Health care’s most underpaid workers

100_4218-2-300x225Vox recently posted an article that frames patients as the health care system’s unpaid workers:

I’m not talking about the work of managing one’s health, the work that diabetics do to monitor their blood sugar or the healthy eating choices a doctor might recommend for an overweight patient. This can be a significant burden in its own right.

What I didn’t understand was the burden patients face in managing the health care system: a massive web of doctors, insurers, pharmacies, and other siloed actors that seem intent on not talking with one another. That unenviable task gets left to the patient, the secret glue that holds the system together.

For me, this feels like a part-time job where the pay is lousy, the hours inconvenient, and the stakes incredibly high. It’s up to me to ferry medical records between different providers, to track down a pharmacy that can fill my prescription, and to talk to my insurance when a treatment gets denied to find out why.

It’s amazing to me that this is the first time I’m reading this characterization of the role of the patient in their own care. It’s true in many areas of health care (as I learned personally last year) and addiction care is no exception.

Getting good care is a lot of work for the patient and requires a lot of time, energy, attention and self-discipline—scarce resources for a lot of patients.

The article does a great job framing just one of the challenges that addiction treatment patients face, especially if they receive care from a provider that does not offer an integrated and complete continuum of care. And, while I view the addiction treatment system as inadequate and deeply troubled, this challenges some of the grass-is-greener-on-the-other-side-of-the-health-care-fence thinking. We frequently hear statements like, “you would never see this with any other patient population.” To be sure, there’s a truth in these statements, but they may be giving the health care system too much credit.

Maybe we can take a little consolation in the idea that we’re not quite as alone as we may have thought in the challenges we face.

Maybe addiction care can play a role in improving health care in general.

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Update 6/1/2016. FULL 911 Good Samaritan Legislation in Michigan

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Great news!!

Both 911 Good Samaritan Bills sailed through the House and are now awaiting Senate action.

I chatted with Rep. Sam Singh yesterday. He’s optimistic about the bills making it through the Senate.

HOWEVER, Rep. Singh said the only problem is the summer legislative schedule. They might only be in session for two more weeks so it is possible that it might not get done until the fall.

Rep. Singh said it would be helpful for citizens to reach out to their Senators and let them know their support.

Find the contact info for your State Senator here.

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(The rest of this post was originally posted 5/12/2016. It is provided here for background.)

Good news!!!

There are 2 bills in the Michigan House of Representatives Criminal Justice Committee that would would provide immunity from criminal charges for people all ages who are seeking emergency medical assistance for themselves or friends as a result of a drug overdose from any illicit drug.

Rep. Pscholka’s bill, House Bill 5649, provides immunity from possession penalties in certain circumstances.

Rep. Singh’s bill, House Bill 5650, provides immunity from use penalties in certain circumstances.

These bills expand upon last years House Bill 4843 by removing limitations based on age and type of drug.

The House Criminal Justice Committee will be taking up these bills on Tuesday, May 17, 2016 at 9:00 AM in Room 327, House Office Building, Lansing, MI.

Contact the House Criminal Justice Committee to let them know you support these bills.

Background

The Facts

Keep these facts in mind:

  • Overdose is now the leading cause of accidental death in the U.S. Most of these overdose deaths are due to opioids.
  • If help arrives in time, overdoses can be safely and quickly reversed with a squirt of naloxone up the patient’s nose.
  • More than half of all overdoses occur in the presence of other people, usually other drug users.
  • Too often, people do not call 911 in a timely manner due to fear of arrest for possession of drugs.

A First Step

At the urging of parents who have lost children to overdose, the Michigan legislature made some good first steps last year. They enacted laws that increased access to naloxone, the drug that reverses overdoses.

On October 13, 2014, Public Acts 311, 312, 313 and 314 of 2014 were signed into law.

These acts will:

  • Allow Narcan to be prescribed to friends and family of heroin addicts, so it’s readily available in the event of an overdose.
  • Protect a person administering Narcan in good faith to be immune from criminal prosecution or professional sanctions.
  • Require emergency medical personnel to carry the drug in their vehicles and be trained in how to administer it.
  • Require the state Department of Community Health to complete annual reports of opioid-related overdose deaths.

Another Step

Last summer, Michigan Rep. Al Pscholka (R-Stevensville) introduced House Bill 4843, a bipartisan measure, that would create Good Samaritan protections for individuals under the age of 21 who seek medical attention for themselves or another person believed to have overdosed. However, the Good Samaritan protections are limited to the illegal possession of prescription drugs (in quantities consistent with personal use) for people under the age of 21.

