The opioid crisis as a disease of despair?

[Note: This is a repost from 1/19/18. This narrative has continued to gather steam over the past year. It’s not that this narrative contains no truth, it’s that it’s incomplete and misleading.]

The narrative that the opioid and overdose crisis is a product of despair has become very popular. The logic is that people in bad economic conditions are more likely to turn to opioids to cope with their circumstances, and that their hopeless environmental conditions make them more likely to die of an overdose. This model frames addiction and overdose as diseases of despair.

This model fits nicely with other writers who have garnered a lot of attention on the internet.

  • Johann Hari presents addiction as a product of a lack of connection to others.
  • Carl Hart frames sociological factors as causative and argues that there’s a rationality to escaping terrible circumstances via drug use and that a form of learned helplessness eventually takes root.
  • Bruce Alexander is frequently cited to support these theories. He did the “rat park” study that found rats deprived of stimulation and social interaction compulsively used drugs, while rats in enriched environments did not.

These understandings are so intuitive, but what if they are wrong?

These narratives make so much sense, and they support other beliefs and agendas many of us hold. Further, it feels like no one is going to harmed by efforts to improve economic, social, and environmental conditions, right?

Well, that’s not quite true. Bill White pointed out that how we define the problem determines who “owns” the problem, and that problem ownership has profound implications for addicts and their loved ones.

Whether we define alcoholism as a sin, a crime, a disease, a social problem, or a product of economic deprivation determines whether this society assigns that problem to the care of the priest, police officer, doctor, addiction counselor, social worker, urban planner, or community activist. The model chosen will determine the fate of untold numbers of alcoholics and addicts and untold numbers of social institutions and professional careers.

The existence of a “treatment industry” and its “ownership” of the problem of addiction should not be taken for granted. Sweeping shifts in values and changes in the alignment of major social institutions might pass ownership of this problem to another group.

With so many bad actors in treatment right now, there is not a great rush to protect the treatment industry.

To be sure, we’d be better off of a significant portion of the industry disappeared. However, the disappearance of specialty addiction treatment would be tragic for addicts and alcoholics in need of help.

Further, it just so happens that there’s good reason to doubt the “diseases of despair” narrative.

New study casts doubt on “diseases of despair” narrative

A new study looked at county level data and examined the relationship between several economic hardship indicators and deaths by overdose, alcohol-related causes, and suicide.

Mother Jones describes the findings this way:

Economic conditions explained only 8 percent of the change in overdose deaths from all drugs and 7 percent of the change in deaths from opioid painkillers—and even that small effect probably goes away if you control for additional unobservable factors. It explained none of the change in deaths from heroin, fentanyl, and other illegal opioids.

They quote the researcher as observing:

Such results probably should not be surprising since drug fatalities increased substantially – including a rapid acceleration of illicit opioid deaths – after the end of the Great Recession (i.e. subsequent to 2009), when economic performance considerably improved.

If it’s not economic hardship, what is it?

Vox describes the study’s conclusions this way [emphasis mine]:

. . . the bigger driver of overdose deaths was “the broader drug environment” — meaning the expanded supply of opioid painkillers, heroin, and illicit fentanyl over the past decade and a half, which has made these drugs much more available and, therefore, easier to misuse and overdose on.

Leonid Bershidsky from Bloomberg noted the following:

The absence of an opioid epidemic in Europe indirectly confirms Ruhm’s finding. European nations have experienced the same globalization-related transition as the U.S. In some of them — Greece, Portugal, Ireland, Spain, even France — economic problems were more severe in recent years than in the U.S. Yet no explosion of overdose deaths has occurred.

. . .

There’s also a notable difference in what substances are causing overdose deaths. In the U.S., heroin accounted for 24 percent of last year’s overdose deaths. In Europe in 2018, its share of the death toll was 81 percent. That should say something about how supply affects the outcomes.

Piling on

Then, as if to drive the point home, BMJ posted a study examining the relationship between opioid exposure and misuse. They looked at post-surgical pain treatment,

Each refill and week of opioid prescription is associated with a large increase in opioid misuse among opioid naive patients. The data from this study suggest that duration of the prescription rather than dosage is more strongly associated with ultimate misuse in the early postsurgical period. The analysis quantifies the association of prescribing choices on opioid misuse and identifies levers for possible impact.

