The Lancet and drug harms: missing the bigger picture – TBS

Values IcebergA Throw Back Sunday post from 2007 on values and evaluating drug harms.

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The Transform Drug Policy Foundation offers a response to the recent Lancet article that ranked drugs by harm. The writer suggest that the article is flawed in two important ways. First he argues that it fails to consider harms caused by the illegal status of the drug. Second, he says that the nature of the paper lends itself to criminalization of the drugs judged to be more harmful.

I’ll use this as an opportunity share an opinion I didn’t share in my original post–it’s impossible to separate values from these kinds of decisions. Values influence which harms are identified, how those harms are ranked, who’s opinion is sought, the intended use influences the design, etc.

UPDATE: I received the following comment from a reader:

“Values influence which harms are identified”. Yes that is a description of what happens at present but is shouldn’t be a prescription for what should happen. If we are to base drug classification on scientific evidence then the aim should be to get as close to objectivity as possible.

Let me clarify. In an ideal world I’d agree with the comment, we could objectively quantify harms and know that there is one set of facts for us to operate from. My judgment is that this is fantasy. For example, purportedly objective American harm reduction discussions tend to very heavily emphasize HIV/AIDS. Why? Because the early American harm reduction advocates were HIV/AIDS advocates.

Other tough questions:

  • Should growing up with an addicted parent be considered a harm? Beyond child protective service cases? If yes, how should this be quantified? If not, why?
  • How about the emotional pain experienced by other family members? If the answer is yes, how should these be weighted relative to the harms caused to children?
  • Should the malaise cast over communities be considered a harm? If one looks at certain communities, American Indian reservations for example, the despair due to alcohol (a legal drug) goes well beyond unemployment. Should the pall addiction can cast over an affected community be considered?
  • Should harms to non-users be weighted more heavily? Based on the belief that the user is exercising personal liberty and assumes risks in doing so?
  • When it comes to making harm reduction policy decisions, one harm reduction strategy can reduce harm to one population and increase risk of harm for another.

Don’t get me wrong, I’m glad this study was done and I look forward to more studies like it. I’m just convinced that values can’t honestly be eliminated from the equation. It might be helpful to integrate scientific evidence and a discussion the values like liberty, safety, etc.

Home at Last

Getting back to the Throw Back Sunday posts after a little break. This one was originally posted in February 2007.
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PBS’s series NOW had a segment on a housing first approach with a man named Footie who is chronically homeless and an alcoholic. He’s clearly a late stage alcoholic, frequently has seizures and may have some cognitive impairment due to years of heavy drinking and seizures. (Streaming video of the entire episode is available at the link above.)

The story made a pretty compelling case for this approach with this him, arguing that it was impossible to address his higher order needs when his physiological and safety needs were not being addressed. Footie was provided an apartment with no contingencies. The approach could make a lot of sense in many cases–the question is which cases and under what conditions?

I had several reactions to the segment. First, had Footie ever been provided with comprehensive treatment of and adequate dosage, duration? Why no contingencies? Maybe his housing shouldn’t be contingent upon abstinence, but how about participation in treatment? If the fear is that this might be a set-up, how about reviewing it at monthly or quarterly intervals so that a bad week does not put him back on the street? Why not at least make it recovery-focused? If this approach is good for Footie and raises his functioning and quality of life to his potential, who’s functioning and quality of life might be reduced to something below their potential? At Dawn Farm, we see some clients who would probably benefit greatly from a recovery-focused housing program that is not contingent upon abstinence. However, how many of clients who are currently in full recovery would have settled into an apartment like Footie’s and never achieved stable recovery and a full, satisfying life? Many, I think.

UPDATE: This isn’t to say it shouldn’t be done, but rather how to go about it in a way that doesn’t lower the bar for all homeless addicts and fail to address what caused their homelessness. Maybe one way to approach it is to ask, “Absent their addiction, would this person still be likely to be homeless?” In the case of Footie, the answer is “probably so”. In the case of most of our homeless clients, the answer is “unlikely”.

Of course, another big question is how to prioritize services in the context of scarce resources.

There is no blame; there is only love

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This week’s throwback Sunday is an essay from the mother of a young woman who is addicted to heroin.

