describing the development of some communities organized around this kind of wellness for really sick people?

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Filed under Advocacy, Controversies, Favorites, Harm Reduction, Mental Health, Mutual Aid, Policy, Research, Treatment

How Dangerous are e-cigarettes?

A lot of cities and organizations are sorting through how to respond to the rise of e-cigarettes. Many are beginning to treat them like cigarettes, extending smoking policies to e-cigarettes. Mark Kleiman thinks this is nuts.

The Los Angeles City Council just voted for a complete ban on e-cigarettes wherever real cigarettes are banned, including parks, beaches, and bars. (UCLA adopted a similar policy campus-wide a few months ago.) Seems to me like a bizarre choice, and likely to retard the movement from cancer sticks to e-cigs that, if not interrupted, might save hundreds of thousands of lives per year.

But, not so fast. A new study finds that e-cigarettes create new cigarette smokers.

E-cigarettes, promoted as a way to quit regular cigarettes, may actually be a new route to conventional smoking and nicotine addiction for teenagers, according to a new UC San Francisco study.

In the first analysis of the relationship between e-cigarette use and smoking among adolescents in the United States, UCSF researchers found that adolescents who used the devices were more likely to smoke cigarettes and less likely to quit smoking. The study of nearly 40,000 youth around the country also found that e-cigarette use among middle and high school students doubled between 2011 and 2012, from 3.1 percent to 6.5 percent.

“Despite claims that e-cigarettes are helping people quit smoking, we found that e-cigarettes were associated with more, not less, cigarette smoking among adolescents,” said lead author Lauren Dutra, a postdoctoral fellow at the UCSF Center for Tobacco Control Research and Education.

“E-cigarettes are likely to be gateway devices for nicotine addiction among youth, opening up a whole new market for tobacco,” she said.

It gets worse:

The authors found that the devices were associated with higher odds of progression from experimenting with cigarettes to becoming established cigarette smokers. Additionally, adolescents who smoked both conventional cigarettes and e-cigarettes smoked more cigarettes per day than non-e-cigarette users.

Contrary to advertiser claims that e-cigarettes can help consumers stop smoking conventional cigarettes, teenagers who used e-cigarettes and conventional cigarettes were much less likely to have abstained from cigarettes in the past 30 days, 6 months, or year. At the same time, they were more likely to be planning to quit smoking in the next year than smokers who did not use e-cigarettes.

Is this an abberation?

The new results are consistent with a similar study of 75,000 Korean adolescents published last year by UCSF researchers, which also found that adolescents who used e-cigarettes were less likely to have stopped smoking conventional cigarettes.

What’s interesting to me it this. We’ve dramatically reduced smoking over the years without criminalizing them by changing the culture. E-cigarettes seem to have the potential to undo these culture changes. It’s like a seemingly less dangerous, but more contagious mutation of an infectious bacteria. Do we wait to see what happens? To see how dangerous it really is? Or, do we try to eliminate or aggressively manage it?

Of course, one of the unknowns is, as these devices become more widespread, what else will they be used for? What else people will start “vaping” with these devices.

via E-cigarettes are gateway to nicotine addiction for teens | University of California.


Filed under Controversies, Harm Reduction, Policy

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.


Filed under Controversies, Harm Reduction, Policy, Research, Treatment

It will kill people as soon as it’s released

images (3)The upcoming release of Zohydro has been getting a lot of attention:

The hydrocodone-based drug is the latest in a long line of painkillers called opioid analgesics. The FDA approved the medication last fall to treat chronic pain, and it is set to become available to patients in March.

The drug was approved against the advice of the FDA’s own advisory board.

Despite a vote of 11 to 2 by an FDA panel to reject the powerful new drug, it was eventually given approval by the FDA for release.

There are concerns about the manufacturer’s access to the FDA.

Last fall, a series of emails were made public from a Freedom of Information Act request. They were emails between two professors who had, for a decade, organized private meetings between FDA officials and drug companies who make pain medicine. The drug companies pay the professors thousands of dollars to attend.

And here’s what has critics concerned. One of those companies was Zohydro’s original manufacturer, Elan Corp. Zogenix wasn’t in the picture yet but went on to partner with Elan.

One physician group isn’t mincing words about the impact of the drug.

“It’s a whopping dose of hydrocodone packed in an easy-to-crush capsule,” said Dr. Andrew Kolodny, president of the advocacy group Physicians for Responsible Opioid Prescribing. “It will kill people as soon as it’s released.”