Last December the Governor signed the Good Samaritan Bill, House Bill 4843, into law.

911 Good Samaritan Laws

NARCAN-KITThe Drug Policy Alliance provides a really good summary of 911 Good Samaritan laws:

Accidental overdose deaths are now the leading cause of accidental death in the United States, exceeding even motor vehicle accidents among people ages 25 to 64. Many of these deaths are preventable if emergency medical assistance is summoned, but people using drugs or alcohol illegally often fear arrest if they call 911,  even in cases where they need emergency medical assistance for a friend or family member at the scene of a suspected overdose.The best way to encourage overdose witnesses to seek medical helpis to exempt them from arrest and prosecution for minor drug and alcohol law violations, an approach often referred to as Good Samaritan 911.

The chance of surviving an overdose, like that of surviving a heart attack, depends greatly on how fast one receives medical assistance. Witnesses to heart attacks rarely think twice about calling 911, but witnesses to an overdose often hesitate to call for help or, in many cases, simply don’t make the call. In fact, research confirms the most common reason people cite for not calling 911 is fear of police involvement.

It’s important to know that this is not a liberal vs. conservative or Republican vs. Democrat issue. Some of the reddest and the bluest states in the country have passed 911 Good Samaritan laws.

Twenty states and the District of Columbia have enacted policies to provide limited immunity from arrest or prosecution for minor drug law violations for people who summon help at the scene of an overdose. New Mexico was the first state to pass such a policy and has been joined in recent years by Alaska, California, ColoradoConnecticut, Delaware, Florida, Georgia, Illinois, LouisianaMaryland, Massachusetts, Minnesota, New Jersey, New York, North Carolina, Rhode Island, Vermont, Washington and Wisconsin.

Further, these laws don’t protect dangerous or predatory criminals.

Good Samaritan laws do not protect people from arrest for other offenses, such as selling or trafficking drugs, or driving while drugged. These policies protect only the caller and overdose victim from arrest and/or prosecution for simple drug possession, possession of paraphernalia, and/or being under the influence.

The Bad News

An overdose is a major medical crisis, right? It’s not unlike a heart attack.

Here’s what happens when someone has a heart attack41KSA2GA12L._SX300_

  1. A person has a heart attack at the grocery store and . . .
  2.  . . . thank goodness, the store has an automatic defibrillator.
  3. Someone has been trained to use the defibrillator and performs the rescue.
  4. Someone else calls 911 to make sure the patient gets all the care they need.
  5. The patient is taken to the emergency department and medically stabilized.
  6. Once stabilized, the patient gets transferred to care that will address the cause of the heart attack and/or care that will prevent future heart attacks.
  7. The patient’s treatment plan will generally include lifestyle changes. (Diet, exercise, etc.)
  8. Then, the patient gets follow-up care that might include:
    • follow up appointments with specialists,
    • periodic tests to monitor for indicators of a recurrence,
    • self-monitoring (blood pressure), and
    • monitoring by the patient’ primary care physician.
  9. If problems recur or there are indications of a potential recurrence, the care plan will be re-evaluated and the patient will get whatever care they need.

Here’s what happens when someone ODs and is rescuednarcan

  1. A person overdoses and . . .
  2.  . . . thank goodness, the someone has naloxone.
  3. The person has been trained to use naloxone and performs the rescue.

Maybe, if they are lucky, these steps happen.

  1. Someone else calls 911 to make sure the patient gets all the care they need.
  2. The patient is taken to the emergency department and medically stabilized.

Naloxone is not enough.

We’d never tolerate cardiac patients being sent home without the proper care. Why should people with an addiction be treated any differently?

The good news

The good news is that there are models that work.

The Gold Standard

A male doctor writes on a patients chart.The best example of what should happen is the the kind of care that opioid addicted doctors, nurses, pilots and lawyers get. They all have low relapse rates and return to work at very high rates.

Here’s what would happen if one of them overdosed at work (or if it was known to their employer):

First, the recovery planning begins with some important assumptions:

  • abstinence is the goal;
  • full recovery with a return to full functioning is the expectation;
  • addiction is a chronic illness and recovery requires long term treatment, support and monitoring; and
  • for recovery to be durable, the addict must be an active participant in treatment and recovery maintenance.