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From NPR’s “This I Believe” series an essay from a mother of a young woman who has struggled with heroin addiction. After years of blaming herself and others, she now believes that there is no blame. Below is an excerpt, but follow the link and her the entire essay in her own voice.

You don’t expect your child to grow up to be a heroin addict. From the moment of her birth, you have hopes and dreams about the future, but they never include heroin addiction. That couldn’t happen to your child, because addiction is the result of a bad environment, bad parenting. There is most definitely someone or something to blame.

That’s what I used to believe. But after failed rehab and long periods of separation from my heroin-addicted daughter, after years of holding my breath, waiting for another relapse, I now believe there is no blame.

I don’t know why or how my daughter became addicted to heroin; I do know that it doesn’t really matter. Life goes on, and Katie is still my daughter.

Katie and I meet for breakfast on Friday mornings now. We drink coffee and talk. I don’t try to heal her. I just love her. Sometimes there is pain and sorrow, but there is no blame. I believe there is only love.

Readiness for change and drug use outcomes after treatment

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This week’s Throwback Sunday is a post about a study on the Transtheoretical Stages of Change (TSOC). It’s relevant due to the ongoing and recent media love for Motivational Interviewing (MI), which is fairly closely tied to the TSOC. (This is disputed, but the motivational interviewing website as 12 pages of search results for “stages of change”.)

Just to be clear, Dawn Farm likes MI. We train staff in MI. We believe it’s a useful tool. However, we also believe it’s often oversold as a treatment for addiction. It may be helpful as a stand-alone intervention for people with low-severity substance use problems. For addiction, it can be very helpful to engage people into other treatments more appropriate for high-severity problems.
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Another study finding that the client’s stage of change is a poor predictor of outcomes:

Results failed to support the hypothesis that taking steps should be associated with less frequent use of illicit opiates at follow-up. No statistically significant associations of any kind were found between readiness for change measures and use of opiates or stimulants at follow-up. A negative association was found between taking steps and benzodiazepine misuse. Readiness for change measures were correlated with heroin use and psychiatric symptom scores at treatment intake.

There has been high profile criticism that the rush to embrace the stages of change has outpaced the evidence. The question isn’t whether the stages of change have any utility. The question is what are they useful for? Patient/family eduction, counselor education, conceptualizing interventions, matching treatments, etc.

The stages of change have undoubtedly changed the field for the better, but there are a lot of weak points that have not been adequately explained–failure to recognize the instability of motivation; disagreements about how to determine the client’s stage of change; failure to account for stable, unplanned change; failure to explain for stable, initially coerced change. I’ve been especially concerned about practitioners relying on the stages of change for treatment placement and the inevitable post hoc deconstructions of treatment “failures” that blame the client’s motivation and then conclude that we wasted money treating them (and suggest that better assessment would have led to the conclusion that the client wasn’t motivated and a better referral).

Robert West, the editor of Addiction, has offered a new model for understanding change, he has called the PRIME theory.

Radical Recovery

This week’s Throwback Sunday is Bill White’s description of radical recovery.

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Be-The-Change-e1348837935700For MLK day, here’s an article by Bill White on “radical recovery.” He describes a convergence of social activism and addiction recovery.

The article offers a model that goes well beyond the the interests of recovering people themselves and encourages advocacy in larger community contexts:

A radical recovery movement is now rising in America. That movement is flowing from the realization that addiction and its progeny of problems are visible everywhere, while recovery from addiction lies hidden. It is rising in the recognition that the stigma attached to AOD problems has increased in recent decades and has fueled the demedicalization and recriminalization of these problems. What started out as “zero tolerance” for drugs rapidly evolved into zero tolerance for people with AOD problems. It is in this regressive climate that a style of recovery is emerging that is radical in its scope (focus on environmental as well as personal transformation), radical in its inclusiveness (celebration of multiple pathways and styles of recovery), and radical in its synthesis of social responsibility and personal accountability. People in recovery are looking beyond their own addiction and recovery experiences to the broader social conditions within which AOD problems arise and are sustained. A radicalized vanguard of people in recovery is using personal transformation as a fulcrum for social change. They are living Gandhi’s challenge to become the change they wish to see in the world. Those who were once part of the problem are becoming part of the solution.

