Addiction treatment, palliative care, or both?

So . . . Monday I posted about a study of a low barrier buprenorphine program.

Toward the end of that post, I raised the tension between treatment-as-harm-reduction and treatment-as-recovery-facilitation and shared a quote from an emergency physician questioning the evidence-base for buprenorphine dispensed in emergency departments, as well as its effectiveness at facilitating “sobriety.”

I added the following:

I imagine that most people who are enthusiastic about these projects would respond that they are not looking for “sobriety.”

This is where clarity about goals for an intervention becomes especially important. If we can agree that addiction is a treatable chronic illness, it seems important to more clearly categorize interventions as treatments for the illness of addiction or as palliative care.

If we sell an intervention as treatment at the public level but treat it as palliative care at the academic level, the public, people with addiction, and people who care about them are likely to feel deceived. It also has the effect of eliding difficult conversations about resource allocation and capacity development. For example, is this $6,000,000 allocated to palliative care or addiction treatment? Because it’s not both.

I pretty quickly regretted binary framing in that last sentence but failed to add an update to the post. I just wasn’t confident that it was accurate. Sure enough, it ended up getting questioned, which is fair. (However, some reactions framed these comments as anti-palliative and anti-buprenorphine, which is incorrect.)

What is palliative care?

The US National Library of Medicine defines palliative care as:

The goal of palliative care is to help people with serious illnesses feel better. It prevents or treats symptoms and side effects of disease and treatment. Palliative care also treats emotional, social, practical, and spiritual problems that illnesses can bring up. When the person feels better in these areas, they have an improved quality of life.

Palliative care can be given at the same time as treatments meant to cure or treat the disease. Palliative care may be given when the illness is diagnosed, throughout treatment, during follow-up, and at the end of life.

For this conversation, the key elements are:

  • that it prevents or treats symptoms, and
  • it can be given at the same time as curative treatments

Note that they mention that it can be given at the same time as curative treatments. This establishes a distinction between curative and palliative treatments.

Palliative vs. Addiction Treatment. Is it Binary?

I wrote that without any deep consideration or conviction about this binary framing, but I gave the impression that the two approaches look something like the Venn diagram below.

no overlap

Some of push back I got might give the impression that there is a high degree of overlap between the two approaches. They might view the relationship as more like the image below.

stong overlap

I suspect the truth might be more like the one below.

partial overlap

Is [enter intervention here] addiction treatment, palliative care, or both?

I am not an expert on palliative care, but I suppose the answer to this depends on the intentions and expectations of the service provider.

If the service provider’s goal and expectation are that the intervention will lead to addiction remission/recovery, then it is addiction treatment.

If the service provider’s goal and expectation are that the intervention will reduce symptoms/suffering related to addiction (but not lead to remission/recovery), then it is palliative care.

As I’ve spent a little time reading more about palliative care, I’m seeing information about concurrent palliative and curative treatment, but nothing about a single treatment being both curative and palliative.

So . . . how could I imagine an intervention being both? I could imagine, based on patient choice, delivering a treatment in a dose or intensity that is expected reduce symptoms/suffering (e.g. illicit opioid use) but is not expected to lead to remission/recovery. However, it is expected that this intervention will engage the patient into a dose/intensity that can be expected to lead to recovery/remission.

Why does it matter which kind of care it is?

In the original post (and above) I said:

If we sell an intervention as treatment at the public level but treat it as palliative care at the academic level, the public, people with addiction, and people who care about them are likely to feel deceived. It also has the effect of eliding difficult conversations about resource allocation and capacity development. For example, is this $6,000,000 allocated to palliative care or addiction treatment?

How we categorize an intervention is how we understand it, evaluate it, and communicate about it. This, in turn, will determine how others will understand it, evaluate it, and communicate about it.

If we categorize an intervention as addiction treatment, it will be (and should be) evaluated on its effectiveness at helping clients achieve recovery/remission. If it is not helping clients achieve recovery/remission, it has failed.

If the intervention is delivered with a dose and intensity that can only reasonably be expected to reduce symptoms (e.g. illicit opioid use) and it’s not accompanied by a commitment to engage the patient into a dose and intensity that can facilitate remission/recovery, it’s palliative.

It we categorize it as both, it should be evaluated on its effectiveness in engaging patients into addiction treatment of adequate dose and intensity to achieve recovery/remission.

The interventions we call treatment and their outcomes will shape how families, people with addiction, policy makers, professional helpers, employers, law enforcement, landlords, neighbors, clergy, and others think about addiction, treatment, and recovery.