The study “excluded patients with presurgical evidence of opioid or other non-specific forms of misuse in the six months before surgery.” (I would have liked more stringent exclusionary criteria, but it’s still instructive.)

Where does this leave us?

I’ll repeat (a modified version of) what I wrote in a post in response to Johann Hari’s TED talk that emphasized lack of purpose and connection as the cause of addiction and add economic factors to the mix.

  • Do economic/social/environmental factors cause addiction? No.
  • Are they important? Yes.
  • Could they influence the onset and course of addiction? Yes.
  • Is addressing those factors important in facilitating recovery for many addicts? Yes.
  • Do economic/social/environmental factors cause addiction? No.

Ok, but what about policy?

This leaves us with some uncomfortable (but obvious, to anyone paying attention to this crisis) findings to consider.

Much of the policy discussion over the last several years has been dismissive of supply as a factor in addiction. This poses very serious concerns about that stance.

I’ve never been dismissive of supply as an important consideration, but I am coming to believe that I’ve underestimated its importance.

A lot of that dismissiveness is in response to the drug war and the moral horror of mass incarceration.

The problem demands more of us than we are typically capable of. We need to figure out how to address illicit and licit supply without resorting to mass incarceration AND assure treatment of adequate quality, duration, and intensity.

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More on “alternative endpoints”

I’ve posted before on “alternative endpoints” for treating opioid use disorders, which is the idea that research on treatments should not just focus on abstinence as an outcome.

There is now a push for alternative endpoints for alcohol use disorders:

Reductions in alcohol use bring about significant improvement in adverse consequences, mental health status, and quality of life, even if the reductions do not reach the level of abstinence, according to recent research presented at the annual meeting of the American Academy of Addiction Psychiatry.

The findings, experts say, demonstrate how a fixation on abstinence or elimination of all heavy drinking – the endpoints the Food and Drug Administration now require in pivotal clinical trials on alcohol use disorder (AUD) treatments – is shortsighted and can unnecessarily discourage people with alcohol use disorder from pursuing treatment.

A fixation on abstinence?

“A fixation on abstinence” sounds like a pretty loaded phrase and I have thoughts. But first, Stuart Gitlow, a past president of ASAM, wrote a response:

I am confused as to whether the entire discussion within the article revolves around alcohol use or whether instead it revolves around alcohol use disorder. And I worry that those advocating for a new endpoint may also have some confusion. I especially am concerned that the referenced article is based on COMBINE data, which itself was quite flawed due to the requirement of a certain volume of alcohol intake for inclusion, thereby studying only a subset of those with alcohol use disorder rather than a representative disease population.

Alcohol use disorder does not have a severity level based upon volume or frequency of alcohol intake. Because of that, the severity of alcohol use disorder does not improve if volume or frequency of intake declines. On the other hand, morbidity secondary to alcohol use disorder may indeed be related to volume and frequency of alcohol intake. And therefore, if volume/frequency declines, morbidity would likely improve, at least for a short period of time.

Similarly, patients with tuberculosis have a cough. The frequency and intensity of coughing is not utilized to determine the severity of TB. However, the coughing can be impairing and can be considered an aspect of morbidity from TB. So here’s the question: If we give something (methadone, perhaps) to improve the cough in TB, resulting in improved morbidity, are we treating the TB? Are we altering the long term TB disease course?

The answer to both is no, of course we’re not.

My thoughts

  • This is a predictable outcome of the DSM 5’s shift from a categorical model of alcohol problems to a continuum model.
    • All alcohol problems were put on a single continuum. This put low severity problems under the same diagnosis as high severity, high chronicity alcohol problems.
    • Abstinence has long been considered the most appropriate treatment goal for high severity, high chronicity problems (addiction), while moderation has been considered an appropriate goal for lower severity problems. (See here, here, and here for examples.)
    • This is exacerbating the pre-existing problems that the research too often fails to distinguish between addiction and lower severity substance use problems.
  • There are important ways in which this is a nonevent, at least for how medications are used.
    • The evidence-base for the current medications focuses on reductions in drinking, not abstinence.
    • The current medications are not very effective at facilitating abstinence, making the current standard seem more theoretical than practical.
  • Do people with low severity alcohol problems (for whom reduced use is a good target) need medications to help them moderate?
  • Who will benefit from this?
    • The best case is that patients will benefit. However, it’s hard to imagine that lowering the bar will improve patients’ options when the current meds only meet that lower standard.
    • It seems very likely that drug manufacturers will benefit from lowering the bar for FDA approval.