Signpost along the road to recovery.The recovery plan is likely to include the following:

  • Formal treatment. The first phase of formal addiction treatment for most of these professionals is residential care ranging from 30 to 90 days.
  • Supportive services. Supportive services used by these professionals includes AA or NA 12-step groups, aftercare groups from their formal treatment programs, and follow-up from case managers.
  • Long-term support and monitoring. After completion of initial formal addiction treatment, they develop a continuing care contract consisting of support, counseling, and monitoring for usually 2 to 5 years.
  • Drug testing. Regular testing for 2 to 5 years, usually with more frequent testing at the start and reduced testing following periods of stable negative drug test results.
  • Dealing with relapse. Relapses are usually addressed by a combination of increased intensity of care and monitoring and by immediately informing family and colleagues of the physician to enlist their support.

Other options

Buprenorphine (Suboxone) and methadone have been shown to reduce drug use, overdose risk, criminal activity and disease transmission.

Some people are able to stabilize and live normal lives on these medications but, at this point, there is no research demonstrating its effectiveness with quality of life indicators like employment.

Many people hope to use these drugs as an interim step toward abstinence. However, there is no established model for successfully transitioning buprenorphine and methadone patients to abstinence. A large federally-funded study attempting to do this reported, “near universal relapse.”

Another option is an injectable drug called Vivitrol. It is injected once per month and can protect against overdose. Unfortunately, it’s very expensive.

Which to choose?

Hope Traffic SignThe gold standard offers a path to full recovery, but it does demand a lot of structure, effort and lifestyle changes.

Many professionals prefer drug maintenance as a goal. It’s an easier plan to implement and many professionals are not confident that their patients are capable of drug-free recovery. (Look for professionals that are optimistic and believe in you ability to achieve full recovery.)

However, most patients and families, for a wide variety of reasons, prefer abstinence as a goal–the most common reason is that they want their life back the way it was before they became addicted.

Patients not sticking with the treatment plan is the biggest barrier to success with both approaches.

It’s harder than it should be

Getting the gold standard for yourself or a family member is likely to be very difficult. But, there are steps you can take to improve the odds.

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Getting good treatment for opioid addiction is hard

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The NYT published an opinion piece that examines the disconnect between the recommendations (Recommendations that are rapidly becoming requirements.) of public health officials and the on-the-ground experience.

MAT advocates are already criticizing the piece as biased, ignorant, anti-science, harmful and stigmatizing. However, I respect the way it avoids simple answers and grapples with real world decisions and experiences.

Despite the criticism, there are statements for medication-assisted treatment (MAT) advocates to like:

. . . treatment with buprenorphine and methadone has been found to cut opioid overdose deaths in half when compared to behavioral therapy alone, and it’s hard to argue with that. [I took a looked at this study in a previous post.]

and

“Overwhelming evidence shows that Suboxone improves outcomes in people with opioid-use disorders,” said Dr. Nora Volkow, director of the National Institute on Drug Abuse. She cited a 2014 study of opioid addicts that found that after 42 months, 31.7 percent were clean and no longer on M.A.T., and 29.4 percent were also clean but still receiving M.A.T.

and

“Let’s be clear,” said Dr. Andrew Kolodny, a longtime Suboxone prescriber in New York and executive director of Physicians for Responsible Opioid Prescribing. “The real crisis is the severe epidemic of opioid addiction and overdose deaths that’s devastating families across the country.”

Dr. Kolodny ranks anti-Suboxone judges like Judge Moore in a category with climate-change deniers and people who believe vaccines cause autism. “When there’s really dangerous heroin on the streets, I’d rather see Suboxone out there, even if it is being prescribed irresponsibly or is being sold by drug dealers,” he said.

and

. . . he’s counted 13 drug-free babies born while he has run Tazewell’s drug court, several to mothers on M.A.T. (Like Erica, they took a drug called Subutex because Suboxone is not recommended for pregnant women.) “How do you put a price on that?” he asked.

There’s also plenty for MAT critics to like.

You can read the piece for those specifics, but the theme is that MAT is not delivering the outcomes that public health officials promise—many people are getting stuck somewhere between addiction and where they want to be (recovery?).

It leaves open the possibilities that the problem is the medication or that it’s lousy treatment providers.

photo credit: davegray

photo credit: davegray

It also give an accurate impression of the terrible state of alternative options:

He finally got clean without M.A.T., but only after long stints in inpatient rehab centers at a total cost of about $60,000.