Clarity is important to avoid the following traps that have harmed people with addiction:

  • Selling an intervention to policy makers, helpers, the public, families and people with addiction one way, but measuring it in another way. Leading to a loss of trust and fueling stigma against recovering people.
  • Moving the goalposts when outcomes are disappointing.
  • Confusion about the kind of services that are or are not available to people with addiction. This confusion can nurture notions that this is an untreatable condition or that addicts don’t want recovery.
  • The “soft bigotry of low expectations” that we’ve discussed here before.

This is also a time where destabilized notions of recovery with vague conceptual boundaries can create confusion that can (inadvertently) amplify these problems.

UPDATE: None of this should be interpreted as condemning low threshold programs, suggesting terminating services to people who continue to use, or suggesting that palliative services have no place. (The overdose crisis has made the need for these services clearer than ever before.)

I’d add that detox is described as palliative in TIP 19, Detoxification From Alcohol and Other Drugs because it’s not treating the disorder.

Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. Supervised detoxification may prevent potentially life-threatening complications that might appear if the patient was left untreated. At the same time, detoxification is a form of palliative care (reducing the intensity of a disorder) for those who want to become abstinent or who must observe mandatory abstinence as a result of hospitalization or legal involvement. Finally, for some patients it represents a point of first contact with the treatment system and the first step to recovery. Treatment/rehabilitation, on the other hand, involves a constellation of ongoing therapeutic services ultimately intended to promote recovery for substance abuse patients.

My intention is to call for clarity about the goals of an intervention, so we know how to understand it, evaluate it, and communicate about it.

For example, if we call detoxification treatment, and evaluate it as treatment, it will be a fail to put . Elimination of detox will seem sensible under this framing. While detox is palliative, it’s a necessary tool for many circumstances and safe engagement into other interventions.

I’d add that clarity about goals and definitions could also address the shortcomings of impatient and residential programs whose intervention is not delivered in a dose, intensity and duration that can be expected to facilitate recovery.

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Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin

There was a lot of enthusiasm about this study on twitter recently.

It appears to be based on this program highlighted in the NY Times last year.

. . . city health workers are taking to the streets to find homeless people with opioid use disorder and offering them buprenorphine prescriptions on the spot.

The city is spending $6 million on the program in the next two years, partly in response to a striking increase in the number of people injecting drugs on sidewalks and in other public areas. Most of the money will go toward hiring 10 new clinicians for the city’s Street Medicine Team, which already provides medical care for the homeless.

Members of the team will travel around the city offering buprenorphine prescriptions to addicted homeless people, which they can fill the same day at a city-run pharmacy.

We’ve reviewed the evidence-base for buprenorphine in previous posts. (And, that the outcomes were not what most people imagine when they hear that it’s the most effective treatment or the gold standard for care.)

A frequent criticism of research is that it doesn’t reflect real world conditions.

Well, this study that actually used real-world, high complexity subjects, and examines an intervention getting a lot of recent attention—low barrier buprenorphine prescribing. The reported the following conclusion:

In conclusion, this study found that a low barrier buprenorphine pilot program successfully engaged and retained a subset of marginalized persons experiencing homelessness in care and in continued treatment with buprenorphine.

What was the intervention being studied?

The researchers studied a low-threshold, same day buprenorphine program co-located with medical outreach and harm reduction services, which they described as follows:

Patients are engaged by peer outreach workers or self-present on a drop-in basis to either a small open-access medical clinic or a nearby syringe access program, where a clinician provides comprehensive substance use assessment and education and calls in a same-day prescription for buprenorphine/naloxone to be filled at a community pharmacy that dispenses the medication free to patients who are uninsured or have Medicaid.

This is especially relevant because of growing calls for this type of low-threshold opioid agonist program.

Who was being studied?

The subjects received a buprenorphine prescription from the street medicine program and were complex cases.

The researchers did a retrospective chart review of 95 patients:

  • 100% used heroin and engaged in injection drug use
    • 61% used methamphetamines
    • 26% used cocaine
    • 8% used benzodiazepines
    • 12% met criteria for unhealthy alcohol use
  • 100% were homeless
  • 58% had a chronic medical condition, such as hypertension or hepatitis C
  • 66% had a psychiatric condition
    • 26% with bipolar disorder or a psychotic disorder.
  • 24% previously sought treatment at this program

How long was the study?

The study was 12 months. (That’s very good. This is considerably longer than most studies. The ideal duration would be 5 years, but studies of that duration are extremely rare.)

What outcomes did the study measure?