Finally, if someone can achieve sustainable quality of life improvements, that they find satisfactory, through reduced use that is achieved with or without medication, that is an unqualified success.

The question is not whether or not that’s a good thing. The question is about which endpoints deliver the best quality of life for which kinds of problems. (And, who decides, for what reasons, and who benefits.)

 

 

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“Everyone should get that kind of care”

Image result for gold standard care

Marie Claire has a well done article about a doctor with addiction and highlights the gold standard care that addicted physicians receive.

The PHP model has shown remarkable results. The first national study of state PHPs, which was published in the Journal of Substance Abuse in 2009, found that of 904 physicians enrolled in 16 state PHP programs, 78 percent had no positive test for either drugs or alcohol during the five years of intensive monitoring, and 72 percent continued to practice medicine. “Almost all my people get better,” says Dr. Paul Earley, medical director of Georgia’s PHP and president-elect of the American Society of Addiction Medicine. “PHPs have a success rate which is unparalleled, and the reason physicians do so well is they get a ton of treatment. Everyone should get that kind of care.” Smaller studies have shown similar results. “Addicted physicians treated within the PHP framework have the highest long-term recovery rates recorded in the treatment outcome literature: between 70 percent and 96 percent,” the authors of the 2009 national study wrote.

Such outcomes raise a question: Why do addicts have to have a medical or pilot’s license to receive such high-quality care? . . .

. . .

The reason doctors get such high-quality care is that the medical profession treats addiction not as a character defect but like the serious condition it is. “Addiction is a chronic brain disease that cannot be treated with short-term measures,” Earley says. “PHPs look at addiction as a chronic disease—more like diabetes than appendicitis. And like diabetes, you have to educate patients on how to care for themselves.” Such care can be expensive: Georgia’s PHP costs $430 per month for five years, for a total of $25,800, plus an additional $120 per month for drug tests, all of which the physicians pay out of pocket—but it’s cheaper than dealing with the health conditions or imprisonment that can come with sustained relapse.

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“shaming,” “stigmatizing,” and call-outs

Something is amiss in recovery advocacy.

Earlier this week, the Surgeon General’s office tweeted the following paraphrase of a speech given by the Surgeon General. (Later clarified to be incorrectly transcribed.)

Addiction is not a moral failing and that it affects “good” families. Nice message, right? We need more influencers to say the same kind of thing, right? Not so fast.

Recovery advocates corrected him for using the word “addict” (some corrections were pretty generous, others were more scolding) and he responded with the following:

People with addiction have called themselves addicts for decades and I’m not aware of any in-group vs out-group differences in use.

John Kelly (2010) was the first person I recall focusing on the associations people have with various words related to people with addiction. That work has been extended by White, Wakeman, Ashford, and Brown.

This work started with words that have innate negative valences, like “abuse” and “dirty.” It’s since extended into all sorts of other words, like addict, relapse, and involves calls for “person-first language” (which emerged in the late 1980s for other populations).

My memory of the emergence of all of this attention to language was at the level of advocacy with storytelling. As a strategic matter, recovery advocates were encouraged to tell their stories with certain language that was found to be less likely to arouse bias and stigma.

On the one hand, this made pragmatic sense to me for advocacy efforts. On the other hand, this also felt backwards. Abandoning objectively neutral words because some people (usually people who hold a negative bias toward people with addiction) have attached negative associations to them seems like a recipe for tail-chasing. What happens when the new words acquire a negative association? Do we just keep changing terms as people with biases learn them and extend their bias to the new terms? (Also, who does this put in control of our language?)

We’ve already seen this happen. Opioid Replacement Therapy and Opioid Substitution Therapy were replaced by Medication Assisted Treatment, which is now on the bad list. This creates significant descriptive problems for the sake of stigma reduction–an early recovery advocacy goal was to distinguish treatment from recovery. The new preferred term, Medication Assisted Recovery, conflates treatment and recovery, undercutting a key message of methadone patient advocacy efforts.

