Category Archives: Research

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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Filed under Dawn Farm, Policy, Research, Treatment

Too expensive? (2015)

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.

  • $14,400 – 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 = $34,860

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 $35,000 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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Filed under Dawn Farm, Policy, Research, Treatment

…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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Filed under Advocacy, Controversies, Dawn Farm, Harm Reduction, Policy, Research

hope is a function of struggle

From On Being, some insight on hope and how people can foster it or inhibit its development:

Ms. Brown: You know, one of the most interesting things I’ve found in doing this work is, you know, something the wholehearted share in common is this real profound sense of hopefulness. And as I got into the literature on hope, very specifically C.R. Snyder’s work from the University of Kansas at Lawrence, that hope is a function of struggle.

Ms. Tippett: Right. I think that’s one of the most stunning sentences that I saw in your writing.

Ms. Brown: Yeah, and that hope is not an emotion, but hope is

...Hope...

…Hope… (Photo credit: ĐāżŦ {mostly absent})

a cognitive, behavioral process that we learn when we experience adversity, when we have relationships that are trustworthy, when people have faith in our ability to get out of a jam.

Ms. Tippett: Right, which is different from this pattern of having faith in us which means telling us everything we do is wonderful and shielding us from pain as long as they can.

Ms. Brown: Right. And, you know, I’m literally — I don’t even know how to talk about it. It really just floors me that, when I go out and I do a lot of talks for big corporations, you know, Fortune 100 companies, how many people tell me — like the HR folks who I end up — luckily, I love them and I get to talk to them a lot, who will tell me how often parents call to go over the performance evaluation of their children or to find out why they didn’t get a raise or a promotion.

Ms. Tippett: Really?

Ms. Brown: Yeah, oh, yeah.

Ms. Tippett: I mean, I just took my daughter to college and we got this lecture, the parents and the families who were there, from like the Dean of Students and it was so clear that they were dealing with that same thing, right? I mean, they basically said I need you to understand that we’re going to take great care of your gem and also that my relationship is to them and not to you. We got this lecture, which was clearly based on parents still trying to control. You know, again, it’s like, boy, we know this, don’t we, this desire that you have to create a beautiful world and life and experience for these people you love?

Ms. Brown: But you know what? I think we lose sight of the beauty. The most beautiful things I look back on in my life are coming out from underneath things I didn’t know I could get out from underneath. You know, the moments I look back in my life and think, God, those are the moments that made me, were moments of struggle.

Ms. Tippett: Or I look back at things I did where, if my parents or I had understood how crazy it was, like if it had been me, I would have tried to intervene and rescue?

Ms. Brown: Oh, for sure.

Ms. Tippett: And you’re right. Those are the moments you become who you are.

Ms. Brown: You know, and I’ve seen how this research has really changed, you know, like I’ll give you just a very specific example. My daughter decides, you know, that she wants to try out for something that she’s really new at. You know, a sport or something that she’s just taken up.

And I think before, maybe even three years ago, before this research, not only before I wrote it up, before I started trying to practice it and live it, I think I would have been the parent who said, you know, either let’s get you in 34 camps before you try out so you’ve mastered it, or I don’t think you should try out for that because there are girls who’ve been playing this sport as long as you’ve been playing soccer …

Ms. Tippett: And you want to shield her from disappointment.

Ms. Brown: Right. And I want to take away that moment that I had. You know, it wasn’t the moment. When I think back and I talk to parents a lot about this, it wasn’t the hard moments that we don’t want to expose them to. It was the isolation and shame we felt around those moments because a lot of us didn’t have people to process them with.

Like I think when I went out for something and didn’t make it, I don’t think my parents were ashamed of me, but I think they were ashamed for me. I don’t think they knew how to talk about that. I don’t think we had a conversation. I know we didn’t have a conversation that I can have with my daughter today where I say, you know what, I’m so proud of you not only for trying, but for letting the people around you who you care about, you let us know how much you wanted it, and it doesn’t get braver than that.

Ms. Tippett: Right. Right. Well, I mean, here’s this other sentence that’s a corollary to the sentence hope is a function of struggle. You say you look at a baby, your newborn baby is hard-wired for struggle. It’s built in us that that is how we are going to shape, that that’s what we’re going to encounter, that’s how we’re going to shape ourselves. That’s actually a really hard thing to take in, you know, as a parent, especially thinking about those moments early on when you first meet this being that is going to have dominance over your life.

Ms. Brown: Yeah, because I think we look and think I can make this right. I can do for her or him what wasn’t done for me. I can protect them from the things that hurt me. I think we are so much more hard-wired for who we are than what people, especially parents, want to believe. And I don’t think our job as parents is to make everything right and perfect and beautiful and true. I think our job is, during struggle, to look at our kids and say, yeah, this is hard and this is tough and you’re hurt.

Ms. Tippett: And you’re not alone, you’re not alone.

Ms. Brown: But you’re not alone.

Ms. Tippett: I’m not going to fix it, but you’re not alone.

Ms. Brown: Right, you’re not alone and I want to make sure you understand that this doesn’t change the fact that you’re worthy of love and belonging.

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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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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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Book Review: The Recovering Body

download (3)Jennifer Matesa’s The Recovering Body: Physical and Spiritual Fitness for Living Clean and Sober seeks to provide “a roadmap to creating our own unique approach to physical recovery” and frames “physical fitness as a living amends to self–a transformative gift analogous to the “spiritual fitness” practices worked on in recovery.”

She focuses on five areas, blending her own experiences, other recovering people, empirical research and practical to-do lists. The five areas are:

  • exercise and activity
  • sleep and rest
  • nutrition and fuel
  • sexuality and pleasure
  • meditation and awareness

I see two reasons this book is an important contribution to recovery literature.

First, it’s the first book I’ve seen (not that I’m well read in the area) that places such emphasis on physical wellness and self-care as an important element of recovery within traditional 12 step recovery paths. I’ve seen it addressed as an aside, and I’ve seen it offered as an alternative path, but not as an important element within traditional recovery paths.

As researchers and clinicians search for every tool to give addicts any possible edge as they initiate and maintain their recovery, we’d be wise to take notice. There is a growing body of evidence to support Matesa’s assertions that these are important elements of recovery rather than frivolous and indulgent accessories to treatment and recovery programs.

Second, I am convinced that the future of treatment and recovery programs (All chronic disease management programs, really.) should emphasize a lifestyle medicine as the foundation of care. After all, “recovery as a lifestyle” epitomizes one of the things addiction treatment has gotten really right historically and something the rest of chronic disease care could learn from us.

Despite this, professionally directed treatment that discusses the idea of the “recovery of the whole person” has mostly been lip service. Matesa brings this concept to life and presents holistic recovery as a lifestyle to be cultivated, practiced and maintained. On this front, she’s far ahead of professionals and researchers. The field is not there yet and too often equates recovery with swallowing pills or passively doing what professional helpers direct them to do. Matesa bypasses professionals and speaks directly to recovering people as a peer, calling them to action and offering experiential and empirical truth. That’s radical, in the best sense of the word.

Her writing is very accessible, is not preachy, and unpretentiously conveyed a lot of deep truths that I hadn’t considered but seemed self-evident as soon as I read them.

On a personal note, as someone who only started paying attention to physical fitness after 20 years of sobriety, the book takes a lot of previously disparate pieces of information that I vaguely knew to be true and organizes them into framework that not only deepened my understanding, but offered a concrete path to continue enhancing and securing my own recovery. I highly recommend it.

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