Their every truth . . .

…most men have bound their eyes with one or another handkerchief, and attached themselves to some one of these communities of opinion. This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars. 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. ~ Emerson

Now the Huffington Post frames people with a preference for abstinence-based recovery as anti-science and backward. Ugh!

How bad is this article? Let me count the ways.

One: They use a variation of the “some people say” tactic (emphasis mine):

Many in the medical establishment oppose the abstinence model — as do officials at the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Administration

Really? Then why do they treat their colleagues with an abstinence-based approach? Actually, they go even further, requiring that their colleagues be treated with an abstinence-based approach. (And, they are very successful with this abstinence-based approach.)

Two: They abandon the “some people” qualifier and frame advocates of abstinence-based recovery as irrational zealots.

Advocates of the abstinence model consider the use of Suboxone or methadone to be tantamount to using heroin itself.

What serious person says it’s equivalent to using heroin? This is a straw man.


Three: They they say abstinence-based approaches cost lives.

. . . a recent Huffington Post investigation found that the bias in favor of abstinence is costing the lives of those it regularly fails.

I posted about that investigation and its problems earlier.

I’ve also posted about a study finding high mortality rates among methadone patients in Australia. (6.5 times higher than the general population with an average of 44 years of potential life lost for each fatality.)

There’s no doubt that being on an opiate replacement drug reduces overdose risk, but only if they take the drug and those drugs have big patient retention problems too. (Here, here, herehere and here.)

Four: They then use relapse rates against abstinence-based treatment:

Over 90 percent of people treated with the abstinence method will relapse.

Note that there is no source and they are holding methadone and abstinence-based treatment to different standards. They don’t report on relapses for drug maintenance patients because studies of maintenance drugs tend to look for reductions in illicit drug use rather than abstinence.

As I recently wrote, the treatment system is failing opiate addicts, but the problem isn’t abstinence-based treatment. It’s the failure to provide treatment of the adequate duration, intensity and quality. In fact, when patients get good care of the adequate intensity and duration, they do very well.

Five: They seek comments from Bankole Johnson, a treatment critic, medication investor and researcher who failed to report conflicts of interest in a timely manner and left one job after losing a whistleblower lawsuit.

Six: They inserted an inane poll asking:

. . . whether it’s more effective for heroin addicts to detox completely and attend Narcotics Anonymous meetings, or for them to receive synthetic opiates under medical supervision . . .

This question feels like a setup. Detoxing addicts and sending them to NA is bad care. And, almost every expert agrees that just giving addicts maintenance drugs is bad care. So, those who are polled are given two bad options and then treated as ignorant because of their answer.

Seven: Then they insert partisan politics into they equation by breaking down responses by Republicans and Democrats. I’ve wondered before whether these attacks on abstinence-based treatment and recovery are part of the culture wars. This would seem to support that notion.

I have more problems with this series of articles that don’t rise to the level of the problems above.

First, the article reports that maintenance drugs are the standard of care in the rest of the developed world. This is largely true, but some countries are re-evaluating their approach. Also, we’ve developed relationships with Japanese treatment providers and addicts and have learned that addicts there believe that maintenance approaches failed them focusing on stability over quality of life.

Second, as mentioned above, these articles fail to acknowledge the success of health professional, lawyer and pilot recovery programs. These programs are abstinence-based, we researched and have very high long term success rates.

Third, these articles make it sound as though relatively few addicts have access to these drugs. Suboxone is the number 39 drug in the US and has sales of more than $1.4 billion. Further, a federal surveys find that ORT admissions accounted for 26% of all admissions. [Not 26% of opioid addiction admissions. 26% of all addiction treatment admissions.]

Finally, this series fails wrestle with the evidence in any meaningful way and the writers fail to ask themselves why reasonable people might prefer abstinence as a goal.

They are correct that there is a lot of evidence for these drugs reducing drug use, crime, disease transmission and overdose. However, reduce is an important word. Most people don’t want reduced drug use, they want full participation in family, professional, community and academic life. Despite the writers’ enthusiasm for maintenance drugs, they do not have an evidence-base for that kind of recovery.

