Tag Archives: addiction

Who’s “we”?

many-and-few

This article is making the rounds and getting some attention. The post below addresses the issues raised. (originally posted on 10/31/2014)

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This article has been forwarded to me by several people. Its author has been writing a series of articles that seek to redefine addiction and recovery.

As Eve Tushnet recently observed, “There’s another narrative, though, which is emerging at sites like The Fix and Substance.com.” This sentence is representative of this alternative narrative:

“The addiction field has struggled with defining recovery at least as long and as fiercely as it has with defining addiction: Since we can’t even agree on whether it’s a disease, a learning disorder or a criminal choice, it becomes even harder to figure out what it means when we say someone has overcome an addiction problem.”

But are “we” really unable to agree that addiction is a disease? Who’s “we”?

It’s not unlike suggestions that there’s wide disagreement on climate change.

“Since we can’t even agree on whether it’s a diseasea learning disorder or a criminal choice, it becomes even harder to figure out what it means when we say someone has overcome an addiction problem.” “. . . just so you know, the consensus has not been met among scientists on this issue. Or that CO2 actually plays a part in this global warming phenomenon as they’ve come up with somehow.”
Health organizations that call addiction a disease or illness:

  • American Society of Addiction Medicine
  • American Medical Association
  • American Psychiatric Association
  • American Hospital Association
  • American Public Health Association
  • National Association of Social Workers
  • American College of Physicians
  • National Institute of Health
  • National Alliance on Mental Illness
  • World Health Organization
Scientific organizations that recognize human caused climate change:

  • American Association for the Advancement of Science
  • American Astronomical Society
  • American Chemical Society
  • American Geophysical Union
  • American Institute of Physics
  • American Meteorological Society
  • American Physical Society
  • Federation of American Scientists
  • Geological Society of America
  • National Center for Atmospheric Research
  • National Oceanic and Atmospheric Administration
Health organizations that dispute the dispute the disease model:

  • I can’t find any. If you have some that are similar in stature to those above, send them to me.
Scientific organizations that dispute human caused climate change:

  • None, according to Wikipedia.

To be sure, there are people who don’t accept the disease model, some very smart people, but they represent a small minority of the experts. (The frequent casting as David vs. Goliath should be a clue.) And, if you look at their arguments, you’ll find other motives (I’m not suggesting nefarious motives) like protecting stigmatizationdefending free will from “attacks”, discrediting AA and advancing psychodynamic approaches, resisting stigma and emphasizing environmental factors.

Attending to some of their concerns makes the disease model and treatment stronger, not weaker. Lots of diseases have failed to do things like adequately acknowledge environmental factors. And, one takeaway from these critics is the importance of being careful about who we characterize as having a disease/disorder explicitly or implicitly (by characterizing them as being in recovery).

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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.

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2014’s top posts: #2

“He’d still be alive”

CANADA TORONTO FILM FESTIVALMuch has been said this week about the death of Phillip Seymour Hoffman.

I’ve heard two recurring themes. First, that he might still be alive if he had been “treated with an evidence-based” treatment, like buprenorphine. Second, that he might still be alive if he hadn’t been inculcated with the disease model, which purportedly fosters learned helplessness.

The buprenorphine argument

I know nothing of the treatment he received and most of these people admit that they don’t either.

Let’s assume, for a moment, that their assumptions are correct.

One problems is that most of these writers fail to deal with the issue of falling buprenorphine compliance ratesThis recent study of 6 month study found a dropout rate of 76% for those without chronic pain and described the compliance rates as consistent with other studies.

Early studies of buprenorphine reported outstanding compliance rates. Those numbers need to be viewed with suspicion and one should wonder whether the promulgation of those numbers is a success of science or marketing.

Their premise seems to be that people prescribed buprenorphine don’t OD. I don’t doubt that people currently taking buprenorhine are at lower risk for OD. However, I’m not aware of any good studies of survival rates that consider real world compliance rates.

