“unintentionally comical” – Johann Hari’s Chasing the Scream

stop with the factsSeth Mnookin reviews Chasing the Scream and finds its review of the science troubling. (Previous post on Hari here.)

The first tip-off that Hari might be in over his head comes when he describes how “a small band of dissident scientists” had uncovered the answers he was looking for after working “almost unnoticed, for several decades.” Hari starts with Gabor Mate, a Hungarian-born Canadian physician whose theories about how the roots of addiction (and lots of other things to boot) can almost always be found in childhood trauma are, in fact, quite well known. To support his portrayal of Mate as a fringe renegade, Hari acts as if a rigid, deterministic model of addiction as a purely physical disease is almost universally accepted; if anything, the opposite is true. Even more problematic is Hari’s wholesale acceptance of Mate’s reductionistic approach when, in fact, there’s a significant body of work demonstrating its shortcomings.

The next researcher to benefit from Hari’s credulousness is Bruce Alexander, a Canadian psychologist who believes that drugs are not the cause of drug addiction. Alexander is best known for his “Rat Park” experiments in the 1970s, which were designed to demonstrate that rats in stimulating, social environments would not become addicted to morphine while rats in cramped, metal cages would. Hari explains why Alexander’s views have not been universally embraced by making the preposterous assertion that “when we think about recovery from addiction, we see it through only one lens — the individual.”

A few pages later, Hari is talking to a Welsh psychiatrist named John Marks, who is a proponent of providing prescription narcotics to addicts. Hari supports Marks’s claims by referring to “research published in the Proceedings of the Royal College of Physicians of Edinburgh” but then buries in the notes the fact that it was Marks himself who was the author of that research. Sometimes, Hari’s unquestioning acceptance of what these researchers say is unintentionally comical: At one point, he quotes Alexander explaining that drug addicts don’t get clean because they would rather spend their time doing “exciting things like rob stores and hang around with hookers.”

Read Mnookin’s entire review here.

4 Comments

Filed under Uncategorized

it will not always be so

minimalwall-hope-10-78-1“The chronicity of addiction is really a kind of fatalism writ large. If an addict knows in his heart he is going to use someday, why not today? But if a thin reed of hope appears, the possibility that it will not always be so, things change. You live another day and then get up and do it again. Hope is oxygen to someone who is suffocating on despair.”–David Carr

[Thanks Janice]

1 Comment

Filed under Uncategorized

12 step groups and meds

SAMHSA-recovery-definitionFrom Melissa Petro on After Party Chat:

I’m hardly an AA advocate; I don’t even do the program anymore. But what Cherkis claims simply wasn’t my experience. Sure, there are individual members who have their own beliefs and experiences about prescription medication—and, yes, some of them have gone on to establish facilities in the name of 12 step—but “We are not doctors” is the official party line. This is what I learned as a member of the program. Never was I taught, nor did I believe, that it was my right to police another person’s sobriety. In this day and age, given the proliferation of prescription medication, including medicine for pain, most 12-steppers I know don’t even think about sticking their noses in another person’s medicine cabinet.

 

3 Comments

Filed under Uncategorized

Drug courts and the “wonder drug”

keep-calm-and-watch-and-learnAnyone who reads this blog regularly knows that the evidence for Suboxone has been oversold and that it often does not address the real-world goals of most addicts or families. They want recovery–a restoration to wholeness and full participation in all spheres of life over the rest of their lifespan. The evidence base for maintenance drugs tends to focus on short term outcomes and on reductions in overdose, disease transmission and criminal justice involvement.

That said, I’ve made it plain that I’m not interested in taking options away from patients, especially well-informed patients.

Along comes this news that the new drug czar is going to require drug courts receiving federal funds allow the use of maintenance drugs. (Under the headline. “Wonder Drug” at Slate.)

It’s got maintenance treatment and harm reduction advocates whoop-whoop-ing. It’s got abstinence-based recovery advocates concerned.

The article begs a lot of questions. For example,

  • If “doctors and scientists view [these drugs] as the most effective care for opioid addicts”, why aren’t more doctors willing to prescribe it? And, why don’t they use these drugs with their addicted colleagues?
  • Why do the authors fail to acknowledge the longer term studies that find poor retention of patients on Suboxone? (Here, here, here, here and here.)
  • How did these “medications, when combined with other behavioral supports” become “the standard of care for the treatment of opiate addiction” when studies have found that people on maintenance medications do not benefit from additional behavioral therapy? (Here, here, here and here.)

However, as a policy matter, given the context within the field, this move makes sense.

Drug courts have sought more than reduced criminal activity. They’ve looked for the same kind of transformational recovery that families often seek. Maybe it’s appropriate for the feds to take these steps. I don’t have any strong feelings about it.

However, this is going to be a very good opportunity to learn a lot about the effectiveness of Suboxone over 12 to 24 months.