None of this is to say that the treatment system isn’t broken, or that people who want them shouldn’t have access to maintenance drugs. It’s just to say we shouldn’t oversell maintenance approaches and describe abstinence-based approaches as “broken” when the real problems are the quality, dose and duration.

The soul of addiction treatment’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.

Strange conclusions – updated w/ link

Choose you evidence carefully by rocket ship
Choose you evidence carefully by rocket ship

We’ve been seeing a lot of claims about the comparative effectiveness of AA or 12 step facilitation (TSF) versus motivational interviewing (MI) or motivational enhancement therapy (MET), most recently here. That AA/TSF is superstitious  voodoo and MI/MET is rational, evidence-based and effective. (Interestingly, the author of the piece used an appeal to authority argument by invoking Bill Miller, one of the developers of MI. Keith Humphreys points out that, “the Miller work is cited to say things he doesn’t believe”.)

Just to be clear, Dawn Farm likes MI. We train staff in MI. We believe it’s a useful tool. However, we also believe it’s often oversold.

At any rate, a new study on MET just popped up in my feed reader. It included a very positive conclusion.

CONCLUSION: Motivational enhancement therapy (MET) appears to increase the percentage of days abstinent in patients with chronic hepatitis C, alcohol use disorders and ongoing alcohol use.

What was that conclusion based on?

FINDINGS: At baseline, subjects in MET had 34.98% days abstinent which increased to 73.15% at 6-months compared to 34.63% and 59.49% for the control condition. Multi-level models examined changes in alcohol consumption between MET and control groups. Results showed a significant increase in percent days abstinent overall [F(1,120.4)=28.0, p<.001] and a significant group by time effect [F(1,119.9)=5.23, p=.024] with the MET group showing a greater increase in percent days abstinent at 6 months compared with the education control condition.

So far, so good. Right? MET resulted in more days without drinking. It’s not total abstinence, but it’s movement in the right direction. That’s a good thing, right?

Oh, wait. There’s more.

There were no significant differences between groups for drinks per week.

Wait. What?

If I understand correctly, that sounds like the MET group drank more when they drank.

The MET group appears to have gone from 19.5 drinking days per month with an average of 7.8 drinks per drinking day, to 8 drinking days per month with an average of 8.3 drinks per drinking day.

The control group appears to have gone from 19.5 drinking days per month with an average of 8.5 drinks per drinking day, to 12 drinking days per month with an average of average 7.8 drinks per drinking day.

Even if you accept drink counting as a good way to measure outcomes, that positive conclusion seems a little less positive, doesn’t it? And, when these authors argue AA or TSF don’t work, but MI or MET do, what does “works” mean?

This isn’t to say that MI isn’t useful, just that you should be suspicious when you see these comparative claims.

So, why do we see this over an over again? I imagine there are a lot of reasons. However, I heard something on the radio last week that might shed some light on on the persistence of these assertions and my sense that we’re caught up in a battle of the culture wars. I hesitate to bring this up, because I don’t want to nourish arguments that AA is religion (I’m an agnostic.), but last weeks’ episode of On Being was on science/religion debates. One of the guests said the following:

Dr. Bradley Correct. There’s another factor that you are alluding to here which is — is that not only is there a science and religion issue going on here, but there is also a power struggle going on, too. This is very much tied up with issues of power. Um, if you go back to the 19th century and look at the writings of people like T. H. Huxley, and, uh, Andrew Dickson White, um, these folks, um, saw so much of the formative influences in culture as coming from religion and they wanted to switch the locus of the power to shape culture to scientists.

And so it became a power struggle. And you see it on the Christian side as well. There are communities that, uh, that kind of want to stay closed, and one way is to make sure that people don’t talk too much to people who think differently themselves. And to create fear and suspicion and I think that’s a lot of what’s going on as well. So you’ve got all these power dynamics outside of the science and religion…

Has addiction treatment become an arena for these power dynamics? A struggle for the locus of power to shape culture?