Now, we learn that buprenorphine was reportedly found in his apartment. I have no idea whether it was prescribed to him or whether he bought it on the street. If it was prescribed to him, it suggests that prescribing the drug may not have the protective properties that advocates claim. If he bought it on the street, it points to the issue of diversion, which raises questions about patient compliance with the drug.

Besides, this was someone who had maintained some sort of remission for 23 years, had been in relapse for one year and had only one, brief detox episode during that period of time. Seems a little rash to assume that that path that had worked for 23 years would be a bad path to try to get him back to.

The disease argument

There’s ample evidence that addiction is a disease and, kind of like the climate change debate, though there is a noisy group of dissenters with high visibility, there is widespread agreement among experts that it’s a brain disease characterized by loss of control.

One of the most common arguments to question the disease model is the existence of natural recovery–that fact that large numbers of “addicts” recovery without any help.

The quotation marks in the previous sentence signal my response. Vietnam vets who returned with heroin problems are a frequently cited example. Most came back to the states and quit heroin on their own. Reports indicate that only 5% to 12% were unable to quit or moderate.

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.

It’s worth noting that this can cut in both directions. There’s a tendency to respond to problem users (people who drink too much, but are not alcoholics.) and dependent non-addicts (most pain patients or these returning vets) as though they are addicts. This results in bad treatment for those people, bad research and it manufactures resentment toward treatment, mutual aid groups and recovery advocates.

We run into the same problem when recovery advocates (who I love and generally agree with) report that there are 23 million Americans in recovery. These kinds of statements tend to be based on surveys asking people something to effect of, “Have you previously had a problem with drugs or alcohol and no longer have one?” That kind of question is going to get a lot of false-positives for what we think of as recovery. It’s a little like asking people if they once had a chronic cough and no longer have one, then inferring that all of those people are in recovery from TB.

We know that relatively large numbers of young adults will meet criteria for alcohol dependence but that something like 60% of them will mature out as they hit milestones like graduating from college, starting a career or starting a family. Are these people addicts in recovery? Or, were they people with a problem of an entirely different kindan acute alcohol problem rather than the chronic brain disease of addiction?

We need to do a better job distinguishing addiction/alcoholism from dependence and look at improving DSM criteria to help with this distinction. Loss of control, over an extended period of time that returns after periods of abstinence is the key to me. Addicts/alcoholics are not people making poor decisions about their drug and alcohol use, they are people who have lost the ability to make execute decisions related to drug and alcohol use.

It’s apples and oranges and these statements about the prevalence of recovery do real damage to the cause. People with addiction shouldn’t be treated with expectations constructed around the experience and pathways of people who do not have the same disease. AND, people who do not have addiction should not be subjected to treatments for people who do have the disease.

A better argument

I’ve spent a lot of time on this blog responding to arguments that pharmacological treatments are better than drug-free treatment. And, I’ll admit that I feel defensive when I hear treatment being attacked. However, when I step back, I have to admit that there’s a lot of bad treatment out there. With and without medications.

These arguments about drug-free vs. drug maintenance miss one really big and really important point. Whichever kind of treatment a person ends up receiving, there’s a really good chance that they will not get the long term monitoring and support that is appropriate for a life-threatening and chronic disease.

Two models that have outstanding outcomes are treatment programs for health professionals and programs for pilots. Both have long term success rates in 90% range. Both of them happen to be drug-free, but the point I want to focus on is that they both provide intensive long term monitoring and support with rapid re-intervention in the event of relapse.

Shouldn’t we have a system that monitored Philip Seymour Hoffman in the same way we monitor people with heart disease? One other example that comes to mind is my dentist. I mean, I don’t even get cavities–there’s nothing urgent going on in my mouth. BUT, my dentist corners me into scheduling another appointment before I leave the office and they start calling and texting me to remind me AND even ask me to reply that I will make my appointment.

If my dentist can deploy the strategies to promote continuity of care, why can’t addiction treatment programs?