This study looked at 4 outcomes over 12 month:

  1. Retention in the program’s medical and harm reduction services
  2. Retention on buprenorphine
  3. Urine drug screen results
  4. Overdoses

Retention in care

Retention in the street medicine program, defined as a visit 1 week prior to or any time after each time point:

  • 74% returned for follow-up after the initial visit at least once during the 12 months of evaluation.
  • 63% at 1 month
  • 53% at 3 months
  • 44% at 6 months
  • 38% at 9 months
  • 26% at 12 months

Retention on buprenorphine

Retention on buprenorphine, defined as having active buprenorphine prescriptions for more than 2 weeks of the month:

  • 55% at 1 month
  • 41% at 3 months
  • 38% at 6 months
  • 34% at 9 months
  • 26% at 12 months
  • 46% had a treatment interruption of 1 month or longer with subsequent return to care

Those percentages seem to be reporting on the % at that particular check-in time, not continuous up to that point.

  • Twenty-nine patients (30%) were retained on buprenorphine for at least two of the evaluation time points (months 1, 3, 6, 9, or 12).
  • Of that 30%:
    • 14 (48%) had continuous active prescriptions for buprenorphine during the time they were treated.
    • 5 (17%) of these patients had an interruption in their buprenorphine prescription of 2–3 weeks,
    • 8 (28%) had an interruption of 4–6 weeks, and
    • 5 (17%) had an interruption of greater than 6 weeks. Seven patients (24%) had multiple interruptions.

Urine drug screens

Two hundred and six urine toxicology tests were completed by the cohort, and 71% of patients who followed up after intake had a toxicology test, with a mean of 2.7 tests and a median of one test per follow-up patient (range 0–25).

If 74% of the 95 followed up after intake, that’s 70 patients. If 71% of them had at least one drug screen, that’s about 50 patients.

The median of one test per follow-up patient would indicate that at least half had only 1 drug screen.

Of the 206 drug screens completed:

  • 63% were positive for opioids
  • 73% were positive for methamphetamines
  • 25% were positive for cocaine
  • 10% were positive for benzodiazepines
  • 81% were positive for buprenorphine
  • 23% of patients had at least one opioid-negative, buprenorphine-positive toxicology test.

Overdoses

Emergency department and hospital records were reviewed for adverse events, including deaths and nonfatal opioid overdoses.

  • 1 patient died from fentanyl and methamphetamine overdose
  • 4 patients received emergency or inpatient medical treatment for an opioid overdose requiring naloxone,
    • 1 of these patients had three overdoses that required naloxone,
  • 5 patients were treated for possible opioid overdose events not requiring naloxone

What we don’t know

There are a few questions the study didn’t answer that could have been answered with the data and outcome measures used:

  • How many subjects were continuously on buprenorphine?
  • Were there any subjects were negative for opioids and other drugs at all points (or most points)?

Other unknowns:

  • The article says that patients were offered referrals to methadone and residential treatment. How many accept those referrals and, if successful referral rates are low, why?
  • Were there any quality of life benefits for the patients?

Wrapping up

The study had some interesting thoughts on drug testing and outcomes:

Our urine toxicology results reflect adherence to buprenorphine concurrent with ongoing use of heroin and methamphetamines in a majority of the cohort. We found some evidence of periods of opioid abstinence, with 23% of patients having at least one opioid-negative, buprenorphine-positive test. In our clinical experience, many patients report taking buprenorphine regularly and using substantially less heroin, while still using heroin occasionally. We are exploring this phenomenon further through qualitative research and in-depth interviews with participants, as it is difficult to measure a decrease in amount of heroin use with the binary tool of a urine toxicology test.

And, under limitations:

Frequency of urine toxicology testing varied among participants, so results could be skewed by participants who had more tests and may not be an accurate reflection of the cohort’s substance use. We are not able to report or compare toxicology test results among individual participants at specific time-points because of the variability in testing practices.

Treatment as harm reduction or recovery facilitation?

This discussion of outcomes highlights the tension between treatment as harm reduction and treatment as recovery facilitation.

A recent opinion piece in Emergency Medicine News brings this tension into focus:

Despite press coverage to the contrary, this study [work done by the group led by Gail D’Onofrio, MD, at Yale on ED-initiated buprenorphine/naloxone for opioid use disorder] never demonstrated any impact of ED-initiated buprenorphine on the only objective measure used to assess sobriety, the urine drug screen, nor were any other outcome differences sustained at six months. (JAMA 2015;313[16]:1636; http://bit.ly/2PBwYWdJ Gen Intern Med 2017;32[6]:660; http://bit.ly/2Cj0lbY.)

Despite this, I’m convinced that within the next five years buprenorphine will be routinely administered in EDs for opioid use disorder.

I imagine that most people who are enthusiastic about these projects would respond that they are not looking for “sobriety.”

This is where clarity about goals for an intervention becomes especially important. If we can agree that addiction is a treatable chronic illness, it seems important to more clearly categorize interventions as treatments for the illness of addiction or as palliative care.