I recently posted about the spotty quality and financial exploitation that’s rampant in the drug-free treatment industry.

Sadly, an addict stuck in limbo  due to inadequate treatment is not an island. For better or worse, communities and loved ones get stuck there too.

“I think she’s gone back to using, but she won’t admit it, ” her mother told me. “I found papers in the bathroom, like what heroin comes in.” She added, “And she went through her brother’s room and stole his clothes — that’s what addicts do.” A judge recently decided to transfer custody of Erica’s baby to his grandmothers.

To its credit the piece does not offer simple solutions. Instead, it lives with the questions.

While some people may do well with medication and others (who can come up with the money) may do well with inadequate doses of drug-free treatment, for most people with opioid addiction, it’s going to take a lot more than medication or getting insurance to cover overpriced 30 day stays in residential treatment.

We need to raise the bar for treatment providers rather than lower the bar for clients. (I’m grateful to work in a place that continues to provide hopeful, compassionate, affordable, responsible and ethical care.)

Why is this so hard to talk about?

This video’s been coming to mind a lot lately.

I’m not just sharing this to take the personal inventory of other people. There’s no doubt I’ve been guilty of these “unfortunate assumptions” at times.

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NA and Recovery from Opioid Addiction

missing pieceThe opioid crisis has generated extensive media coverage, attention from public health officials and new policy agendas.

Bill White, Marc Galanter, Keith Humphreys and John Kelly have noticed some trends in the coverage and public health responses.

Public health responses have focused primarily on 1) suppression of illicit opioid markets, 2) public education on opioid addiction risks, 3) prescription medication disposal campaigns, 4) opioid-focused physician training and prescription monitoring, 5) new non-opioid protocols for non-cancer pain management, 6) introduction of abuse-deterrent opioid formulations, 7) increased legal access and distribution of naloxone (Narcan®) for overdose intervention, and 8) efforts to expand access to addiction treatment—particularly medication assisted treatment (MAT).

But there’s a troubling omission. What is it?

As long-tenured addiction researchers, the authors have supported these efforts, but have been struck by the scant attention given to the role recovery mutual aid organizations such as Narcotics Anonymous (NA) can play and are playing in the national response to opioid addiction. If NA is mentioned at all in public or policy discussions of opioid addiction, it is as a fleeting reference to its existence as a post-treatment referral option, or, more frequently, in criticism of its alleged hostility toward maintenance medications in the management of opioid addiction.

The writers identify 11 misconceptions about NA that contribute the neglect of this story:

Misconception 1: NA is a treatment for opioid addiction and other substance use disorders.

Misconception 2: NA meetings and the NA program are not widely accessible.

Misconception 3: NA suffers from a lack of members in long-term recovery. (Variations: There are no “oldtimers” in NA like those found in AA. There is too much street culture in NA. Opioid addicts should be referred to AA rather than NA because AA has a stronger recovery culture. I referred a client to NA, and they were offered drugs at their first meeting. Don’t most NA members have criminal backgrounds? My clients would be offended by the profanity at NA meetings.)

Misconception 4: Opioid-dependent youth should not be referred to NA due to concerns about its effectiveness and safety.

Misconception 5: NA does not effectively serve women, ethnic minorities, and other historically disenfranchised populations

Misconception 6: NA is anti-treatment.

Misconceptions 7: People addicted to opioids do not seek help from NA due to its stance on maintenance medications. People in medication-assisted treatment for opioid addiction should not be referred to NA due to NA’s attitudes toward maintenance medications.

Misconception 8: People with a co-occurring psychiatric illness should not be referred to NA because they will be encouraged to cease using their medications.

Misconception 9: People should not be encouraged to attend NA unless they have a pre-existing religious orientation that would make a Twelve-Step program acceptable to them.

Misconception 10: NA (Twelve-Step) involvement is another form of dependency (one addiction for another) that personally and politically disempowers its members, compromises quality of life, and perpetuates social isolation within a drug-oriented social network.

Misconception 11: NA does not have a role in reducing the social costs of opioid addictions nor in other social contributions

What do they see as the most neglected story in opioid addiction?

There is a pervasive pessimism about the long-term prospects of recovery from opioid addiction. Tens of thousands of NA members in long-term recovery from opioid addiction stand as a living refutation of such pessimism. That fact is the least told story in the public media and in professional discussions of opioid addiction.