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Top posts of 2014: #12

Abstinence—The Only Way to Beat Addiction?

StrawmanWhat killed Philip Seymour Hoffman? According to Anne Fletcher, it wasn’t the doctor who prescribed him the pain medication that began his relapse, it wasn’t the prescribers of the combination of meds found in his body, it wasn’t his discontinuing the behaviors that maintained his recovery for 23 years, it wasn’t a drug dealer, and it wasn’t addiction itself.

According to her it was 12 step groups for promulgating an alleged myth:

This is exactly what happened when Amy Winehouse, Heath Ledger, Corey Monteith, and most recently, Phillip Seymour Hoffman were found dead and alone. Scores of people most of us never hear about suffer a similar fate every year.

Why does this keep happening? One of the answers is that many people struggling with drug and alcohol problems have been “scared straight” into believing that abstinence is the only way out of addiction and that, once you are abstinent, a short-lived or even single incident of drinking or drugging again is a relapse. “If you use again,” you’re told, “you’ll pick up right where you left off.” Once “off the wagon,” standard practice with traditional 12-step approaches is to have you start counting abstinent days all over again, and you’re left with a sense that you’ve lost your accrued sober time.

She’s describing a theory often referred to as the “abstinence violation effect”. The argument is that the “one drink away from a drunk” message in 12 step groups is harmful and makes relapses worse than they might have been.

One problem. The theory is not supported by research. (See here and here. It hasn’t even held up with other behaviors.)

Two things are important here.

  • First, many people experience problems with drugs and alcohol without ever developing an addiction. Most of these people will stop and moderate on their own. These people are not addicts and their experience does not have anything to teach us about recovery from addiction.
  • Second, loss of control is the defining characteristic of addiction. The “one drink away from a drunk” message is a colloquial way of describing this feature of addiction.

Further, she characterizes AA as opposing moderation for problem drinkers, when AA literature itself says, “If anyone who is showing inability to control his drinking can do the right- about-face and drink like a gentleman, our hats are off to him.” 12 step groups believe that real alcoholics will be incapable of moderate drinking, but they are clear that they have no problem with people moderating, if they are able. This is a straw man.

We’re left to wonder why a best selling author and NY Times reporter would attack 12 step groups with a straw man argument and a long discredited theory.

via Abstinence—The Only Way to Beat Addiction? Part 1 | Psychology Today.

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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.

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Who’s “we”?

many-and-fewThis article has been forwarded to me by several people. Its author has been writing a series of articles that seek to redefine addiction and recovery.

As Eve Tushnet recently observed, “There’s another narrative, though, which is emerging at sites like The Fix and Substance.com.” This sentence is representative of this alternative narative:

“The addiction field has struggled with defining recovery at least as long and as fiercely as it has with defining addiction: Since we can’t even agree on whether it’s a disease, a learning disorder or a criminal choice, it becomes even harder to figure out what it means when we say someone has overcome an addiction problem.”

But are “we” really unable to agree that addiction is a disease? Who’s “we”?

It’s not unlike suggestions that there’s wide disagreement on climate change.

“Since we can’t even agree on whether it’s a diseasea learning disorder or a criminal choice, it becomes even harder to figure out what it means when we say someone has overcome an addiction problem.” “. . . just so you know, the consensus has not been met among scientists on this issue. Or that CO2 actually plays a part in this global warming phenomenon as they’ve come up with somehow.”
Health organizations that call addiction a disease or illness:

  • American Society of Addiction Medicine
  • American Medical Association
  • American Psychiatric Association
  • American Hospital Association
  • American Public Health Association
  • National Association of Social Workers
  • American College of Physicians
  • National Institute of Health
  • National Alliance on Mental Illness
  • World Health Organization
Scientific organizations that recognize human caused climate change:

  • American Association for the Advancement of Science
  • American Astronomical Society
  • American Chemical Society
  • American Geophysical Union
  • American Institute of Physics
  • American Meteorological Society
  • American Physical Society
  • Federation of American Scientists
  • Geological Society of America
  • National Center for Atmospheric Research
  • National Oceanic and Atmospheric Administration
Health organizations that dispute the dispute the disease model:

  • I can’t find any. If you have some that are similar in stature to those above, send them to me.
Scientific organizations that dispute human caused climate change:

  • None, according to Wikipedia.