If we sell an intervention as treatment at the public level but treat it as palliative care at the academic level, the public, people with addiction, and people who care about them are likely to feel deceived. It also has the effect of eliding difficult conversations about resource allocation and capacity development. For example, is this $6,000,000 allocated to palliative care or addiction treatment? Because it’s not both.

UPDATE: Follow-up post here.

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The APA Meeting: A Photo-Essay

From Slate Star Codex, on the 2018 APA conference:

The first thing you notice at the American Psychiatric Association meeting is its size. By conservative estimates, a quarter of the psychiatrists in the United States are packed into a single giant San Francisco convention center, more than 15,000 people.

. . .

The second thing you notice at the American Psychiatric Association meeting is that the staircase is shaming you for not knowing enough about [fill in the medication].

The author lists 10 things you notice at the APA meeting.

The pharma marketing in the photo essay is striking. Check it out.

Looks like the 2018 conference had 209 exhibitors. The 2019 exhibitor fees start at $1500, with most booths costing $2000 or $2300. That brings the exhibitor fees to somewhere between $400k and $500k. I wonder about the value of all the meals and swag exhibitors bought for attendees, let alone the speaking deals set up. Wow.

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Revisiting recovery-oriented harm reduction (part 3)

So . . . we’ve dusted off and reviewed my history with recovery-oriented harm reduction.

We’ve also explored why I believe recovery and harm reduction should remain distinct constructs.

This sets the stage to revisit and update the concept.

What is recovery-oriented harm reduction?

Recovery-oriented harm reduction (ROHR) seeks to address the historical failings of both abstinence-oriented treatment and harm reduction services. ROHR views recovery as the ideal outcome for any person with addiction and uses recovery (for addicts only) as an organizing and unifying construct for treatment and harm reduction services. Admittedly, these judgments of the historic failings are my own and represent the perspective of a Midwestern U.S. recovery-oriented treatment provider.

Addiction is an illness. The defining characteristic of the disease of addiction is diminished and/or loss of control related to their substance use.

Drug use in addiction is not freely chosen. Because the disease of addiction affects the ability to choose, drug use by people with addiction should not be viewed as a lifestyle choice or manifestation of free will to be protected. It is not a expression of personal liberty, it is a symptom of an illness and indicates compromised personal agency.

All drug use is not addiction. There is a broad spectrum of alcohol and other drug use. Addiction is at the extreme of the problematic end of that spectrum. We should not presume that the principles that apply to the problem of addiction are applicable to other AOD use.

ROHR is committed to improving the wellbeing of all people with addiction. ROHR services are not contingent on recovery status, current AOD use, motivation, or goals. Further, their dignity, respect, and concern for their rights are important are not contingent on any of these factors.

An emphasis on client choice—no coercion. While addiction indicates an impaired ability to make choices about AOD use, service providers should not engage in coercive tactics to engage clients in services. Service engagement should be voluntary. Where other systems (legal, professional, child protection, etc.) use coercive pressure, service providers should be cautious that they do not participate in the disenfranchisement or stigmatization of people with addiction.

For those with addiction, full recovery is the ideal outcome. People with addiction, the systems that work with them, and the people around them often begin to lower expectations for recovery. In some cases, this arises in the context of inadequate resources. In others, it stems from working in systems that never offer an opportunity to witness recovery. Whatever the reason, maintaining a vision of full recovery as the ideal outcome is critical. Just as we would for any other treatable chronic illness.

The concept of recovery can be inclusive — it can include partial, serial, etc. While this series argues for a distinction between recovery and harm reduction, Bill White has described paths that can be considered precursors (precovery) to full recovery.

Recovery is possible for any person with addiction. ROHR refuses cultural, institutional, or professional pressures to treat any sub-population as incapable of recovery. ROHR recognizes the humbling experiential wisdom that many recovering people once had an abysmal clinical prognosis.

All services should communicate hope for recovery. ROHR recognizes that hope-based interventions are essential for enhancing motivation to recover and for developing community-based recovery capital. Practitioners can maintain a nonjudgmental and warm approach with active AOD use while also conveying hope for recovery. All ROHR services should inventory the signals they send to individuals and the community. As Scott Kellogg says, “at some point you need to help build a life after you’ve saved one.”

Incremental and radical change should be supported and affirmed. As the concepts of gradualism and precovery indicate, recovery often begins with small incremental steps. These steps should not be dismissed or judged as inadequate. They should be supported and possibly even celebrated and they should never be treated as an endpoint. Likewise, radical change should not be dismissed as unrealistic or unsustainable pathology.

ROHR looks beyond the individual and public health when attempting to reduce harm. ROHR wrestles with whether public health is being protected at the expense of people with addiction, whether harm is being sustained to families and communities, and whether an intervention has implications for recovery landscapes.

