Category Archives: Policy

Anti-treatment zombie stats


This 90% statistic has been frequently cited to discredit specialty addiction treatment.

Ninety percent of those who enter addiction-treatment programs in the U.S. don’t receive evidence-based treatment

I asked David Scheff about it several weeks back. He said it was from RAND and referred me to his book. I looked in his book and couldn’t find the reference. I asked him about it and he said he’d get back to me. Now, Alcoholism & Drug Abuse Weekly explains why I couldn’t find it.

“Ninety percent of those who enter addiction-treatment programs in the U.S. don’t receive evidence-based treatment” — an assertion David Sheff made in his blog on last fall, and then restated in another blog February 2 — is based on an 11-year-old report by RAND, Sheff told ADAW. What the report actually says is that 90 percent of people with alcohol dependence did not receive the treatment that was recommended. But it doesn’t say that they entered treatment at all. In other words, the statement is inaccurate.

To be sure, there’s a lot of bad treatment out there, and it should be covered by the media. However, much of the coverage is biased against specialty treatment and has a pro-physician-directed treatment bias. (As though lousy treatment in medical settings is a rarity.)

There are a lot of fair criticisms that can be made against a lot of the treatment in the US. But these vague blanket criticisms (90%) don’t help addicts or their families find good treatment. And, the implication that any treatment with medication is good while any treatment without is primitive voodoo is false and damaging. Also, the blanket nature of the attacks slanders and alienates ethical professionals who provide good care.

As Alcoholism & Drug Abuse Weekly set the record straight, another journalist defended the error by arguing that it was in an opinion section and the false statistic was used to support a conclusion she said was true.

What can you do when the journalists, who have the soapbox, argue that they’re right, even when their facts are wrong?

. . . most men have bound their eyes with one or another handkerchief, and attached themselves to some one of these communities of opinion.  This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars.  Their every truth is not quite true.  Their two is not the real two, their four not the real four; so that every word they say chagrins us, and we know not where to begin to set them right.– Ralph Waldo Emerson

via McLellan on the state of evidence-based treatment, and an old RAND report.


Filed under Advocacy, Controversies, Policy, Research

It’s “changed the whole world”

box-closed-pen-02_grandeA few weeks ago, I asked about how e-cigarettes might be used for other drugs and Dirk Hanson pointed out that it was already happening. The Detroit Free Press covered this segment of the pot economy:

Chris Folkerts started selling electronic cigarette-like devices from the trunk of his car two years ago. Now he and two partners own one of the biggest brands in the business, with products in 4,000 stores nationally, an art deco office on the city’s fashionable Miracle Mile and an endorsement deal with rapper Snoop Dogg.

The rapid success of Grenco Science, the privately held company Folkerts founded, mirrors the fast growth of the business it is in — marketing devices that allow marijuana users to vaporize their psychoactive weed rather than smoke it.

“This is a big industry — it is the future,” Folkerts, 31, says. “We’re really on the cusp of exploding.”
. . .
“It’s a perfect combination — it’s so easy (and) there’s no odor,” says Marcie Beckett, a San Diego mother of two who is part of a coalition opposing marijuana legalization. “People beware: Kids can now use these vaping devices to use marijuana, and you’ll never know.”
. . .
High Times magazine, which chronicles pot culture, recently expanded to its largest size ever, up 26 pages to 152 pages, to make room for vaporizers ads, Managing Editor Jen Bernstein says.
. . .
“I’ve been in the business for 20 years, and I’ve never seen anything impact the market like this,” says Tony Van Pelt of Pomona, Calif., who sells vaporizers and related items online and in stores.

“This is the moment I’ve been waiting for,” he says. “This vaporizing thing has changed the whole world.”

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Filed under Controversies, 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