To be sure, there are people who don’t accept the disease model, some very smart people, but they represent a small minority of the experts. (The frequent casting as David vs. Goliath should be a clue.) And, if you look at their arguments, you’ll find other motives (I’m not suggesting nefarious motives) like protecting stigmatizationdefending free will from “attacks”, discrediting AA and advancing psychodynamic approaches, resisting stigma and emphasizing environmental factors.

Attending to some of their concerns makes the disease model and treatment stronger, not weaker. Lots of diseases have failed to do things like adequately acknowledge environmental factors. And, one takeaway from these critics is the importance of being careful about who we characterize as having a disease/disorder explicitly or implicitly (by characterizing them as being in recovery).

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you are still valued and respected

charles outreach accept

DJ Mac directs us to an interview with a English recovering harm reduction advocate, Kevin Jaffray.

He shares a little of his own experience of fighting and, eventually, entering recovery. [emphasis mine]

Speaking as someone who came into abstinence kicking and screaming – thankfully with my health intact – after a number of chaotic years in addiction, I have to say with my hand on my heart that I would not have got this far if I had not spent a number of years being educated around the risks of my chosen lifestyle and gently guided through the years of chaos with a non-judgemental and non-enforced guiding hand of harm reduction. Those who reached out to me during that time carried me through some of the most destructive years of my life and kept me safe when no one else took the time to care. So being alive and healthy is actually quite a significant positive outcome in my opinion.

meet them where they are atMy own personal experience is how I became involved in carrying a message that there is a way out should you choose to take it and if not, you are still a valued and respected member of the community who deserves to be treated the same as every other member of that community, if not with more respect and due attention.

I’m struck by the repeated references to change and care. He repeatedly asserts that the goal is change and how critical care was for him. He doesn’t reference and harm reduction services, but keeps coming back to care.

It’s interesting, when he talks about his experience of the harms of addiction, he’s not just talking about infections, diseases or near-death experiences–he talks about living with addiction.

The years I spent living with addiction and all its related issues, as did my family and everyone who came close to me over the years. Addiction is not an isolated issue and its ripple effect can be as far reaching as it is deep.

There are those among us who can use safely and those who can remain recreational users. I take my hat off to them and have a, some might say controversial but, very real respect for them and an underlying jealousy if I’m honest. I was not one of them and the result was years of unadulterated chaos everywhere I went. Years of feeling like I did not belong anywhere, years of searching for connection, and years of battling stigma and isolation.

The feelings I lived with for those years were almost debilitating and I became trapped in a cycle of addiction where the pain of being was overwhelming and the substances dulled the pain of being, not a nice experience in any way, shape or form. Don’t get me wrong, I had some amazing times on substances but the effect it was having on my loved ones and significant others eventually added to the pain and became part of the downward spiral. I ended up alone and destitute.

All the needles, safe injection rooms and naloxone in the world won’t reduce those harms–but human connection and recovery can. I’m sure there are interventions I could not join him in, but there is a lot of common ground here to build from. Reading his experience and reflecting on Dawn Farm’s work makes me proud that we offer safe, compassionate, nonjudgmental recovery-oriented care.

His suggestions for people who want to help?

Support your local mutual aid groups; if there aren’t any, think about starting one up. Join online forums and add your voice to the already existing campaigns. Run events in your area. Get out there in your community and talk to people, find out what’s missing. Look for the deficits and fill them. Your community can always be improved. Asset map your community, don’t try and reinvent the wheel, just build more spokes from what is already there.

 

 

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