Dopey, Boozy, Smoky—and Stupid

Kleiman's recent book on marijuana legalization. There's something in it to make everyone mad.
Kleiman’s recent book on marijuana legalization. There’s something in it to make everyone mad.

This week’s Throwback Sunday post focuses on a 2007 policy article by Mark Kleiman. In 2013, Kleiman was selected as the project leader to write Washington State’s marijuana regulations after the drug was decriminalized through a ballot initiative.

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The National Interest has a lengthy article on drug policy by Mark A.R. Kleiman. I disagree with several of his points but this is exactly the kind of thoughtful contribution that the American drug policy debate needs more of.

I tend to see his perspective as hyper-rational (Possibly to balance the moral panic of drug crusaders and fetishization of drug culture by many legalization advocates.) and somewhat removed from both the suffering of addiction and the radical transformation that full recovery offers. I think he risks reducing policy issues to an accounting exercise but he expresses strong, well-informed opinions without and ideological ax to grind (Although there clear Libertarian themes.) and does so without characterizing and dismissing people who think differently.

After outlining the sad state of American drug policy he says:

These are depressing facts that cry out for a radical reform to solve the drug problem once and for all. But the first step toward achieving less awful results is accepting that there is no one “solution” to the drug problem, for essentially three reasons. First, the potential for drug abuse is built into the human brain. Left to their own devices, and subject to the sway of fashion and the blandishments of advertising, many people will wind up ruining their lives and the lives of those around them by falling under the spell of one drug or another. Second, any laws—prohibitions, regulations or taxes—stringent enough to substantially reduce the number of addicts will be defied and evaded, and those who use drugs in defiance of the laws will generally wind up poorer, sicker and more likely to be criminally active than they would otherwise have been. Third, drug law enforcement must be intrusive if it is to be effective, and enterprises created for the expressed purpose of breaking the law naturally tend toward violence because they cannot rely on courts to settle disputes or police to protect them from robbery or extortion.

Any set of policies will therefore leave us with some level of substance abuse—with attendant costs to the abusers themselves, their families, their neighbors, their co-workers and the public—and some level of damage from illicit markets and law enforcement efforts. Thus the “drug problem” cannot be abolished either by “winning the war on drugs” or by “ending prohibition.” In practice the choice among policies is a choice of which set of problems we want to have.

But the absence of a silver bullet to slay the drug werewolf does not mean we are helpless. Though perfection is beyond reach, improvement is not. Policies that pursued sensible ends with cost-effective means could vastly shrink the extent of drug abuse, the damage of that abuse, and the fiscal and human costs of enforcement efforts. More prudent policies would leave us with much less drug abuse, much less crime, and many fewer people in prison than we have today.

The reforms needed to achieve these ambitious goals are radical rather than incremental. But they are not simple, or all of a piece, or in any one of the directions defined by current arguments around American dinner tables, on American editorial pages or in American legislative chambers. The conventional division of drug programs into enforcement, prevention and treatment conceals more than it reveals. So does the standard political line between punitive drug policy “hawks” and service-oriented drug policy “doves.” Neither side is consistently right; some potential improvements in drug policy are hawkish, some are dovish, and some are neither.

I disagree with the hawk vs. doves dichotomy. The service-oriented doves are really divided into at least two camps. An older, more deeply entrenched group but shrinking group of treatment professionals who might be dovish relative to hawks, but generally support some form of prohibition. Then there is a newer group of doves who aren’t all that service-oriented but are more radically dovish, advocating more radical decriminalization.

He offers five principles to guide policy decisions:

First, the overarching goal of policyshould be tominimize the damage done to drug users and to others from the risks of the drugs themselves (toxicity, intoxicated behavior and addiction) and from control measures and efforts to evade them.That implies a second principle: No harm, no foul. Mere use of an abusable drug does not constitute a problem demanding public intervention. “Drug users” are not the enemy, and a achieving a “drug-free society” is not only impossible but unnecessary to achieve the purposes for which the drug laws were enacted.

Third, one size does not fit all: Drugs, users, markets and dealers all differ, and policies need to be as differentiated as the situations they address.

Fourth, all drug control policies, including enforcement, should be subjected to cost-benefit tests: We should act only when we can do more good than harm, not merely to express our righteousness. Since lawbreakers and their families are human beings, their suffering counts, too: Arrests and prison terms are costs, not benefits, of policy. Policymakers should learn from their mistakes and abandon unsuccessful efforts, which means that organizational learning must be built into organizational design. In drug policy as in most other policy arenas, feedback is the breakfast of champions.