This paper perfectly captures a recurring theme of this blog. I’m grateful they’ve shone a light on this story that is omitted from the current narratives about the opioid crisis.

A message for the recovery advocacy movement to promote?

It would seem that this makes the case for more recovery advocacy efforts to get this story out there, right? Especially with Bill White said the following in his post introducing the paper, “Tens of thousands of NA members in long-term recovery from opioid addiction stand as a living refutation of such pessimism.”

So, where are they? Why aren’t advocacy groups countering pessimism with this particular story?

Well, sharing this particular story gets complicated. (This story is often present, but in a vague or generic way that omits any reference to a drug-free path.)

According to the paper, NA “publications define the NA program as one of complete abstinence, including abstinence from maintenance medications used in the treatment of addiction.”

The current recovery advocacy movement is so committed to affirming MAT and other paths to recovery that celebration of a drug-free path is often viewed as divisive and stigmatizing. (Some of this advocacy emerges from grassroots, some from federal funding, some from media narratives and some from professional interests.)

It’s also becoming a difficult to discuss topic in professional settings. For example, I attended a speech and panel with Michael Botticelli and the University of Michigan and an audience asked about the the place of drug-free treatment in policy and advocacy. While Mr. Botticelli was very polite, the question was met with condescension and head-shaking (literally) by other expert panelists and it was responded to as though it were a manifestation of ignorance and stigma.

For another example, I recently posted about the The Unicorn Project, a local advocacy project with the following core message:

Media reports and comments from “experts” give the impression that opioid addiction (heroin, vicodin, etc.) is a near hopeless condition and that the only hope is maintenance on other opioids (buprenorphine and methadone).

Some of these reports acknowledge that there are people who achieve drug-free recovery, but imply that they are extremely rare. It almost sounds like everyone’s heard of them, but no one’s seen one—like unicorns.

We know this isn’t true.

We want people to know that opioid addicts can achieve full recovery without opioid maintenance drugs. And, it’s not rare or unusual when people get the right kind of help.

This post received several angry messages via comments, facebook and email.

Why? Is the unicorn message exclusive? Does it put down other paths to recovery? Here are a few of the messages from the site.

We’re not here to argue that medications like buprenorphine and methadone are bad, or that our path to recovery or one form of treatment is better than another.

. . .

We believe that all addicts should have reasonable access to the full array of evidence-based treatment and recovery support services, including MAT, detox, outpatient treatments, long-term residential, case management, peer support etc.

. . .

We have no interest in ranking recovery, declaring one form as superior to another or invalidating any path to recovery–someone achieving recovery with the assistance of medication or through a faith community is not inferior to any other form of recovery. Any addict achieving recovery, whatever their path, is cause for celebration.

Further, any addict who has not yet sought or achieved recovery is deserving of respect.

 

So, it doesn’t rank paths to recovery, says all recovery should be celebrated and even argues for access to MAT.

This begs the question of whether there’s room for inclusion of this particular message in the current recovery advocacy movement (particularly with the influential role of government funds) without push-back from other advocates that this message contributes to overdose deaths and stigmatizes MAT patients.

I’m not suggesting the inclusion of this message and exclusion of other messages. But, is there room for advocates to say, “Saving lives with naloxone is great, but what comes after the overdose rescue?” or “Maybe some of that $1.1 billion should go to helping people who want drug-free treatment.”  or “You know, there are tens of thousands of people in drug-free recovery from opioid addiction in NA alone. Most of them probably got inadequate treatment. Imagine what’s possible if we provided access to drug-free treatment of adequate quality, intensity and duration? Maybe we should advocate for that too.”

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Sentences to ponder

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from: Restoring Sanctuary: A New Operating System for Trauma-Informed Systems of Care by Sandra L. Bloom, Brian Farragher on adaptive vs. technical problems in helping relationships.

In human service delivery, we have a historical burden to carry in that there is a long-standing belief that in our line of work we are dealing with technical problems. A client carries a diagnosis, and that means we give him or her a medication or a specific behavioral plan and the client should respond. Technical problems generally lend themselves to cookbook kinds of solutions such as “Ten Easy Steps to Put Your Backyard Grill Together” or “The Proper Procedure for Filling XYZ Form.”

But in reality, the problems we are dealing with are generally adaptive problems, problems that have never been solved before. We may have solved a problem like this one before but not this one. This is a different client. This is a different day, a different year. The people involved in delivering the new response are different. There are always different variables that make this problem different from the last one. Every story is a different story; every reenactment is a different reenactment.