ROHR should aggressively address counter-transference. ROHR recognizes a history of providers imposing their own recovery path on clients while others enjoy vicarious nonconformity or transgression through clients. These tendencies should be openly discussed and addressed during training and ongoing supervision.

ROHR refuses to be a counterforce to recovery. ROHR seeks to be a bridge to recovery and lower thresholds to recovery rather than position itself as a counterforce to recovery. Recognizing that addiction/recovery has become a front in culture wars, ROHR seeks to address barriers while also being sensitive to the barriers that can be created in this context. When ROHR seeks to question the status quo, it is especially wary of attempts to differentiate from recovery that deploy strawmen, recognizing that this rhetoric is harmful to recovering communities and, therefore, to their clients’ chances of achieving stable recovery.

ROHR sees harm reduction as a means to an end. ROHR views harm reduction as strategies, interventions, and ideas to reduce harm. As such, it is wary of harm reduction as a philosophy or ideology, which sets the stage for seeing harm reduction as an end unto itself. Back to Scott Kellogg’s point, “at some point you need to help build a life after you’ve saved one.” The end we seek is recovery, or restoration, or flourishing. Seeing harm reduction as a philosophy or ideology risks viewing it as “the thing” rather than “the thing that gets us to the thing.”

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Revisiting recovery-oriented harm reduction (part 2)

Yesterday, we began to revisit the concept of recovery-oriented harm reduction. Why recovery-oriented harm reduction and not just recovery? 13 years ago, recovery-oriented harm reduction was thought of as a bridge between harm reduction and treatment or recovery. Today, in some circles, it might invite questions about why one would want to maintain a distinction between harm reduction and recovery.

Defining harm reduction

Harm Reduction International defines harm reduction this way:

Harm reduction refers to policies, programmes and practices that aim to minimise negative health, social and legal impacts associated with drug use, drug policies and drug laws. Harm reduction is grounded in justice and human rights – it focuses on positive change and on working with people without judgement, coercion, discrimination, or requiring that they stop using drugs as a precondition of support. Harm reduction encompasses a range of health and social services and practices that apply to illicit and licit drugs. These include, but are not limited to, drug consumption rooms, needle and syringe programmes, non-abstinence-based housing and employment initiatives, drug checking, overdose prevention and reversal, psychosocial support, and the provision of information on safer drug use. Approaches such as these are cost-effective, evidence-based and have a positive impact on individual and community health.

Harm reduction emerged in response to the failures of medical, public health, and addiction treatment systems to meet the needs of people currently using alcohol and other drugs. Harm reduction saves lives and has challenged other systems (like my own) to face their shortcomings and biases and improve our services. Harm reduction is an essential part of the service continuum and its existence has created pressure to improve the care delivered by other systems.

Defining recovery

There have been several proposed definitions of recovery by academics, professional associations, panels, federal agencies, and state agencies. The trend among these definitions is toward more porous conceptual boundaries and greater inclusion. The first wave of attempts to define recovery seemed to originate from a sentiment like the following, “There are people out there who are doing what you call recovery. They just are not doing it in 12 step groups or they are using medication to assist their recovery. They are just using another pathway to get to the same destination (i.e. outcome). To exclude this people from the boundaries of recovery is inaccurate and wrong. And, by the way, you might want to wrestle with whether there are ways in which your thresholds are too low (e.g. tobacco use and other unhealthy behaviors). Recovery is less about the pathway and more about the destination/outcome.” The best example of a definition arising from this wave is from the Betty Ford Consensus Panel:

Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.

The next wave of definitions seemed to arise from something like, “What you’ve thought of as recovery is way too narrow. It shouldn’t be confined to addiction. There’s a whole spectrum of problems and changes within the context of those problems that constitute recovery. It’s not a outcome at all. It’s a process, and anyone engaged in a process to improve their wellness is in recovery. Recovery is the pathway not the destination/outcome.” SAMHSA’s definition is an example of this is type:

A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

Another, more recent, example is from the Recovery Science Research Collaborative:

Recovery is an individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.

Process, direction, outcome?

Long before researchers and scholars took an interest in recovery, recovering people have described recovery as a process. What’s interesting here, is that I think recovering people have thought of recovery as a process and a destination/outcome. Some might think of it as a process that leads to an outcome, while others might think of it as an outcome maintained by a process. Whatever the case, both elements are considered essential. The Betty Ford Consensus Panel definition integrates a lifestyle (destination) that is voluntarily maintained (process). This more recent wave of definitions emphasize a process and a direction (“improvement . . . striving . . . full potential” and “sustained efforts to improve wellness”) rather than an outcome or destination.

Does it matter?

