Too expensive? (2016)

October 17, 2016October 15, 2016 ~ Jason Schwartz

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:

That health professionals have more recovery capital and are more likely to recover than other addicts.
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.
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.

Too expensive? (2015)

November 22, 2015November 23, 2015 ~ Jason Schwartz ~ 5 Comments

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:

That health professionals have more recovery capital and are more likely to recover than other addicts.
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.
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.”

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.

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

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.

…let us work together

June 14, 2015June 14, 2015 ~ Jason Schwartz ~ 2 Comments

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:

personal experiences of recovery and/or relationships with people in sustained recovery,

addiction-specific professional education,

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

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

What makes treatment effective? (addictionandrecoverynews.wordpress.com)
Recovery should not become an ideology (addictionandrecoverynews.wordpress.com)
Addiction Treatment With a Dark Side (addictionandrecoverynews.wordpress.com)

hope is a function of struggle

May 24, 2015May 17, 2015 ~ Jason Schwartz

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… (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.

2014’s top posts: #2

January 1, 2015 ~ Jason Schwartz ~ 6 Comments

“He’d still be alive”

Much 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 rates. This 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 kind—an 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?

Book Review: The Recovering Body

October 12, 2014 ~ Jason Schwartz

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.

The Emperor of All Maladies

August 10, 2014August 8, 2014 ~ Jason Schwartz

Throwback Sunday – I thought this old post on parallels between cancer, oncology, addiction, addiction treatment and recovery would be a good pairing with yesterday’s post on professional attitudes toward difficult to treat illnesses.

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I’ve been reading The Emperor of All Maladies and I’ve been very struck by the parallels between the is philosophical and practical challenges faced by cancer and addiction researchers, advocates and practitioners.

One of the pioneers of cancer research, treatment and advocacy faced difficult decisions about whether to disclose his own illness:

Proud, guarded, and secretive—reluctant to conflate his battle against cancer with the battle—Farber also pointedly refused to discuss his personal case publicly.

The rhythms of hope and despair

the clinic seemed perpetually suspended between two poles—both “wonderful and tragic . . . unspeakably depressing and indescribably hopeful.” On entering the cancer ward, Goldstein would write later, “I sense an undercurrent of excitement, a feeling (persistent despite repeated frustrations) of being on the verge of discovery, which makes me almost hopeful.

“The mood among pediatric oncologists changed virtually overnight from one of ‘compassionate fatalism’ to one of ‘aggressive optimism.’”

“ALL in children cannot be considered an incurable disease,” Pinkel wrote in a review article. “Palliation is no longer an acceptable approach to its initial treatment.”

The zeal and necessity of the advocates:

She had found her mission. “I am opposed to heart attacks and cancer,” she would later tell a reporter, “the way one is opposed to sin.” Mary Lasker chose to eradicate diseases as some might eradicate sin—through evangelism. If people did not believe in the importance of a national strategy against diseases, she would convert them, using every means at her disposal.

The tension between the patient’s welfare and the professional and intellectual needs of the doctors and researchers:

“There is an old Arabian proverb,” a group of surgeons wrote at the end of a particularly chilling discussion of stomach cancer in 1933, “that he is no physician who has not slain many patients, and the surgeon who operates for carcinoma of the stomach must remember that often.” To arrive at that sort of logic—the Hippocratic oath turned upside down—demands either a terminal desperation or a terminal optimism. In the 1930s, the pendulum of cancer surgery swung desperately between those two points.

Political feminism, in short, was birthing medical feminism—and the fact that one of the most common and most disfiguring operations performed on women’s bodies had never been formally tested in a trial stood out as even more starkly disturbing to a new generation of women. … It was as if the young woman in Halsted’s famous etching—the patient that he had been so “loathe to disfigure”—had woken up from her gurney and begun to ask why, despite his “loathing,” the cancer surgeon was so keen to disfigure her.

“We shall so poison the atmosphere of the first act,” the biologist James Watson warned about the future of cancer in 1977, “that no one of decency shall want to see the play through to the end.”

