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.

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.

Reducing overdoses

hand drowning

A new leader in the Open Society Institute shares a sensible perspective on reducing overdoses:

Looking ahead, reducing drug overdoses will require major shifts in how we approach substance use.

First, and possibly most importantly, Maryland needs to connect individuals struggling with addiction to high-quality addiction treatment that is integrated with their primary care. Primary care providers should be monitoring the long-term health and progress of those struggling with addiction, ensuring that the substance use treatment they are receiving dovetails with an overall health strategy.

Next, we need better monitoring of how often pain medication is prescribed. Research indicates there is an increase in the prescription of opioids that is not driven by clinical necessity. Many public health officials have identified the rise in prescriptions of opioids as a significant factor driving pharmaceutical overdose deaths, which quadrupled between 1999 and 2010, and as a gateway to other substances such as heroin.

Additionally, we need to educate patients that prescription drugs are, in fact, highly addictive and should be used with caution. A strategic and hard-hitting public awareness campaign would help people better understand the slippery slope from prescription drugs to street drugs.

And finally, we must undo the stigma that paralyzes individuals struggling with addiction that deters them from seeking help. This will require a shift in public policy — beginning at the highest levels — from criminalization to a focus on the medical and public health implications of addiction.

Top posts of 2014: #6

Suboxone retained 9 of 103
bupe retention

A new study on office-based treatment of adolescents with  Suboxone was just published by the Journal of the American Society of Addiction Medicine.

The good news, drug screens were done at clinic visits and 85% of drug screens were negative for heroin and marijuana. (It’s not clear why they limited testing to these drugs.)

The bad news, most folks stopped coming to the clinic:

Program retention was the major barrier to treatment success (Fig. 1). After 1 visit, 75% returned for a second visit. At 60 days, 45% of patients were still retained, and by 1 year 9% were retained and still active in the program.

This means that, of the 103 young people in the study, 67 of them dropped out within 2 months and 94 dropped out within a year.

This would appear to undermine arguments for buprenorphine as a strategy for preventing overdose deaths.

These retention problems don’t stop the authors from putting a positive spin on it:

We submit these retention rates as preliminary benchmarks against which other approaches might be compared. Considering the chronic relapsing nature of addiction, long-term opioid substitution therapy with BUP/NAL should gain wider acceptance. Outpatient BUP/NAL should be seen as an important component of adolescent and young adult opioid addiction treatment.

Unfortunately, now that this is published, this spin will be used to frame this treatment as evidence-based.

The soul of addiction treatment

dream-dreamer-dreams-girl-Favim.com-1055216I’ve never met Scott Kellogg, but I appreciate his presence in the field. He’s struck me as a pragmatist who tries to find third ways and has a conservative temperament. There are too few people who fit that description.

His recent piece for Substance and  Pacific Standard is on “A Struggle for the Soul of Addiction Treatment.”

I’ve had growing concerns that our field has become a new battleground for the culture wars without many of us even realizing it was happening or conceiving that treatment belonged on any “side” of  a culture war.

This piece is a response to a report called “The New Paradigm for Recovery” that identifies physician health programs, pilot programs and lawyer programs as the gold standard for addiction treatment. (These programs have outstanding outcomes in terms of substance use, as wells as return to employment and other quality of life factors.)

The paper suggests that we should identify the critical elements from these programs and find ways to extend those elements into programs that are available to everyone.

Kellogg uses this response to outline the battle lines. It’s worth noting that the primary objections are philosophical rather than treatment focused.

He characterizes the new paradigm’s model as a moral model that characterizes addicts as “bad”. He suggests it’s born of stigma and perpetuates stigma.

He rejects the disease model and is troubled that treatment is not medical enough.

“The fact that they do not really believe it is a “disease” can be seen in the ongoing opposition to methadone, buprenorphine, and, to a lesser extent, psychiatric medications.”

This is odd, given that, just a few paragraphs earlier he lamented the stature of the authors.

“But it is notable that the working group that produced the report included, in addition to DuPont, such major figures in the field of addiction as Dr. Stuart Gitlow, the president of the American Society of Addiction Medicine; Dr. John Kelly, a major researcher on recovery at Harvard University; Dr. Marvin Seppala, chief medical officer at the Hazelden Foundation; Dr. Gregory Skipper, director of Professional Health Services at Promises Treatment Center; and William White, one of the leading proponents of Recovery Management and a major addiction treatment historian. What this demonstrates is that the philosophy of judgment, punishment, and control is so pervasive and engrained that highly trained, well-meaning mainstream clinicians utilize it even as they set out to do something good for their patients.”

I don’t know the positions of all of the authors, but Gitlow has worked for a buprenorphine manufacturer, Seppala very publicly started burprenorphine maintenance at Hazelden and White has been a forceful advocate for methadone.