In is paper on the conceptual boundaries of recovery (read the whole thing) Bill White observed:

Defining recovery also has consequences of great import for those competing institutions and professional roles claiming ownership of AOD problems. Choosing one word over another can shift billions of dollars from one cultural institution to another, e.g., from hospitals to prisons. Medicalized terms such as recover, recovery, convalescence, remission, and relapse convey ownership of severe AOD problems by health care institutions and professionals, just as words such as redeemed and reborn, rehabilitate or reform, and stop and quit shift problem ownership elsewhere. It is important to recognize that rational arguments for particular definitions of recovery may mask issues of professional prestige, professional careers, institutional profit, and the fate of community economies. The answer of who has authority to define recovery will vary depending on the question, “define for what purpose?” Given that defining recovery could generate unforeseen and harmful consequences, efforts to define recovery should include broad representation from: 1) individuals and family members in recovery, 2) diverse recovery pathways and styles, 3) diverse ethnic communities, and 4) policy, scientific, and treatment bodies, including leaders of the major institutions that pay for behavioral health care services.

So . . . yes, it matters. A lot. To a lot of people and a lot of interests. I don’t presume any nefarious motives. I imagine everyone believes their definition will ensure more people recover or will protect recovery from a harmful erosion of its boundaries. In some cases, they wish to extend it to include mental illness and other problems. In other cases, they wish to include people who are taking steps toward change, but have not yet crossed the threshold into traditional notions of recovery. Others want to secure the status of MAT patients within the boundaries of recovery. Others see opportunities for stigma reduction and political action by enlarging the number of people in recovery. Others see opportunities to address the needs of people with lower severity problems. Others may see progress on stigma reduction benefiting people in recovery but neglecting people who still use alcohol and other drugs. Others see the concept of recovery as imbued with moral panic and wish to challenge that. There have been attempts to address some of these issues and bridge the divide between harm reduction and recovery. Scott Kellogg has proposed a model he calls gradualism. He describes it as follows:

[Gradualism] seeks to create a continuum between the world of harm reduction interventions and the abstinence-oriented treatment field. Again, this approach differs from other calls for integration (Denning, 2001; Marlatt et al., 2001) because there is a much greater emphasis on making abstinence the eventual endpoint of most harm-reduction enterprises. This paradigm would combine the harm reduction emphases on outreach to the addicted, incremental change, and gradual healing with the abstinence-oriented therapeutic perspective that the use of substances in an addictive or abusive manner is antithetical to the growth and wellbeing of humans.

Bill White has proposed the concept of precovery, which he described this way:

Precovery is a recovery incubation period arising during active drug use that moves one from the center of addiction to the edge of addiction. Experiences within this stage prepare us for the potential break-up of the person-drug relationship and move us close enough to the recovery territory to feel its contagious pull. Brief sobriety experiments within this boundary region do not constitute sustainable recovery, but they have the potential to incrementally move us to the center of the recovery experience and the physical and cultural world in which that experience is nested. The center of recovery is a region of stability and safety within the recovery process.

These models embrace harm reduction, but not as recovery. They embrace harm reduction as a path to recovery.

Why does it matter?

Why does it matter if harm reduction is placed inside the definition of recovery? There are a few concerns:

  • It defines recovery in a way that is contrary to the lived experience of cultures and communities that have identified with the concept.
  • This tension between professionally developed definitions and organic, indigenous definitions is likely to alienate communities of recovery rather than engage them. Bill White suggested that the job of professionals “is to do what the community at any given moment cannot do.” It is our role to fill gaps, address unmet needs, support the community, or even try to facilitate the creation of new communities, rather than try to bend the community to our vision of a better community.
  • These definitions fail to consider who “recovery” is important to and what its redefinition might mean to them. For example, consider the founding of AA. The date of Dr. Bob’s achievement of sobriety (or, recovery) is considered to be founding date of AA. By some of the proposed definitions, Dr. Bob was in recovery for some time prior to this. One could argue that he was in a “individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.” Was this period of time recovery to him? His wife? His children? His coworkers? His patients? If that period is characterized as recovery, what does that do to the relationship between all of these people and the concept?
  • “Recovery” is an attractive label for a reason. It’s become associated with wellness, citizenship, and other positive attributes. It’s clear that these attributes do not accurately described many people traditionally considered to be “in recovery” and may exclude others who do live up to those attributes. However, extending the label too far risks eroding the positive associations that make “recovery” attractive in the first place.

Tomorrow’s post will revisit the parameters of recovery-oriented harm reduction.

UPDATE: One more relevant thought from a recent post. I believe, if these new definitions take root, recovering people will feel a need to establish typologies of recovery or select a new word to convey the identity they share. Productive discussion around typologies is likely to become very challenging. The need for typologies stems from the desire to distinguish one type from another, and use them. How might they be used? They would likely be used to organize research and programming around each type. This means these typologies would be used in inclusion/exclusion criteria for everything from research to treatment to recovery housing to collegiate recovery programs to physician health programs to state or unstated hiring practices. And, if there was success in establishing typologies, wouldn’t that bring us back to our starting point?