Because our work is so complex and outcomes are so uncertain, we yearn for technical problems; as a result, we often treat adaptive problems as if they were technical problems.

This is not meant to suggest that addiction is a adaptive. However, many of the behavioral, social, cognitive, emotional, psychiatric and spiritual barriers we face are adaptive.

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Is rehab “outdated, expensive and deadly”?

This article, calling rehab “outdated, expensive and deadly” is wrong about some important things and right about some important things.

What it gets wrong

On medication assisted treatment (MAT):

  • It overstates the effectiveness of buprenorphine. If the medication “eliminates” and is so “effective”, you think they’d have better outcomes than this (Which is not an outlier and was spun as proof of buprenorphine’s effectiveness).
  • It gives false comfort about the protective effects of these medications against death by overdose.
    • While the study he linked to did find death rate 50% higher for people receiving only psychosocial support vs. methadone, he failed to acknowledge a few other points of interest.
      • First, who thinks psychosocial support is an adequate intervention for opioid addiction?
      • Second, 47.5% of all overdose deaths were people currently enrolled in methadone treatment.
    • I’ve blogged before that the death rate for people in MAT. It’s still very high. See here, here and here for just a few examples.
    • There’s no argument that being on an opiate replacement drug reduces overdose risk, but only if they take the drug and those drugs have big patient retention problems too. (Here, here, hereherehere and here.)
  • It give a false impression that MAT is unavailable to most people with opioid addiction.

While he paints maintenance assisted treatment with a broad positive brush, he paints abstinence-based treatment with a broad negative brush. In doing so, he fails to mention that there is a model, in which residential treatment is one element, that has far superior outcomes to other approaches. This model is the gold standard and is used with addicted pilots and health professionals. (Yes, there are questions about about how differences in recovery capital and motivation might influence outcomes. But, it’s worth mentioning, isn’t it? Isn’t it reasonable to believe there’s a lot that can be learned from these programs?)

GotEthicsNewWhat it gets right

  1. Treatment for opioid addiction that amounts to little more than detoxification—getting the patient to 30 days abstinent—and not following that care with robust recovery monitoring and support is dangerous.
  2. There are a lot of phony success rates touted—in abstinence-based treatment and MAT.
  3. Exorbitant fees for residential and inpatient treatment are common.
  4. Charging large sums of money for inadequate care and making misleading success claims amounts to financial exploitation.
  5. There is too little consistency and accountability in all forms of treatment—abstinence-based and MAT. There is a lot of bad care out there.
  6. The opioid crisis is drawing attention and money to addiction treatment. As a field, the cost of failure will be huge and will set us back decades.
  7. The length of treatment is driven by funding rather than patient need or a gold standard of care—in abstinence-based treatment and MAT.
  8. Most programs do not provide good informed-consent—in abstinence-based treatment and MAT.

The writer doesn’t say this, but an implication of his arguments is that too many services focus on recovery initiation and too few focus on recovery maintenance.

The gold standard model includes eight, ten or fourteen elements (depending on how you count them). Offering just a few of these elements is common practice. That practice is inadequate, possibly dangerous and any marginally informed professional should know better.

What to do about it?

A sad fact is, for far too many people, their choices are inadequate medication-free treatment or inadequate medications assisted treatment (MAT). Given these choices, for a lot of people, inadequate MAT is probably less bad than inadequate medication-free treatment.

I write frequently about the gold standard of care—the care that addicted doctors receive. They have outstanding outcomes. (I’ve even suggested that abstinence vs. MAT arguments may be a distraction from focusing on the need for long term recovery management.)

A lot of people express doubt about whether than model can be adapted to meet the needs of other people with addiction.

All of these concerns have merit. Yet, we don’t really know because we haven’t tried.

I believe we should put effort into adapting and delivering the gold standard to all people with opioid addiction.

Where we can’t offer the gold standard to patients, we should at least tell them it exists, but it’s too expensive or there are no providers. (But, not necessarily at the expense of anything else.) Where can offer some, but not all, elements of the gold standard, we should share that information too.

Critics of abstinence-based treatment are right that there has been too little meaningful informed consent.

People with addiction should be told about the treatments that exist, and the evidence for them. When discussing the evidence for an approach, they ought to be informed about the extent to which the evidence aligns with their goals.

Then, they should be told about the treatments that are available to them. And, they ought to be told why some treatments aren’t available to them—not covered, too expensive, no provider available, policy barriers, etc.

