Dangerous Treatment and the Science of Safety

We are concerned about the dangers of addiction as never before. For good reason–the opioid epidemic has become an overdose epidemic.

One undercurrent in the coverage of the issue is the implication that abstinence-based treatment contributes to overdose deaths. (There’s no question maintenance drugs reduce overdose risk and short term abstinence-based treatment of opioid addiction is irresponsible. However, there’s a lot more to the story. I’ve addressed this in several previous posts.)

A recent Addiction Professional article includes a sidebar entitled, “Dangers of drug-free treatment“.

This is pretty frustrating when the gold standard is abstinence-based and is restricted to a few elite groups.

Then, right on time, comes Kevin McCauley with his new video, Memo to Self: Protecting Sobriety with the Science of Safety.


McCauley introduces us to the Swiss Cheese Model of safety that he borrows from his background in aviation.

He uses this safety framework to propose a plan for protecting recovery. He proposes 10 protective layers. (Or, if you prefer, layers of cheese.)

His 10 layers are as follows:

  1. Treatment (residential or inpatient)
  2. A therapist, coach, and/or advocate (for regular recovery maintenance check-ups)
  3. Recovery residences
  4. Mutual support groups
  5. A relapse plan
  6. Drug testing (frequent and prolonged)
  7. Job or school (for meaning and purpose)
  8. An addiction medicine specialist
  9. Medication
  10. Hedonic rehabilitation (learning to have fun in recovery)

sw_not_aligned

Within this frame each layer provides a layer of protection and choosing to remove a layer increases the risk of relapse. This safety frame provides a way to make these risk increasing decisions more concrete and less emotionally charged. If there’s good reason to remove a particular layer, it also sets up exploration of what might be done to add another layer to replace it.

Unlike most educational videos, it’s not boring, preachy and tedious. McCauley gets us to laugh at his story and, in doing so, gets us to reflect on our own experiences with the distorted thinking of early recovery and see the importance of building protective layers to get the very precarious early months of recovery.

Further, one of the limitations of all lifestyle medicine approaches has been the dearth of knowledge about maintaining change over years and decades. This safety model provides a way of thinking through what layers are needed, not just to achieve stable recovery, but also to maintain stable recovery over years and decades.

The too-frequently and simplistically proposed solution (prescription?) for the overdose epidemic is opioid replacement medication, like buprenorphine or methadone. This model makes plain that, at best, these medications (or others, like vivitrol) compose only one layer of a safety plan. Of course, going to inpatient treatment is also only one layer.

Unfortunately, the treatment system does not deliver anything resembling this model for anyone other than doctors, pilots and possibly lawyers. This makes the video and model especially important for programs that want to improve their services as well as families and addicts that want to piece together these layers of protection on their own.

This video is a real service to treatment providers, advocates, families and addicts. It is highly recommended.

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Most popular posts of 2015 – #1 – Why so irrational about AA?

AA isn't the only way to recover, but no reasonable person can say it's ineffective.

AA isn’t the only way to recover, but no reasonable person can say it’s ineffective.

Gabrielle Glaser has gotten another AA bashing article published and it’s getting a lot of attention. Of course she doesn’t really offer a tangible alternative.

I’m not going to write another piece rebutting it, but I’ll point you to a few relevant posts.

First, in New York magazine, Jesse Singal dismantles Glaser’s arguments.

As with any story about a complicated social-science issue, there are aspects of Glaser’s argument with which one could easily quibble. For one thing, she repeatedly conflates and switches between discussing AA, a program that, whatever one thinks about it, is clearly defined and has been studied, in one form or another, for decades, and the broader world of for-profit addiction-recovery programs, which is indeed an underregulated Wild West of snake-oil salesman offering treatments that haven’t been sufficiently tested in clinical settings. Her argument also leans too heavily on the work of Lance Dodes, a former Harvard Medical School psychiatrist. He has estimated, as Glaser puts it, that “AA’s actual success rate [is] somewhere between 5 and 8 percent,” but this is a very controversial figure among addiction researchers. (I should admit here that I recently passed along this number much too credulously.)

But on Glaser’s central claim that there’s no rigorous scientific evidence that AA and other 12-step programs work, there’s no quibbling: It’s wrong.

Next, one of my previous posts lays out the evidence for the use of 12 step groups.

Then, here are some of my responses to Dodes.

Finally, some posts on addiction treatment and recovery being made a front in the culture wars, including a response to a previous Glaser article.

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Most popular posts of 2015 – #2 – We all wish love was enough

fear_false_evidence_appearing_realThis article, claiming to have discovered the long suppressed cause of addiction, has been making the rounds and has been recommended by a lot of people.