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Revisiting recovery-oriented harm reduction (part 1)

meet them where they are at

The opioid crisis, for good reason, has elevated the role and visibility of harm reduction over the last decade. This seems like a good time to revisit a concept I’ve discussed here several times over the years—recovery-oriented harm reduction.

In 2003, we wrote an article about harm reduction that articulated 6 values that guide our approach to services.

  1. Drug use by addicts is inherently bad and oppressive.
  2. Every addict must be treated with the belief that recovery is possible for him or her, and interventions must place supreme value on recovery from addiction.
  3. Any intervention must attempt to assess “aggregate harm” done to the addict, other interested persons and the community.
  4. Any intervention targeting addicts must communicate hope to both the individual and the community.
  5. Does the program reinforce the culture of addiction or the culture of recovery?
  6. Stewardship of community resources must be integral to this dialogue.

We encouraged other providers to identify their values and hoped that this might lead to more productive dialogue and collaboration.

In 2006, I suggested that this article was really a call for “recovery oriented harm reduction.”

In 2008, I proposed an outline of recovery-oriented harm reduction:

Recovery is all about freedom. The freedom to live one’s life in the way one chooses without being a slave to addiction or being controlled by treatment or criminal justice systems.

. . .

I’ve been thinking about a model of recovery-oriented harm reduction that would address the historic failings of abstinence-oriented and harm reduction services. The idea is that it would provide recovery (for addicts only) as an organizing and unifying construct for treatment and harm reduction services. Admittedly, these judgments of the historic failings are my own and represent the perspective of a Midwestern U.S. recovery-oriented provider:

  • an emphasis on client choice–no coercion
  • all drug use is not addiction
  • addiction is an illness characterized by loss of control
  • for those with addiction, full recovery is the ideal outcome
  • the concept of recovery is inclusive — can include partial, serial, etc.
  • recovery is possible for any addict
  • all services should communicate hope for recovery–recognizing that hope-based interventions are essential for enhancing motivation to recover
  • incremental and radical change should be supported and affirmed
  • while incremental changes are validated and supported, they are not to be treated as an end-point
  • such a system would aggressively deal with counter-transference – some people may impose their own recovery path on clients, others might enjoy vicarious nonconformity through clients

By this time, harm reduction was already moving toward the mainstream. (Maybe it would be more accurate to say that the mainstream was already moving toward harm reduction?) However, the opioid crisis and, more specifically, the overdose crisis has accelerated the process. A result has been not just a mainstreaming of harm reduction, but an effort to redefine recovery from a process involving “sobriety” to a process of improved wellness, effectively placing harm reduction inside that definition of recovery.

More on that tomorrow.

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Follow up – Responses to charges against Invidior

So . . . a week and a half ago, Indivior, the manufacturer of Suboxone, was charged with conspiracy, health care fraud, mail fraud and wire fraud.

Prosecutors said:

Indivior misled doctors and government health programs into believing that the drug, Suboxone Film, was safer and less likely to be abused than rivals, the Justice Department said in a statement Tuesday.

. . .

Federal prosecutors in the Western District of Virginia said Indivior’s deceptions had contributed to an epidemic that has killed thousands of people.

I posted the story, along with discussion about SAMHSA’s proposed guidelines for recovery homes. The proposed guidelines acknowledge diversion as a reality and a risk to be managed. This acknowledgement is important, though I worry that their attitude may be cavalier.

The problem of diverted maintenance medications has been well-known by people with addictions and practitioners for at least a decade. However, in public treatment and recovery advocacy forums, the problem has been taboo and raising the issue often resulted in having one’s judgement and motives questioned. (I was actually in a forum with a high level official from the Office of Drug Control Policy where an attendee very diplomatically raised the concern. That attendee was politely advised that discussion of the matter is likely to complicate accomplishing the goals of his office. He, therefore, discouraged discussing those concerns in public forums.)

About 9 days after news of the charges against Indivior were made public, an organization called the Addiction Policy Forum posted an article by an esteemed addiction scholar. The article used a recent study about the diversion of buprenorphine to argue that diverted buprenorphine is typically used in ways that are consistent with therapeutic purposes.

This article was widely circulated in treatment/research/advocacy circles in response to the concerns raised by the Indivior charges. The implication was that the evidence-base doesn’t support concerns about non-therapeutic misuse.

What was not mentioned in these tweets and posts is that the Addiction Policy Forum is funded by drug makers, including Indivior. These tweets and posts also failed to note that the study referenced in the article was funded by Indivior.