He’s also troubled by the emphasis on external control, seeing this as evidence of a moral model.

“The report recommends that following formal treatment, the individual should become involved in an accountable system of care management that includes (1) signing an abstinence contract and (2) agreeing to be under a supervisory or monitoring authority (family, employer, legal entity) that (3) subjects them to frequent random drug testing and (4) provides negative sanctions for any lapses, relapses, or missed drug testing, while (5) encouraging or mandating attendance at mutual aid groups.”

As DuPont discussed the topic before this report was published, I also expressed some pause at his emphasis on sanctions.

I’ve got to say, though, don’t we have all sorts of behavioral economists suggesting that we learn from Odysseus and find ways to restrict our ability to make poor decisions in the future, often with the help of others. Isn’t this along those lines?

They describe monitoring authorities and sanctions as elements of these programs with good outcomes, but they do not propose making all addicts subject to some monitoring authority. However, Debra Jay recently proposed a model that creates recovery monitoring and support systems within families. I imagine that’s exactly the kind of ideas that a paper like this hopes to stimulate, and it’s free of any legal or occupational coercion.

He presents the alternative, “Scientific/Humanist Model” and presents a model of functional analysis for looking at substance use. (Again, rejecting the disease model’s assumption of pre-existing genetic and neurological factors.

I have to admit that I find it odd that a paper presenting evidence for models with outstanding outcomes for a difficult to treat illness gets labeled as moral, while the “scientific” model rejects the model on philosophical objections (rather than evidence) and rejects the scientific consensus on addiction as a disease.

There are 2 things I find very troubling about this discussion. (Not about Kellogg, rather about this larger, ongoing discussion.)

First, no alternative with similar outcomes is offered. Or, why not challenge the authors and practitioners to address his concerns, like the model’s lack of evidence for voluntary engagement? Are there lessons from harm reduction that can inform this model to maximize voluntary engagement? Again, this suggests that the objections are not pragmatic but ideological.

Second, and more concerning is that Kellogg seems to have flipped the light switch on and exposed the underlying culture war by using political jargon and calling for “progressives” to work to advance their model. (Ironic, given the egalitarian call from the paper–the rest of us should have access to the kind of care that is currently limited to a few elite groups.)

Ugh. I can’t even stomach real politics.

Bill White wrote about a struggle for addiction treatment’s soul in 2002. His take addresses some of the concerns of Kellogg’s constituency in, what I think, is a more accurate and constructive way.

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.

In that same book, he offered these reflections on the historical lessons that addiction treatment professionals should carry forward.

So what does this history tell us about how to conduct one’s life in this most unusual of professions? I think the lessons from those who have gone before us are very simple ones. Respect the struggles of those who have delivered the field into your hands. Respect yourself and your limits. Respect the addicts and family members who seek your help. Respect (with hopeful but healthy skepticism) the emerging addiction science. And respect the power of forces you cannot fully understand to be present in the treatment process. Above all, recognize that what addiction professionals have done for more than a century and a half is to create a setting and an opening in which the addicted can transform their identity and redefine every relationship in their lives, including their relationship with alcohol and other drugs. What we are professionally responsible for is creating a milieu of opportunity, choice and hope. What happens with that opportunity is up to the addict and his or her god. We can own neither the addiction nor the recovery, only the clarity of the presented choice, the best clinical technology we can muster, and our faith in the potential for human rebirth.

Does that betray some anchoring in a moral model? I’m sure some will find evidence of that and superstition. However, I see a model that, in its best moments, is rooted in empirical knowledge as well as experiential knowledge, choice, empowerment, hope, respect, humility, patience and love.

Book Review: It Takes a Family

41VSgiYt5mLI just finished Debra Jay’s new book, It Takes a Family: A Cooperative Approach to Lasting Sobriety and wanted to share a few thoughts with you.

Bill White was one of the first people I heard challenge our failure to distinguish between treatment and recovery. Jay picks up this theme and details the limitations of treatment–that treatment is good at stabilization, but in most cases it’s not designed to provide long term recovery support and monitoring. Where White’s focus is challenging treatment providers to develop systems and services to provide long term recovery monitoring and support, Jay’s focus is on giving families and addicts the information and tools to develop their own systems of long-term recovery monitoring and support.

Jay identifies Physician Health Programs as the gold standard for addiction treatment and outlines eight elements that they share:

  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

She proceeds with chapters on addiction as a disease, why our emphasis on motivation is misplaced, an inventory of the behaviors associated with successful recovery (suggesting that relapse is not random), a new look at enabling and the toll that addiction takes on families–adults and children.

All of these chapters are extremely well done and concise, however, two chapters stand out to me.