Then, they should be free to choose the treatment they prefer. And, within reason, they should be free to change their mind.

 

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Update. FULL 911 Good Samaritan Legislation in Michigan

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Good news!!!

There are 2 bills in the Michigan House of Representatives Criminal Justice Committee that would would provide immunity from criminal charges for people all ages who are seeking emergency medical assistance for themselves or friends as a result of a drug overdose from any illicit drug.

Rep. Pscholka’s bill, House Bill 5649, provides immunity from possession penalties in certain circumstances.

Rep. Singh’s bill, House Bill 5650, provides immunity from use penalties in certain circumstances.

These bills expand upon last years House Bill 4843 by removing limitations based on age and type of drug.

The House Criminal Justice Committee will be taking up these bills on Tuesday, May 17, 2016 at 9:00 AM in Room 327, House Office Building, Lansing, MI.

Contact the House Criminal Justice Committee to let them know you support these bills.

Background

The Facts

Keep these facts in mind:

  • Overdose is now the leading cause of accidental death in the U.S. Most of these overdose deaths are due to opioids.
  • If help arrives in time, overdoses can be safely and quickly reversed with a squirt of naloxone up the patient’s nose.
  • More than half of all overdoses occur in the presence of other people, usually other drug users.
  • Too often, people do not call 911 in a timely manner due to fear of arrest for possession of drugs.

A First Step

At the urging of parents who have lost children to overdose, the Michigan legislature made some good first steps last year. They enacted laws that increased access to naloxone, the drug that reverses overdoses.

On October 13, 2014, Public Acts 311, 312, 313 and 314 of 2014 were signed into law.

These acts will:

  • Allow Narcan to be prescribed to friends and family of heroin addicts, so it’s readily available in the event of an overdose.
  • Protect a person administering Narcan in good faith to be immune from criminal prosecution or professional sanctions.
  • Require emergency medical personnel to carry the drug in their vehicles and be trained in how to administer it.
  • Require the state Department of Community Health to complete annual reports of opioid-related overdose deaths.

Another Step

Last summer, Michigan Rep. Al Pscholka (R-Stevensville) introduced House Bill 4843, a bipartisan measure, that would create Good Samaritan protections for individuals under the age of 21 who seek medical attention for themselves or another person believed to have overdosed. However, the Good Samaritan protections are limited to the illegal possession of prescription drugs (in quantities consistent with personal use) for people under the age of 21.

Last December the Governor signed the Good Samaritan Bill, House Bill 4843, into law.

911 Good Samaritan Laws

NARCAN-KITThe Drug Policy Alliance provides a really good summary of 911 Good Samaritan laws:

Accidental overdose deaths are now the leading cause of accidental death in the United States, exceeding even motor vehicle accidents among people ages 25 to 64. Many of these deaths are preventable if emergency medical assistance is summoned, but people using drugs or alcohol illegally often fear arrest if they call 911,  even in cases where they need emergency medical assistance for a friend or family member at the scene of a suspected overdose.The best way to encourage overdose witnesses to seek medical helpis to exempt them from arrest and prosecution for minor drug and alcohol law violations, an approach often referred to as Good Samaritan 911.

The chance of surviving an overdose, like that of surviving a heart attack, depends greatly on how fast one receives medical assistance. Witnesses to heart attacks rarely think twice about calling 911, but witnesses to an overdose often hesitate to call for help or, in many cases, simply don’t make the call. In fact, research confirms the most common reason people cite for not calling 911 is fear of police involvement.

It’s important to know that this is not a liberal vs. conservative or Republican vs. Democrat issue. Some of the reddest and the bluest states in the country have passed 911 Good Samaritan laws.

Twenty states and the District of Columbia have enacted policies to provide limited immunity from arrest or prosecution for minor drug law violations for people who summon help at the scene of an overdose. New Mexico was the first state to pass such a policy and has been joined in recent years by Alaska, California, ColoradoConnecticut, Delaware, Florida, Georgia, Illinois, LouisianaMaryland, Massachusetts, Minnesota, New Jersey, New York, North Carolina, Rhode Island, Vermont, Washington and Wisconsin.

Further, these laws don’t protect dangerous or predatory criminals.

Good Samaritan laws do not protect people from arrest for other offenses, such as selling or trafficking drugs, or driving while drugged. These policies protect only the caller and overdose victim from arrest and/or prosecution for simple drug possession, possession of paraphernalia, and/or being under the influence.