Like a lot of things, it contains some truth but is not the Truth.

People generally bring up rat park and returning Vietnam vets to advance 2 arguments.

  1. That you can’t catch addiction by just being exposed to the drug.
  2. That environment is the real problem. If you put people in bad environments, they’ll look like addicts. If you enrich addicts’ environments, they’ll stop being addicted.

I whole-heartedly agree with argument #1. You can expose 100 people to drugs like cocaine and heroin and a relatively small minority will develop chronic problems–5 to 23, depending on the study you look at. So, even if the outlier studies were true, we’re still talking about 77% not becoming addicted.

Every field has its goofballs, but in my two decades in the field I have not heard any serious practitioners or researchers argue that simple exposure (even to large doses over an extended period) causes addiction.

Argument #2 is much weaker. It’s my understanding that follow-up studies with rats have failed to reproduce these findings and suggested genetic factors were important. The strongest statement you can make about environment is that it is a risk factor, but not anything approaching a cause.

As for returning Vietnam vets, this is from a post I wrote a few years ago:

These stories often ignore the fact that:

“. . . there was that other cohort, that 5 to 12 per cent of the servicemen in the study, for whom it did not go that way at all. This group of former users could not seem to shake it, except with great difficulty.”

Hmmmm. That range….5 to 12 percent…why, that’s similar to estimates of the portion of the population that experiences addiction to alcohol or other drugs.

To me, the other important lesson is that opiate dependence and opiate addiction are not the same thing. Hospitals and doctors treating patients for pain recreate this experiment on a daily basis. They prescribe opiates to patients, often producing opiate dependence. However, all but a small minority will never develop drug seeking behavior once their pain is resolved and they are detoxed.

My problem with all the references to these vets and addiction, is that I suspect most of them were dependent and not addicted.

So…it certainly has something to offer us about how addictions develops (Or, more specifically, how it does not develop.), but not how it’s resolved.

Why is it so frequently cited and presented without any attempt to distinguish between dependence and addiction? Probably because it fits the preferred narrative of the writer.

So. . . rat park and returning Vietnam vets are not quite what he describes. Let’s continue.

I do appreciate the article’s call for compassion and I am a believer that purpose, meaning and connection are important elements of stable recovery. However, as I continue reading the article, I am reminded of Ralph Waldo Emerson:

Their every truth is not quite true. Their two is not the real two, their four not the real four; so that every word they say chagrins us, and we know not where to begin to set them right.

mencken-complex-problemHe says that addiction that begins with  prescribed pain medication “virtually never happens.” Well, it’s hard to pin down exactly how often it happens, due to chicken and egg questions related to how many pain patients have pre-existing substance use problems. However, reported estimates range from  “from 2.8% (Cowan et al., 2003) to 50% ( Saper et al., 2004).”

What about the Portugal miracle? We’ll a few things to keep in mind. First, the decriminalization approach is focused on getting addicts into treatment. Housing and treatment may be addressed, but it’s clear the focus is on treatment. Second, Portugal was starting from the position of a terrible heroin problem. They’ve gone from 1% addicted to 0.5% addicted. That’s great, but to provide a little context, the National Survey on Drug Use and Health pegs current heroin users at 0.1% of the U.S. population.

So . . . the article doesn’t tell the whole story, it oversimplifies some very complex issues and presents us with straw man arguments. (Who says that anyone who uses heroin is going to get hooked for life? [Note that he had to go back to a commercial from the 1980s and that a search for the reported text of the commercial only produces references to his article.] Or, that behavioral, environmental, social and other factors are unimportant in the development, course and recovery from addiction?)

I also worry about the implied message that we just love them enough, they’ll get well. I see countless families that provide housing, jobs, connection and love–only with watch their loved one slip further and further into addiction.

Addiction is a complex problem. Multiple factors influence it’s development, course and resolution. This is always the case with chronic disease. There’s a cultural narrative out there that addiction is not a disease, that it is rational, that it’s a product of environment, that it’s a learning disorder, that framing it as a disease is a foundation for violating individual liberties and that recovery needs to be redefined. Intended, or not, stories like this are part of that narrative.

I don’t engage in ad hominem arguments, but, while we’re on the topic of narratives, it would seem strange to not point out that this author has a history of playing fast and loose to advance a narrative.

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Most popular posts of 2015 – #3 – The treatment system is failing opiate addicts

Doha15Stories like this are getting a lot of attention lately:

State Sen. Chris Eaton is planning to introduce legislation to encourage opiate treatment providers and doctors to break with an abstinence-based model and embrace evidence-based practices for treating addiction, the Minnesota Democrat told The Huffington Post.