Fifth, in discussing programmatic innovations we should focus on programs that can be scaled up sufficiently to put a substantial dent in major problems. With drug abusers numbered in the millions, programs that affect only thousands are barely worth thinking about unless they show growth potential.

Finally, he offers an agenda for policy change. I doubt I could ever comfortably endorse some of these. Others, I find myself resisting, but in the context of radical change (rather than incremental), they may be more acceptable.

  • Don’t fill prisons with ordinary dealers.
  • Lock up dealers based on nastiness, not on volume.
  • Pressure drug-using offenders to stop.
  • Break up flagrant drug markets using low-arrest crackdowns.
  • Deny alcohol to problem drinkers.
  • Raise the tax on alcohol, especially beer.
  • Eliminate the minimum drinking age.
  • Prevent drug dealing among kids.
  • Say more than “No.”
  • Don’t rely on DARE.
  • Encourage less risky forms of nicotine use.
  • Let pot-smokers grow their own.
  • Encourage problem drug users to quit without formal treatment.
  • Expand opiate maintenance.
  • Work on immunotherapies.
  • Get drug enforcement out of the way of pain relief.
  • Create a regulatory framework for performance-enhancing chemicals.
  • Figure out what hallucinogens are good for, and don’t let the drug laws interfere with religious freedom.
  • Stop sacrificing foreign policy and human rights objectives to drug control.

Throwback Sunday – Pessimistic Paternalism

blank signI’m doubling up this week with two posts on harm reduction from December 2006.

I’ve written often about the subtle bigotry of low expectations, these two posts illustrate that concern. (I like my reference to “pessimistic paternalism disguised as compassionate pragmatism.”)

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Debate on abstinence

A horrifying excerpt from a debate in a British treatment provider magazine. (It’s at the bottom of both pages.) I don’t completely understand the context–whether they are debating a “motion” in a binding way for the specialty society that publishes the magazine or if it’s a devise for a magazine column.

One of the participants proposed that detox is dangerous due to the possibility of reduced tolerance and unintentional overdose in the event of a relapse. Harm reduction advocates used to argue that they represented a needed choice philosophy in working with addicts. The is the worst kind of pessimistic paternalism disguised as compassionate pragmatism–and there’s nothing representing real choice.

…Detox can be dangerous and is not very often successful. Death rates are higher in recently detoxed patients.

Many people request detox but we need to recognise that maintenance is a very worthwhile option. Maintenance patients need our support – including psychological support – and harm reduction has to be our goal.

The NTA says rehab providers have to provide mechanisms for rapid referral into maintenance programmes. Getting people off drugs is dangerous.

Bill Nelles,founder of The Alliance,said: ‘Let’s take the morality out of drug treatment and put the humanity back in’. Judy Bury [GP] said it is our job as GPs to keep people alive until they are ready to change.

There’s not much evidence for long-term effectiveness of detox,but it can reduce tolerance. People cannot do abstinence when they walk in the service. The move toward abstinence-based treatment is dangerous and will increase drug-related deaths.

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“Recovery Impatience”

Lowering_The_Bar_Cover_2010.09.22Let’s hope that the concept of “recovery impatience” does not catch on. Keep in mind that this is in the context of a country with a big emphasis on methadone and 60% of the methadone recipients have expressed a preference for abstinence based treatment.

“We are now seeing the emergence of a culture of “recovery impatience”: the demand for people to move quickly to a drug-free lifestyle while denying the significance of other factors – such as low income and life in neglected communities – which make rapid achievement to a drug-free life impossible for the majority,” she said.

“The combination of totally unrealistic expectations, along with the demonisation of drug users, is having a trickle-down effect on practice, with “firmer” responses becoming more acceptable.

“We are in danger of harking back to the days when those seeking treatment were labelled as feckless and chaotic, deemed as having given up their right to be involved in their own treatment or to be treated with the dignity, respect and quality of care afforded other vulnerable groups in society.”

Recovering Alcoholics With Poor Sleep Perceptions Will Likely Relapse

This post from 2006 shares findings that distress over sleep problems is a better predictor of relapse than sleep problems themselves.