The demands of caring for patients with such an all-consuming illness:

As Carla’s doctor, I needed to be needed as well, to be acknowledged, even as a peripheral participant in her battle. But Carla had barely any emotional energy for her own recuperation—and certainly none to spare for the needs of others. For her, the struggle with leukemia had become so deeply personalized, so interiorized, that the rest of us were ghostly onlookers in the periphery: we were the zombies walking outside her head.

“To some extent,” he wrote about his patients, “no doubt, they transfer the burden [of their disease] to me.”

The tension between physicians offering palliative care and patients wanting more:

The daughter looked at me as if I were mad. “I came here to get treatment, not consolations about hospice,” she finally said, glowering with fury.

The fear and existential implications of cancer:

Will you turn me out if I can’t get better? —A cancer patient to her physician, 1960s

“I don’t know why I deserved the illness in the first place, but then I don’t know why I deserved to be cured. Leukemia is like that. It mystifies you. It changes your life.”

The pull of palliative care:

As trial after trial of chemotherapy and surgery failed to chisel down the mortality rate for advanced cancers, a generation of surgeons and chemotherapists, unable to cure patients, began to learn (or relearn) the art of caring for patients. It was a fitful and uncomfortable lesson. Palliative care, the branch of medicine that focuses on symptom relief and comfort, had been perceived as the antimatter of cancer therapy, the negative to its positive, an admission of failure to its rhetoric of success.

The movement to restore sanity and sanctity to the end-of-life care of cancer patients emerged, predictably, not from cure-obsessed America but from Europe.

she encountered terminally ill patients denied dignity, pain relief, and often even basic medical care—their lives confined, sometimes literally, to rooms without windows. These “hopeless” cases, Saunders found, had become the pariahs of oncology, unable to find any place in its rhetoric of battle and victory, and thus pushed, like useless, wounded soldiers, out of sight and mind.

Saunders responded to this by inventing, or rather resurrecting, a counterdiscipline—palliative medicine. (She avoided the phrase palliative care because care, she wrote, “is a soft word” that would never win respectability in the medical world.) … she created a hospice in London to care specifically for the terminally ill and dying, evocatively naming it St. Christopher’s—not after the patron saint of death, but after the patron saint of travelers.

“The resistance to providing palliative care to patients,” a ward nurse recalls, “was so deep that doctors would not even look us in the eye when we recommended that they stop their efforts to save lives and start saving dignity instead . . . doctors were allergic to the smell of death. Death meant failure, defeat—their death, the death of medicine, the death of oncology.” Providing end-of-life care required a colossal act of reimagination and reinvention.

Saunders refused to recognize this enterprise as pitted “against” cancer. “The provision of . . . terminal care,” she wrote, “should not be thought of as a separate and essentially negative part of the attack on cancer. This is not merely the phase of defeat, hard to contemplate and unrewarding to carry out. In many ways its principles are fundamentally the same as those which underlie all other stages of care and treatment, although its rewards are different.”

A hint of recovery-oriented palliative care?: [emphasis mine]

Opiates, used liberally and compassionately on cancer patients, did not cause addiction, deterioration, and suicide; instead, they relieved the punishing cycle of anxiety, pain, and despair.

Urban myths exposed

April 23, 2014 ~ Jason Schwartz ~ 1 Comment

Points 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.

Anti-treatment zombie stats

March 22, 2014March 22, 2014 ~ Jason Schwartz ~ 8 Comments

zombie

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 Time.com last fall, and then restated in another Time.com 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.

Category: Research

Too expensive? (2016)

1. “Health professionals have more recovery capital and are more likely to recover than other addicts.”

2. “Heath professionals are uniquely motivated because of the threat of license suspension/revocation.”

3. “Treating everyone in this manner would be too expensive.”

Too expensive? (2015)

1. “Health professionals have more recovery capital and are more likely to recover than other addicts.”

2. “Heath professionals are uniquely motivated because of the threat of license suspension/revocation.”

3. “Treating everyone in this manner would be too expensive.”

…let us work together

2014’s top posts: #2