I want to make it clear that I know nothing of Senator Eaton and am not questioning her motives.

If this was really motivated by a desire to spread evidence-based treatments, there’d be another, more interesting debate brewing.

That debate would be whether Senator Eaton should introduce legislation requiring that Physician Health Programs (PHP) start treating addicted health professionals with maintenance medications.

I doubt Senator Eaton wants that. I doubt she even knows much about Physician Health Programs. Her source of information about opioid addiction treatment was the Huffington Post article that painted abstinence-based treatment as hopelessly anti-evidence and ineffective while painting maintenance medications as THE answer to this problems that’s been with us for ages.

Why would she want to change opiate addiction treatment for the general population, but not for doctors? Because the treatment system for the general population is failing addicts and their families while the Physician Health Programs are producing outstanding outcomes.

Is the difference that one is abstinence-based while the other uses maintenance medications? No.

The difference is that PHPs get treatment and recovery support of an adequate quality, intensity and duration while the general population does not.

Debra Jay identified 8 essential ingredients in PHPs:

  1. Positive rewards and negative consequences
  2. Frequent random drug testing
  3. 12 step involvement and an abstinence expectation
  4. Viable role models and recovery mentors
  5. Modified lifestyles
  6. Active and sustained monitoring
  7. Active management of relapse
  8. Continuing care approach

PHPs provide treatment, recovery support and monitoring for up to 5 years and 85% of participants have no relapses. Of the 15% who relapse, most of them have only one relapse over that 5 year period.

Will maintenance medications improve treatment for the general population? It’s hard to imagine they will when they have the same retention problems that abstinence-based treatments have. Further, most of the treatment delivered with maintenance medications suffers from the same problem as abstinence-based treatment– inadequate quality, intensity and duration. (By duration, I mean the accompanying behavioral support as well as retention on the medication.)

So . . . this solution really focuses on the wrong problem.

The problem isn’t that treatment is abstinence-based. The problem is that abstinence-based and maintenance treatments too often do not provide adequate quality, intensity and duration.

So, why advocate to spread access to a treatment we won’t use on addicted physicians rather than spread access the gold standard of care that addicted physicians receive? That’s the danger of advocacy journalism that is dressed up as objective reporting.

I’m grateful to work in a place the works so hard to increase access to treatment and recovery support of an adequate quality, intensity and duration.

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Most popular posts of 2015 – #4 – Hari and the truth


Johann Hari is getting a new wave of attention after a recent TED talk. I’m not surprised he’s getting so much attention. He’s a great story teller with a compelling narrative.

However, while is narrative does contain some important truths, he’s just plain wrong about the cause of addiction.

Over the next few days I will repost some previous posts on his book and articles.

First, I’ll bottom-line his thesis.

  • Do lack of purpose and connection cause addiction? No.
  • Are purpose and connection important? Yes.
  • Could lack of purpose and connection influence the onset and course of addiction? Yes.
  • Are creating purpose and connection important elements in facilitating recovery for many addicts? Yes.
  • Do lack of purpose and connection cause addiction? No.

Hari has a history of playing fast and loose to advance a narrative. I’ll point out just one of those today, his discussion of Portugal.

Hari:

In the year 2000, Portugal had one of the worst drug problems in Europe. One percent of the population was addicted to heroin, which is kind of mind-blowing, and every year, they tried the American way more and more. They punished people and stigmatized them and shamed them more, and every year, the problem got worse. And one day, the Prime Minister and the leader of the opposition got together, and basically said, look, we can’t go on with a country where we’re having ever more people becoming heroin addicts.

What really happened:

Hannah Laqueur, a rising young scholar at UC Berkeley, asks a novel question in her analysis of Portugal: Is there any evidence that the 2001 law actually was a radical move from criminalization to decriminalization of drug use? Looking at the 8 years of data prior to the law, she found that the average population of people in prison for simple drug possession was about 21. Not 21% of prisoners but 21 people in a nation of 10 million!. Prior to the elimination of prison sentences in 2001, drug possession convictions accounted for just 0.3% of Portugal’s prison population.

The 2001 law’s removal of incarceration as a penalty was thus simply a formalization of longstanding criminal justice policy. Looking at drug use indicators before and after 2001 and attributing any change to the “radical decriminalization” is thus wrong-headed because no such change occurred.

Not as dramatic, huh?

Why would a journalist make such a mistake? Probably because the truth doesn’t fit with his narrative. And, this is the pattern in Hari’s book–he cherry-picks and massages evidence to support his narrative.

