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).

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).

ASAM president also medical director for drug company

phrma2I missed this a while back. Turns out that ASAM’s president works for a buprenorphine manufacturer.

Stuart Gitlow, M.D., is the president of the American Society of Addiction Medicine (ASAM) and also medical director — as a consultant — for Orexo, which makes Zubsolv, a newly approved buprenorphine-naloxone medication (see ADAW, July 15).

The first public charge of a conflict of interest was made last month via Twitter by Mark Willenbring, M.D., former director of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism. In the tweet, Willenbring suggested that ASAM should examine its policies about conflicts of interest. While the connection with Orexo doesn’t mean that Gitlow’s beliefs and statements about buprenorphine are incorrect, it does raise questions, said Willenbring, now in private practice in St. Paul, Minnesota, where he provides treatment for substance use disorders and is a strong proponent of medication-assisted treatment. “At the same time, how can someone who is employed by the drug company have any credibility when his financial interest is in selling the drug?” Willenbring told ADAW. “My concern is with the increasing public perception, especially in psychiatry and addiction treatment, that financial interests taint and discredit professional opinions.” Gitlow’s dual roles, said Willenbring, raise this question: “Is he speaking for ASAM as a professional or for the pharmaceutical company as a salesman?”

While I don’t follow ASAM closely, I’ve seen no evidence of Gitlow advocating for any policy that would not receive broad agreement among ASAM membership.

However, as ASAM engages in advocacy around prescribing limits for buprenorphine, is it a conflict that the organization’s president gets a paycheck from a manufacturer?

Who’s guarding the hen house?

money-pillsFrom the NY Times:

Addiction experts protested loudly when the Food and Drug Administration approved a powerful new opioid painkiller last month, saying that it would set off a wave of abuse much as OxyContin did when it first appeared.

An F.D.A. panel had earlier voted, 11 to 2, against approval of the drug, Zohydro, in part because unlike current versions of OxyContin, it is not made in a formulation designed to deter abuse.

Now a new issue is being raised about Zohydro. The drug will be manufactured by the same company, Alkermes, that makes a popular medication called Vivitrol, used to treat patients addicted to painkillers or alcohol.

In addition, the company provides financial support to a leading professional group that represents substance abuse experts, the American Society of Addiction Medicine.

Hmm. Let’s see,

  • they profit from a drug that will produce addiction;
  • they profit from a drug to treat addiction;
  • they manage to get their drug approved over a very lop-sided FDA panel objections;
  • they fund the American Society of Addiction Medicine (ASAM);
  • they funded the publication of a portion of the ASAM Patient Placement Criteria, which is the dominant framework for treatment placement decisions;
  • another of ASAM’s sponsors makes billions off of a medication with “near universal relapse” when they try to taper patients off it (It’s worth noting that the feds have also invested heavily in promoting Suboxone.);
  • ASAM engages in advocacy for the products these companies produce;
  • ASAM’s professional status and power places it in the position of conferring legitimacy and illegitimacy to treatments and policies;
  • people who questions these treatments and policies are dismissed as crackpots who reject empiricism.

Who makes policy?

[hat tip: Love First]

DSM 5 Substance Use Disorders: A Concise Summary

DSM_5_2Terry Gorski has a nice summary of substance use disorders in the DSM-5.

Here’s his analysis at the end of the post:

The DSM 5 is criticized for combining the the DSM IV categories of substance dependence (addiction marked by a pattern of compulsive use or loss of control) and substance abuse disorders (using in a manner that causes problems but does not have a pattern of compulsive use). The 2011 definition of addiction by the American Society of Addiction Medicine (ASAM) is consistent with DSM IV but not DSM 5.

The DSM IV, like the ASAM definition is based upon the idea that there is a DIFFERENCE IN KIND between substance abuse and dependence/addiction.

The DSM 5 is inconsistent with the ASAM definition because it is based upon the idea that there is only A DIFFERENCE IN DEGREE between abuse and addiction based upon the number of symptoms.

This is a critical difference in the underlying theory of addiction between the DSM IV and DSM 5 and a break in the progressive development of the fundamental concept if addiction which began with the DSM III.

 

NAATP launches counteroffensive to medication push

This is very welcome news:

Frustrated that medication-assisted treatment is coming across as the addiction field’s standard of care simply because drug company studies are dominating the research landscape, a group of some of the most prominent leaders in treatment administration is vowing to fight back. These leaders have enlisted the help of another heavy hitter in A. Thomas McLellan, PhD, CEO of the Treatment Research Institute (TRI), to issue a white paper that will highlight the evidence basis for residential, abstinence-based services.

It’s also a little confusing.

Confusing for two reasons. First, I saw McLellan speak at a conference a couple of years ago and he was very enthusiastic about medication as a front line treatment provided in primary care settings.

Second, one of the participating treatment programs was Hazelden. Just yesterday, Hazelden announced its adoption of buprenorphine maintenance.

What prompted this initative? Two things.

First, events at this year’s ASAM conference:

If there was one precipitating event this year that propelled this group into action after much past discussion, Moore says it was the annual conference of the American Society of Addiction Medicine (ASAM) back in the spring. He says that several medical directors at prominent addiction treatment facilities, including his center’s top physician, returned from the conference reporting that the content was completely dominated by pharmaceutical research, particularly related to the opiate maintenance drug buprenorphine.

Second, drug company research is creating pressure from reimbursement sources.

And partly because of the emergence of pharmaceutical research, other sectors of the field appear to be embracing medication-assisted recovery as the first line of defense. In an extreme example, Moore says that in New Jersey, Seabrook House found itself combating managed care policies that were blocking any attempts to place opiate addicts in their late teens into residential treatment, mandating that these young people be seen instead by buprenorphine-prescribing physicians in private practice.