The chapter on the disease model takes some very complex information and conveys it in a manner that is very clear and concise. Rather than just describing neurological mechanisms, Jay describes addiction as it is experienced by the addict and those who love them. It’s not frothy emotional appeal, but it’s description is emotional and experiential as well as intellectual.

The chapter on enabling is unlike anything I have ever read on the topic. It is nonjudgmental and conveys and unparalleled level of empathy for the addict and the family. It explores the chronic stress associated with living with addiction and the impulse to protect not just the addict, but also the family–detaching and letting the addict hit bottom often means that the family hits bottom with the addict. In the absence of a viable alternative, fear of losing the family rules decision-making. That alternative is Structured Family Recovery. Structured Family Recovery provides a path to enabling recovery.

The second half of the book is a step-by-step guide to implementing Structured Family Recovery.

So, what is Structured Family Recovery? It’s a way for families and addicts to try to construct their own version of the same gold standard that addicted physicians get. It’s a commitment from the family for each family member to develop a recovery plan of their own and attend a weekly family meeting (via conference call) in which all family members are accountable to each other. The focus is not of the addict, rather it is on the family as a whole. Jay provides several checklists for families and 52 weeks of outlines for the family meetings. There is a lot about the model that excites Jay, but one of the most interesting is the family’s new-found empathy for the addict. When the family member is accountable for working a recovery program of their own they develop greater empathy, understanding and respect for how difficult this is for the addict.

The first chapter of this section continues the refreshing and startling level of insight and empathy for all parties, with sections about how to talk to your addict and how the addict can talk with their family. These sections sensitively and impressively speak to the nuanced, conflicted and powerful feelings and thoughts experienced by everyone–the addict’s ache to get the spotlight off themselves and family member’s fear, anger, hope and relief.

Professionals who view Physician Health Programs as the gold standard have been searching for ways to emulate elements of the model for all of our clients in a voluntary and sustainable manner. Jay has done an enormous service to addicts, families and the field in offering a potentially free approach for achieving this goal. This will be invaluable for clinicians who are looking for ways to extend support and monitoring. More importantly, this book empowers families and addicts to do it themselves.

Debra Jay and her husband (Jeff) are renowned and respected interventionists who serve a lot of high-powered families and individuals. However, the thing I respect and admire most about them is their generosity in sharing their knowledge, experience and tool kits with the rest of us. Love First gave us step-by-step instructions for interventions and helped families decide if they could do it on their own. It Takes a Family continues their open source tradition by giving families Jay’s entire model and helps them decide whether they are capable of doing it on their own.

For less that $11 (relatively) intact families who are committed to working together to support recovery and heal their family now have a detailed road map written in a confident and reassuring voice that makes the reader feel like Debra is right next to you and understands exactly what you’re going through.

Recovering executive function

red-pencilI was listening to the podcast of this On Being episode this morning and get to wondering about its application to addiction treatment and recovery. (The first 15 minutes or so cover the really relevant concepts.)

The interviewee is Adele Diamond,  an educator, researcher and scientist who focuses on early childhood and the role of executive function in academic and life success.

She broke executive function down into three areas:

  1. inhibitory control
  2. working memory-the ability to hold on to a concept and explore. examine or play with it
  3. cognitive flexibility

She has an early childhood curriculum that is focused on fostering/supporting the development of executive function. In the interview, she discussed some activities and tricks designed to develop or engage executive function. For example, her curriculum uses particular kinds of play and drama. She also gave an example of helping kids who mirror write by asking them to write problem characters in red pencil. (Just stopping writing and picking up the red pencil was enough of an intervention for most kids.)

This got me thinking about addiction as, in part, a disorder of the brain’s executive function. If one of the tasks of early recovery is to restore or re-develop executive function, what strategies and activities could help accomplish that? What strategies do we already use, or do mutual aid groups use, to achieve this?

What are our red pencils and how can we find more of them?

 

the revolving door

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Points has an interview with Bill White. He makes several points that his followers will be very familiar with, but I don’t remember him putting it together so concisely. I’ve also heard him discuss recovery capital and acute care models, but never heard him frame the acute care model as working well for low to moderate severity with high recovery capital. It puts a different frame on the the persistence of the model and cultural barriers to changing it.