  • What will happen when you prescribe it to patients who are in a system that provides long term and robust recovery monitoring with enforced abstinence from illicit drugs and participation in behavioral treatment/support?
  • Will patients want to stay on the drug?
  • If not, will courts treat the decision to discontinue maintenance as non-compliance with treatment?
  • How will improvements in quality of life measures for these participants compare to other participants?
  • Will they experience the same benefits from the behavioral interventions that other participants do?

3 Comments

Filed under Uncategorized

Sentences to ponder

hope“Critical thinking without hope is cynicism. Hope without critical thinking is naïveté.” Maria Popova

Comments Off on Sentences to ponder

Filed under Uncategorized

Addiction, recovery and problem ownership

208071_f260I had a brief but good conversation with a colleague today that reminded me of what’s at stake in the way we define addiction.

How we define addiction determines which helpers and which systems own the problem. Addiction is most frequently being rolled into mental health, but also into criminal justice, public health, traditional medicine, etc.

Of course, good stewardship is important and the categorically segregated addiction treatment system has failed on many counts.

Here are a few thoughts from Bill White on the topic from Slaying the Dragon and some Counselor articles:

On problem ownership:

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

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

On the segregation-integration pendulum:

American history is replete with failed efforts to integrate the care of alcoholics and addicts into other helping systems. These failed experiments are followed by efforts to move such care into a categorically segregated system that, once achieved, is followed with renewed proposals for service integration. After fighting 40 years to be born as an autonomous field of service, addiction treatment is once again in the throes of service-integration mania. This cynical evolution in the organization of addiction treatment services seems to be part of two broader pendulum swings in the broader culture, between specialization and generalization and between centralization and decentralization. Once we have destroyed most of the categorically segregated addiction treatment institutions in America, a grassroots movement will likely arise again to recreate them.

On the historical essence of addiction counseling:

If AOD problems could be solved by physically unraveling the person-drug relationship, only physicians and nurses trained in the mechanics of detoxification would be needed to address these problems. If AOD problems were simply a symptom of untreated psychiatric illness, more psychiatrists, not addiction counselors would be needed. If these problems were only a reflection of grief, trauma, family disturbance, economic distress, or cultural oppression, we would need psychologists, social workers, vocational counselors, and social activists rather than addiction counselors. Historically, other professions conveyed to the addict that other problems were the source of addiction and their resolution was the pathway to recovery. Addiction counseling was built on the failure of this premise. The addiction counselor offered a distinctly different view: “All that you have been and will be flows from the problem of addiction and how you respond or fail to respond to it.”

Addiction counseling as a profession rests on the proposition that AOD problems reach a point of self-contained independence from their initiating roots and that direct knowledge of addiction, its specialized treatment, and the processes of long-term recovery provide the most viable instrument for healing and wholeness. If these core understandings are ever lost, the essence of addiction counseling will have died even if the title and its institutional trappings survive. We must be cautious in our emulation of other helping professions. We must not forget that the failure of these professions to adequately understand and treat addiction constituted the germinating soil of addiction counseling as a specialized profession.

On the soul of the field and its future:

In the face of such threats (managed care, facility closures, merger mania & integration into behavioral health systems), the field is experiencing a strange phenomenon. As the core of the addiction treatment field shrinks, the field is growing at the periphery. Where the total amount allocated to residential and inpatient treatment services is shrinking, the numbers of outpatient services is actually increasing, as is a growing number of new specialty programs that extend addiction treatment services into allied fields. The growth zone of the addiction treatment industry is not at the traditional core but in the delivery of addiction treatment services into the criminal justice system, the public health system (particularly AIDS related projects), the child welfare system, the mental health system, and the public-welfare system. If one looks at these trends as a whole, what is emerging in the 1990s is a treatment system less focused on the goal of long-term personal recovery than on social control of the addict. The goal of this evolving system is moving from a focus on the personal outcome of treatment to an assurance that the alcoholic and addict will not bother us and will cost us as little as possible.

The fate of the field will be determined by its ability to redefine its niche in an increasingly turbulent health-care and social-service ecosystem. That fate will also be dictated by more fundamental issues – the ability of the field to: 1) reconnect with the passion for service out of which it was born; 2) re-center itself clinically and ethically; 3) forge new service technologies in response to new knowledge and the changing characteristics of clients, families, and communities; and 4) the ability of the field to address the problem of leadership development and succession.

Comments Off on Addiction, recovery and problem ownership

Filed under Uncategorized

Schools giving Scientology a platform with students

01This is not new, but it’s good that it’s getting attention again.

A Church of Scientology-backed anti-drug program is spreading its message to students in dozens of city public schools, DNAinfo New York has learned.

The Foundation for a Drug Free World, which was founded in 2006 by the controversial church, visited 30 city public schools last year, providing free anti-drug programs to elementary, middle and high school students in all five boroughs, according to its Facebook page.

Comments Off on Schools giving Scientology a platform with students

Filed under Uncategorized