Disclosures from: Cicero, T., Ellis, M., & Chilcoat, H. (2018). Understanding the use of diverted buprenorphine. Drug And Alcohol Dependence, 193, 117-123. doi:10.1016/j.drugalcdep.2018.09.007

The study found that diversion was pretty common, with  58% of subjects reported having used diverted buprenorphine. It also found that 52% of subjects reported having used buprenorphine to get high.

It seems strange to defend Indivior’s medication from allegations that Indivior has been deceptive by circulating an article published by an Indivior funded organization that cites an Indivior funded study without acknowledging Indivior’s role in the study.

So, if Indivior funded and promulgated research finds high rates of diversion and that “52% reported using buprenorphine to get high or alter mood”, what does other research say?

Well, another post referenced a study that also found misuse of buprenorphine to be very common. One of the authors summarized their findings as follows:

Some claims for buprenorphine products have proven not to be true. People bluntly report ability to get a “high” within clinically approved doses despite early claims otherwise. Buprenorphine is commonly diverted and misused, despite early claims that the drug would not lend itself to such patterns. . . . this study looks at the real-world conditions and experiences collected on 1,674 people who report themselves as having a history of disordered use of many different drugs (including alcohol) and who have recently engaged in a recovery program to become abstinent from all substances that cause a “high,” or which mask unpleasant emotions.

Key Findings for those reporting prior use of buprenorphine products in the prior 6 months:

  • 4.2% had only obtained buprenorphine by legal prescription
  • 60% had only obtained buprenorphine by illegal means
  • 35.9% had obtained buprenorphine by both illegal and illegal means
  • 10% had overdosed with buprenorphine while taking other drugs or alcohol
  • No matter how obtained, 56.1 % to 81.2% report getting a good “high” on buprenorphine
  • Efficacy: 25.2% = helped // 31.5% = no effect // 43.3% = made problems worse

Now, it’s important to note that the subjects in this study were participants in drug-free treatment, which likely creates a selection bias.

With that in mind, one way to read that is that maintenance medications may be unhelpful, bad, or risky for a significant number of people with opioid addiction, many of them know it, many of them find their way to non-maintenance treatment (if available), and that it will not be helpful to push these patients into maintenance treatments or environments with maintenance medications.

I should add that I am open to the inverse being true too. None of this is an argument that maintenance treatments should not be available to any patient that wants them. As I’ve repeatedly stated in this blog, it’s just a push for good informed consent that empowers patients to advocate and choose for themselves.

Bill White’s recent post on chaos and recovery speaks to the variability in what helps some and harms others:

Unique service combinations that are transformative for one individual may exert no effects, minimal effects, or even harmful effects on others. This proposition affirms the need for expansive menus of recovery support elements (as opposed to a fixed “program”) and rapid adaptations in such offerings based on individual responses to services over time. It also suggests that any single pathway model of addiction and recovery will only result in sustained recovery for a limited subset of the total population of AOD-affected individuals and that those outside that subset could be injured when subjected to mismatched interventions. In medicine, such injuries are referred to as iatrogenic illnesses (e.g., treatment-caused harm).

. . .

Suggesting such complex interactions within the recovery process is not an invitation to therapeutic nihilism or abandonment of science, e.g., the suggestion that all treatment and recovery frameworks are worthy and only need their elements combined. (Some may be ineffective or harmful.) It is instead an invitation to bring ALL of  evidence-based, practice-informed ingredients into our service and support milieus, mixing and matching them as we draw from the experiential knowledge of people in recovery, while closely monitoring and adapting personal responses to various service clusters that are chosen. It further calls for a heightened level of professional humility and personal awe that unseen forces may be at work in providing a detonation point for these combustible ingredients.

Again, none of this is an argument to reduce access to any kind of treatment. Rather, it’s a call to talk more openly about what the evidence says and doesn’t say about the benefits, what we know and don’t know about the harms and risks, as well as the limitations.

I should add that non-maintenance treatments are not exempt from ethical concerns, as this week’s news and previous posts indicate.

UPDATE: One other theme in some of the reactions paint diversion as a product of a shortage of prescribers, citing reports that only 5% of US physicians have a waiver to prescribe buprenorphine.

To me, that seemed like an unhelpful statistic. I don’t know what percentage of US physicians are specialists like ophthalmologists, oncologists, nephrologists, surgeons, etc. I wouldn’t expect most specialists to prescribe something like buprenorphine under any regulatory circumstance.

So . . . I did a little googling.

That number of waivered physicians constitutes the equivalent of 27.8% of all primary care and psychiatrists in the US.

That seems substantial to me.

Further, a post from 3 years ago addressed concerns about access to maintenance medications. One would assume that buprenorphine sales and utilization have increased since these numbers were generated in 2010 and 2013.

 

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