. . . the cultural fate of addiction treatment may well be dictated by a more fundamental flaw in the very design of addiction treatment and the field’s capacity or incapacity to respond to that design flaw. Modern addiction treatment emerged as an acute care model of intervention focused on biopsychosocial stabilization. This model can work quite well for people with low to moderate addiction severity and substantial recovery capital, but it is horribly ill-suited for those entering treatment with high problem severity, chronicity, and complexity and low recovery capital. With the majority of people currently entering specialized addiction treatment with the latter profile, the acute care model’s weaknesses are revealed through data reporting limited treatment attraction and access, weak engagement, narrow service menus, ever-briefer service durations, weak linkages to indigenous recovery support services, the marked absence of sustained post-treatment recovery checkups, and the resulting high rates of post-treatment addiction recurrence and treatment readmission. Addiction treatment was developed in part to stop the revolving doors of hospital emergency rooms, jails and prisons. For far too many, it has become its own revolving door. Slaying the Dragon documents these weaknesses and current efforts to extend the design of addiction treatment toward models of sustained recovery management nested within larger recovery-oriented systems of care—with the “system” being the mobilization of recovery supports within the larger community.

I’m grateful to work in a program that provides long term care and support.

The gold standard

gold standard   definition of gold standard by Medical dictionary

Recovery Review has a terrific post reviewing a journal article examining addiction treatment for physicians.

He pulled this from the source journal article:

Recognizing that SUDs are biological disorders with major behavioral components (just like diabetes and coronary artery disease), the relatively high level of success exhibited by physicians whose care is managed by PHP is important with respect to the potential for success in addiction treatment generally. Indeed, the observed rate of success among physicians directly contradicts the common misperception that relapse is both inevitable and common, if not universal, among patients recovering from SUDs.

Recovery Review summarizes the elements of Physician Health Programs:

  • Doctors sign binding contracts
  • Abstinence is the goal
  • Weekly doctor-specific mutual aid groups
  • Attendance at 12-step mutual aid groups (AA, NA, CA etc)
  • The regulatory boards are often avoided if doctors comply
  • Extended care (five years)
  • Recovery often starts with an active/planned intervention
  • This is followed by an intensive residential (or out-patient) rehab period, usually three months long
  • Withdrawal from work during treatment
  • Active monitoring and care management
  • Active family engagement
  • Mental & physical health needs assessed
  • Active management of relapse
  • Random drug and alcohol tests over the five years

He also summarizes the take-aways to improving treatment for other populations:

  1. Adopt the contingency management aspects of PHPs
  2. Offer frequent random drug testing
  3. Create tight linkages with 12-step programmes and abstinence standards
  4. Active management of relapse by intensified treatment and monitoring
  5. Continuing care approach
  6. Focus on lifelong recovery

This is an important and extremely well written post. Please read the whole thing here.

Learning from the AIDS epidemic

 

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The American Journal of Medicine has an interesting commentary examining parallels between the AIDS epidemic and the opioid epidemic.

While the early history of government inaction, public fear, and stigmatization of HIV/AIDS is a shameful stain on this country’s conscience, 30 years later we have achieved tremendous victories, and the disease has transitioned from a veritable death sentence to a chronic condition for which most live a normal life, many with just a pill a day. The collaboration of affected communities, the public health system, physicians, and ultimately, government agencies to advance scientific understanding and disseminate an effective model of care provides lessons applicable to our current opioid epidemic.

To effectively address opioid addiction in this country, we need a comprehensive campaign for prevention, diagnosis, and treatment. Standard-of-care treatment models must be developed and disseminated based on existing evidence. Enhanced education of the medical community is necessary, and educational resources for addiction in medical training should be equivalent to that of other chronic diseases. While the intertwined issues of educational opportunity, employment, safe housing, and poverty must be acknowledged, remedying social determinants of health is not a prerequisite for implementation of effective treatment. Lastly, we could learn a lot from the HIV/AIDS campaign of “nothing for us without us” and involve patients with addiction in the design and implementation of programs meant to serve them.

There are immediate steps that can be taken to address the catastrophic death toll from unintentional overdose. Routine distribution and training in the use of naloxone, an opioid antagonist, is an effective and scalable intervention that is proven to save lives. Efforts to reformulate pain medications and decrease the availability of painkillers through physician education, prescription drug-monitoring programs, and crackdowns on “pill mills” also are important in preventing future addiction. However, we must be cognizant of those already addicted who, as the availability of pharmaceutical opioids declines in the absence of effective treatment, may turn to illicit opioids thereby introducing many other problems.

Ryan_2From the perspective of a provider who has worked with a few AIDS patients, it seem that the sea change moment was the passing of the Ryan White CARE act when we started making very expensive care available to low income AIDS patients, regardless of their insurance or ability to pay.

The average annual cost of HIV care in the ART era was estimated to be $19,912 (in 2006 dollars; $23,000 in 2010 dollars).3 The most recent published estimate of lifetime HIV treatment costs was $367,134 (in 2009 dollars; $379,668 in 2010 dollars).4

What would happen if we passed legislation that allowed all addicts to access the same kind of treatment that addicted health professionals get? How would the cultures of addiction treatment and addiction change. How would cultural attitudes toward addiction change? If there was a way out? For everyone?