Related posts here.

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Prisons or spas?

housing3The Huffington Post continues its longform advocacy journalism on the issue of medication assisted treatment.

Jason Cherkis puts his attention on a real issue of rural access to medication assisted treatment by sharing the story of a South Dakota man who travels 350 miles to get his buprenorphine prescription.

Anyone who wants access to this treatment should have access to it and should not have to drive hundreds of miles.

Unfortunately, in making this case, he repeats some of the mistakes of earlier articles.

Parts of it read like a Reckitt Benckiser marketing pitch.

In the U.S., buprenorphine is mainly sold under the brand name Suboxone, in which form it’s combined with naloxone, the drug that can reverse the effects of an overdose. If someone tries to misuse Suboxone by injecting it, the predominant effect will be that of the naloxone, not the buprenorphine. It’s an important safety feature; think of it like an airbag for those with fierce cravings.

spa-300x225Other parts sound like a hit piece on drug-free treatment approaches.

But the U.S. drug treatment system — which is mostly a hodgepodge of abstinence-only and 12-step-based facilities that resemble either minimum-security prisons or tropical spas — has for the most part ignored the medical science and been slow to embrace medication-assisted treatment, as The Huffington Post reported in January.

There is no doubt that there are programs that resemble prisons and others that resemble spas. However, this dichotomy is no more true than stating buprenorphine maintenance programs are mostly a hodgepodge of  programs that resemble amoral pill-mills or medical maximalists who believe the sole solution to every problem is a new pill.

Now, why did the writer frame the issue this way and fail to also advocate for access to the gold standard treatment? If you care about addicts and you care about choice and you’re an objective reporter, wouldn’t this make sense? There’s plenty to criticize on the treatment system and reasonable people can disagree on treatment approaches, but why be so dismissive of one approach (Without questioning whether common problems are issues related to the type of treatment or the execution.) and so uncritically embracing of the other.

 

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Most popular posts of 2015 – #5 – We should re-examine policies for opioid addicted physicians?

can of wormsThis is interesting.

A physician posted a message to an ASAM discussion board about his dissonance related to working in a treatment facility that does not use opioid maintenance treatments. Specifically, buprenorphine.

ASAM turned the message board post into a magazine article and summarizes responses to the message.

There’s a lot that one could respond to. However, there’s one point I’d like to draw your attention to. Among the solutions highlighted in the article is this:

Restrictive policies on MAT also affect physicians who themselves may have opioid use disorder. This should be re-examined as a part of advocacy and future work[2-8].

If you don’t know a lot about this, this might seem like a pretty uncontroversial proposal.

Let’s step back and consider this for a moment.

  • The doctor is frustrated that his non-physician colleagues and decision makers do not support his preferred approach.
  • He posts a message on a board for other addiction physicians and seeks some guidance.
  • They cite evidence (We could ask, “evidence for what?“) and suggest that ignorance, fuzzy thinking, greed and ideology are preventing the advancement of their preferred approach . . .
  • AND, they note that the model of care for addicted physicians, Physician Health Programs (PHPs), also rejects their preferred approach.
  • Because of this, they suggest re-examining the PHP approach to include their preferred approach.

Now, a little about PHPs:

Now, a little about their preferred approach:

  • The alternative that they are proposing doesn’t quite live up to their hype. (For a few examples, look here, here and here.)
  • The evidence base for the alternative they are proposing focuses on different outcomes–like reduced drug use, reduced disease transmission, reduced overdose and reduced criminal activity–rather than stable recovery.

So, let’s review:

  • Some addiction docs are frustrated about the lack of acceptance of opioid maintenance medications and are engaged to advocacy to legitimize them.
  • However, they do not use them with their peers. They’ve found a better way. The PHP approach is viewed as the gold standard because of its outstanding outcomes for addicted physicians and patient safety.
  • Now, they suggest that the field should re-examine the gold standard, to replace it or integrate their preferred approach (which has poor outcomes relative to the PHP model) with the goal of conferring legitimacy on their preferred approach.
  • This should be done to overcome the ignorance, fuzzy-thinking, greed and ideology preventing the legitimization of their preferred approach.

This isn’t to suggest that abstinence-based providers are good while other providers are bad. Or, that there’s no place for these medications in the treatment of addictions. I just want patients to have full informed consent and access to quality care of an appropriate duration and intensity.

However, the suggestion that addiction docs should tinker with the gold standard (that produces outstanding outcomes and protects patients) so that they can promote an approach with shaky outcomes is cause for skepticism of their efforts and risks de-legitimizing both approaches.

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