That post title is awful and misleading. Sorry. Looks like I took it straight from the press release.

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A study from local researchers. The headline overstates the findings from this 18 subject study. They found that subjective impressions of sleep were better predictors of relapse that objective measures of sleep. Does this suggest that CBT could be an important strategy for treatment complaints of insomnia?

“Our study suggests that in early recovery from alcoholism, people perceived that it took them a long time to fall asleep and that they slept through the night,” said Conroy. “The reality was that it did not take them as long to fall asleep as they thought it did, and their brain was awake for a large portion of the night. On average, the participants that were less accurate about how they were sleeping were more likely to return to drinking.”

“In other words,” added Timothy A. Roehrs, director of research at the Sleep Disorders and Research Center at Henry Ford Hospital, as well as professor of psychiatry and neurobehavioral sciences at Wayne State University School of Medicine in Detroit, “alcoholics perceive their sleep is disturbed and that is the reality. The clinician should pay attention to the alcoholic’s sleep complaints as the complaint of poor sleep predicts relapse. Previous studies had shown that PSG findings predict relapse; this study now shows a complaint is sufficient.”

Drugs: why we should medicalise, not criminalise – TBS

Here’s a Throwback Sunday post from 2006 on a call for more drug maintenance and my take on some problematic underlying assumptions.

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Lowering_The_Bar_Cover_2010.09.22This sounds so rational. When you read the whole column (originlly published in the Sunday Times), it’s also wrapped in the language of social justice. However, her arguments are so flawed that it’s difficult to know where to begin.

Of course we should try to get drug addicts off their drugs. It is good that waiting times are now shorter for rehabilitation. But treatment doesn’t work unless users really, really want to give up. And even then, they often relapse because the cravings are so strong. So it is not surprising that enforced treatment and rehabilitation is so unsuccessful. A National Audit Office report on the Government’s Drug Treatment and Testing Order, a court-administered mandatory programme for addicts, found that 80 per cent of offenders were reconvicted within two years.

It is much more sensible to prescribe a maintenance dose for addicts, which they must take under supervision so they cannot sell it on, until they are ready to try to give up. That way, they can attempt to lead a normal life, to refrain from crime, to stay off the streets, even to hold down a job, until they can wean themselves off the drugs.

Among the flawed assumptions are that:

  • addicts don’t want help;
  • treatment is only helpful if they’re in the “action” or “preparation” stage of change;
  • the failure of their lousy treatment system means treatment doesn’t work;
  • legalization would be a panacea for consuming countries and producing countries;
  • crime should be the measuring stick for the effectiveness of drug policy;
  • abstinence focused treatment is ineffective;
  • doing more would be too expensive;
  • we have to choose between legalization and maintenance

I’m struggling to find the words, but I also find it troubling that among some HR advocates there is something resembling a fetishizing of heroin addiction or vicarious derivation of street credibility. While speaking to some harms, they fail to grasp the pain and demoralization that addicts experience when they call it an illness but treat it like a lifestyle choice. Why such half-measures when addiction is concerned? Why is the case for treatment on demand framed as a symptom of some kind of moral panic? I suppose I am guilty of moral alarm at the “suble bigotry of low expectations.” (Now, now, principles before personalities.)

Choice and Free Will: Beyond the Disease Model of Addiction – TBS

This Throw Back Sunday (we’ll settle on that name for these posts) post was originally posted in 2006. I appreciate the author’s attempt to shift the conversation away from false dichotomies.

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determinist by alyceobvious
determinist by alyceobvious

Interesting commentary on choice and stigma:

…of course what’s meant by personal weakness and bad choices, when stigmatizing addicts, is that the addict should have risen above his weakness; he could have chosen otherwise at the time addiction took hold. There’s an implicit assumption of contra-causal agency: no matter what influences and factors came to bear, the addict could have done otherwise, but simply chose not to.

The key point, though, on an enlightened understanding of the moral dimension of addiction, is that it is specific behavior that’s the potential target of sanctions, not the mythical moral core. Once bad choices are seen as outcomes of causes and conditions, not free will, then we won’t imagine that there’s any virtue in the blanket condemnation of the addict as a bad person, even though we must still judge some behavior as wrong.