From Walter Ginter, medication-assisted recovery advocate:

The problem with the methadone community is we have too many people who think methadone is a magic bullet for that disease—that recovery involves nothing more than taking methadone.

This view is reinforced by people who, with the best of intentions, proclaim, “Methadone is recovery.” Methadone is not recovery. Recovery is recovery. Methadone is a pathway, a road, a tool. Recovery is a life and a particular way of living your life. Saying that methadone is recovery let’s people think that, “Hey, you go up to the counter there, and you drink a cup of medication, and that’s it. You’re in recovery.” And of course, that’s nonsense. Too many people in the methadone field learn that opiate dependence is a brain disorder, and they think that that’s all there is to it. But just like any other chronic medical condition, it has a behavioral component that involves how you live your life and the daily decisions you make.

White, W. (2009). Advocacy for medication-assisted recovery: An interview with Walter Ginter.

So . . . I get the pragmatic and strategic reasons to encourage advocates to adopt certain language but question the wisdom of it. However, this has evolved from a strategy to be used by recovery advocates to a requirement of anyone making public statements on the topic, with call-outs for shaming and being an agent of stigma.

I also don’t understand whose wishes this represents. How many people with addiction object to or feel harmed by the term addict? Hasn’t our message been that we’re resilient and resourceful people who only want the same opportunities as everyone else–the elimination of discriminatory barriers to treatment, employment, school, etc?

I’ve also previously expressed anxiety before about treatment and recovery being drawn into culture war battles. (And, culture wars have only heated up over the last several years.) Of course, this isn’t a culture war hotzone, but the enforcement and call-outs give it a similar feel–that there are sides, and one side is righteous and fighting for justice, while the other side are agents of stigma, injustice, and discrimination.

  • At what point do some of these efforts to reduce stigma alienate potential allies? IDK.
  • How well do recovery advocates represent to the beliefs, preferences, and priorities of people with addiction? IDK. However, it’s difficult for me to believe that these reactions to this tweet are representative of the views of significant numbers of people with addiction outside of advocacy circles.

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“the sale of opioids and the treatment of opioid addiction are ‘naturally linked'”

Of interest to me is their interest in entering the addiction treatment market.

ProPublica has a new report that review’s documents from a lawsuit filed against Purdue Pharma. The suit alleges that Purdue misled doctors and the public in ways that created the opioid crisis and blamed patients when they, predictably, developed opioid use disorders.

First, on how addiction treatment medications would fit into their business model:

In internal correspondence beginning in 2014, Purdue Pharma executives discussed how the sale of opioids and the treatment of opioid addiction are “naturally linked” and that the company should expand across “the pain and addiction spectrum,”

Second, on Purdue’s assessment of the market:

In September 2014, Purdue embarked on a secret project to join an industry that was booming thanks in part to OxyContin abuse: addiction treatment medication. Code-named Project Tango, it involved Purdue executives and staff as well as Dr. Kathe Sackler, a daughter of the company co-founder Mortimer Sackler and a defendant in the Massachusetts lawsuit. . . .

Internally, Purdue touted the growth of an industry that its aggressive marketing had done so much to foster.

“It is an attractive market,” the team working on the project wrote in a presentation. “Large unmet need for vulnerable, underserved and stigmatized patient population suffering from substance abuse, dependence and addiction.”

While OxyContin sales were declining, the internal team at Purdue touted the fact that the addiction treatment marketplace was expanding.

“Opioid addiction (other than heroin) has grown by ~20%” annually from 2000 to 2010, the company noted.

Questions

  • Is Purdue an outlier in the industry?
  • Or, does it represent business approaches that are common within the industry?
  • What lessons should we draw from Purdue’s use of doctors and research to support their claims?
  • What does this teach us about the relationship between pharma and government?
  • What false beliefs may be widely accepted in medicine and the media that represent a similar risk or poor care?

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Survival, stabilization, AND flourishing

A great tweet from Brandon Bergman:

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Free markets and opioids

This makes zero sense in an opioid crisis.

Who wants this? Are doctors and patients saying that the array opioid medications is incomplete?

What’s driving this? Public health? Ideology? Market forces?

Why are only 4 legislators speaking up?

You fill in the blanks.

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