Doctor Skeptic reviews the research on opioids as a pain management options and concludes with this:

The bottom line
1. Opioids may not be effective for chronic non-cancer pain, and their use in such patients is associated with side effects, tolerance, dependence, and addiction.
2. Despite this, prescription opioid use is increasing and with that, the rates of opioid abuse and opioid related death are also increasing.
3. Harms from prescription opioids are over-represented in the socially disadvantaged.



Filed under Advocacy, Controversies, Policy, Research

Medication: The smart-pill oversell

Unlock-Your-PotentialGiven the simultaneous explosion in ADHD diagnosis, prescribed use of stimulants and non-medical use of stimulants, maybe it’s time to look at the cost/benefit ratio. We’ll it’s clear that the benefits aren’t all that. What to make of it?

Researchers are beginning to address this paradox. How can medication that makes children sit still and pay attention not lead to better grades?

One possibility is that children develop tolerance to the drug. Dosage could also play a part: as children grow and put on weight, medication has to be adjusted to keep up, which does not always happen. And many children simply stop taking the drugs, especially in adolescence, when they may begin to feel that it affects their personalities. Children may also stop treatment because of side effects, which can include difficulty sleeping, loss of appetite and mood swings, as well as elevated heart rate.

Or it could be that stimulant medications mainly improve behaviour, not intellectual functioning. In the 1970s, two researchers, Russell Barkley and Charles Cunningham, noted that when children with ADHD took stimulants, parents and teachers rated their academic performance as vastly improved9. But objective measurements showed that the quality of their work hadn’t changed. What looked like achievement was actually manageability in the classroom. If medication made struggling children appear to be doing fine, they might be passed over for needed help, the authors suggested. Janet Currie, an economist at Princeton University in New Jersey, says that she might have been observing just such a phenomenon in the Quebec study that found lower achievement among medicated students1.

And it may simply be that drugs are not enough. Stimulant medications have two core effects: they help people to sustain mental effort, and they make boring, repetitive tasks seem more interesting. Those properties help with many school assignments, but not all of them. Children treated with stimulants would be able to complete a worksheet of simple maths problems faster and more accurately than usual, explains Nora Volkow. But where flexibility of thought is required — for example, if each problem on a worksheet demands a different kind of solution — stimulants do not help.

What about those non-medical users? Don’t they get a boost?

In people without ADHD, such as students who take the drugs without a prescription to help with school work, the intellectual impact of stimulants also remains unimpressive. In a 2012 study of the effects of the amphetamine Adderall on people without ADHD, psychologists at the University of Pennsylvania in Philadelphia found no consistent improvement on numerous measures of cognition, even though people taking the medication believed that their performance had been enhanced10.

via Medication: The smart-pill oversell : Nature News & Comment.

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Addicts and Disease

Dirk Hanson has a great post on resistance to the disease model.

I’m a believer in harm reduction as part of the continuum of addiction interventions, but there is often a chasm between the way harm reductionists and treatment providers frame the problem. This can make it difficult to work together. Dirk does a great job illuminating an element of the differences in frames.

For harm reductionists, addiction is sometimes viewed as a learning disorder. This semantic construction seems to hold out the possibility of learning to drink or use drugs moderately after using them addictively. The fact that some non-alcoholics drink too much and ought to cut back, just as some recreational drug users need to ease up, is certainly a public health issue—but one that is distinct in almost every way from the issue of biochemical addiction. By concentrating on the fuzziest part of the spectrum, where problem drinking merges into alcoholism, we’ve introduced fuzzy thinking with regard to at least some of the existing addiction research base. And that doesn’t help anybody find common ground.

He also offers some historian David Courtwright’s perspective on resistance to the disease model.

Historian David Courtwright, writing in BioSocieties, says that the most obvious reason for this conundrum is that “the brain disease model has so far failed to yield much practical therapeutic value.” The disease paradigm has not greatly increased the amount of “actionable etiology” available to medical and public health practitioners. “Clinicians have acquired some drugs, such as Wellbutrin and Chantix for smokers, Campral for alcoholics or buprenorphine for heroin addicts, but no magic bullets.” Physicians and health workers are “stuck in therapeutic limbo,” Courtwright believes.

Interesting. Because medical practitioners have had a difficult time establishing a role for themselves, there’s a lot of resistance to recognizing it as a disease.

When we look at the chronic disease burden, does this lead to bias in favor of pills and procedures, and neglect of lifestyle medicine?

Dirk also gets into the ways addicts benefit from the disease model. Check out the whole post.

via Addiction Inbox: Addicts and Disease.

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