The Bad News

An overdose is a major medical crisis, right? It’s not unlike a heart attack.

Here’s what happens when someone has a heart attack41KSA2GA12L._SX300_

  1. A person has a heart attack at the grocery store and . . .
  2.  . . . thank goodness, the store has an automatic defibrillator.
  3. Someone has been trained to use the defibrillator and performs the rescue.
  4. Someone else calls 911 to make sure the patient gets all the care they need.
  5. The patient is taken to the emergency department and medically stabilized.
  6. Once stabilized, the patient gets transferred to care that will address the cause of the heart attack and/or care that will prevent future heart attacks.
  7. The patient’s treatment plan will generally include lifestyle changes. (Diet, exercise, etc.)
  8. Then, the patient gets follow-up care that might include:
    • follow up appointments with specialists,
    • periodic tests to monitor for indicators of a recurrence,
    • self-monitoring (blood pressure), and
    • monitoring by the patient’ primary care physician.
  9. If problems recur or there are indications of a potential recurrence, the care plan will be re-evaluated and the patient will get whatever care they need.

Here’s what happens when someone ODs and is rescuednarcan

  1. A person overdoses and . . .
  2.  . . . thank goodness, the someone has naloxone.
  3. The person has been trained to use naloxone and performs the rescue.

Maybe, if they are lucky, these steps happen.

  1. Someone else calls 911 to make sure the patient gets all the care they need.
  2. The patient is taken to the emergency department and medically stabilized.

Naloxone is not enough.

We’d never tolerate cardiac patients being sent home without the proper care. Why should people with an addiction be treated any differently?

The good news

The good news is that there are models that work.

The Gold Standard

A male doctor writes on a patients chart.The best example of what should happen is the the kind of care that opioid addicted doctors, nurses, pilots and lawyers get. They all have low relapse rates and return to work at very high rates.

Here’s what would happen if one of them overdosed at work (or if it was known to their employer):

First, the recovery planning begins with some important assumptions:

  • abstinence is the goal;
  • full recovery with a return to full functioning is the expectation;
  • addiction is a chronic illness and recovery requires long term treatment, support and monitoring; and
  • for recovery to be durable, the addict must be an active participant in treatment and recovery maintenance.

Signpost along the road to recovery.The recovery plan is likely to include the following:

  • Formal treatment. The first phase of formal addiction treatment for most of these professionals is residential care ranging from 30 to 90 days.
  • Supportive services. Supportive services used by these professionals includes AA or NA 12-step groups, aftercare groups from their formal treatment programs, and follow-up from case managers.
  • Long-term support and monitoring. After completion of initial formal addiction treatment, they develop a continuing care contract consisting of support, counseling, and monitoring for usually 2 to 5 years.
  • Drug testing. Regular testing for 2 to 5 years, usually with more frequent testing at the start and reduced testing following periods of stable negative drug test results.
  • Dealing with relapse. Relapses are usually addressed by a combination of increased intensity of care and monitoring and by immediately informing family and colleagues of the physician to enlist their support.

Other options

Buprenorphine (Suboxone) and methadone have been shown to reduce drug use, overdose risk, criminal activity and disease transmission.

Some people are able to stabilize and live normal lives on these medications but, at this point, there is no research demonstrating its effectiveness with quality of life indicators like employment.

Many people hope to use these drugs as an interim step toward abstinence. However, there is no established model for successfully transitioning buprenorphine and methadone patients to abstinence. A large federally-funded study attempting to do this reported, “near universal relapse.”

Another option is an injectable drug called Vivitrol. It is injected once per month and can protect against overdose. Unfortunately, it’s very expensive.

Which to choose?

Hope Traffic SignThe gold standard offers a path to full recovery, but it does demand a lot of structure, effort and lifestyle changes.

Many professionals prefer drug maintenance as a goal. It’s an easier plan to implement and many professionals are not confident that their patients are capable of drug-free recovery. (Look for professionals that are optimistic and believe in you ability to achieve full recovery.)

However, most patients and families, for a wide variety of reasons, prefer abstinence as a goal–the most common reason is that they want their life back the way it was before they became addicted.

Patients not sticking with the treatment plan is the biggest barrier to success with both approaches.

It’s harder than it should be

Getting the gold standard for yourself or a family member is likely to be very difficult. But, there are steps you can take to improve the odds.

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