Reducing overdoses

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.

Over-medicalization of health?

A new book, The American Health Care Paradox: Why Spending More Is Getting Us Less, offers an interesting take on why the United States’ huge investments in health care doesn’t translate into better health. Vox did an interview with the book’s authors.

The paradox that we outline is one that a lot of readers will be familiar with: that the United States has very high health-care costs, and in many cases middling — and sometimes lousy — health outcomes when you look at certain metrics. These are metrics — like infant mortality and life expectancy — where, when you look across developed nations, we’re really at or near the bottom.

People cited this paradox before our book, and tried to explain it in any number of different ways. That included rationales like, “Well, U.S. health outcomes are bad because too few people have insurance” or “because prices are just high.”

What our book tries to do is offer another reason that hasn’t been talked about much in health policy: maybe “health spending” isn’t telling us the whole story. Maybe we need to look at a broader summary of what resources nation puts in to support population health.

To do this, we included social services spending in our study, which captures things like housing, food assistance, and job training. The ratio of health to social-service spending was more predictive of several outcomes than health spending alone. This led us to suggest that social-service spending — and, more broadly, attention to the social determinants of health — could be a missing piece in the health reform discourse.

In explaining the concepts in the book, the authors make a very interesting and provocative statement.

To address the problem of over-medicalization of health we need to actually get to the way people relate to their own health, no matter how wealthy they are.

What?!? “Over-medicalization of health”?!?

What do they mean by that?

Think about shoulder pain or back pain. It’s very common in the American public to think “What kind of MRI do I need? What kind of specialist should I go to?” as opposed to thinking “Hm, maybe the briefcase I’ve been carrying around is too heavy. Maybe I’m not sleeping well. Maybe I haven’t hit the gym for the last three weeks.”

It strikes me that this is extremely relevant to the status of addiction treatment, especially as the Affordable Care Act takes effect.

What we have is a chronic disease approach that hasn’t been executed perfectly, but has avoided over-medicalization and it is facing growing pressure to medicalize. It’s also interesting that physicians treat their addicted peers with a model that avoids over-medicalization, but we’re losing support for similar approaches with the general public.

It’s also seems to me that Recovery Management does a good job of seeking to address these social determinants.

I also just saw a very relevant quote on Recovery Review from David Best.

So this question about community recovery capital is partly about stigma and discrimination – whether professionals (in the addictions and related field) believe that people recover and act accordingly. If you are in a system where all the addiction money is spent on substitution therapies, on detox and on counselling, your system does not believe that people recover!

Personal Failure or System Failure?

Bill White explaining why inadequate treatment may be worse than no treatment:

What we know from primary medicine is that ineffective treatments (via placebo effects) or an inadequate dose of a potentially effective treatment (e.g., as in antibiotic treatment of bacterial infections) may temporarily suppress symptoms.  Such treatments create the illusion of resumed health, but these brief symptom respites are often followed by the return of illness–often in a more severe and intractable form.  This same principle operates within addiction treatment and recovery support services.  Flawed service designs may temporarily suppress symptoms while leaving the primary disorder intact and primed for reactivation.  But now the treated individual has three added burdens that further erode recovery capital.  First, there is the self-perceived experience of failure and the increased passivity, hopelessness, helplessness, and dependency that flow from it.  Second, there are the perceived failure and disgust from others and its accompanying loss of recovery support–losses often accompanied by greater enmeshment in cultures of addiction.  Finally, there are the very real other consequences of “failed treatment,” such as incarceration or job loss that inhibit future recovery initiation, community re-integration and quality of life.

The personal and social costs of ineffective treatment are immense.  If we as a society and as a profession want to truly give people with severe and complex addictions “a chance,” then we have a responsibility to provide systems of care and continued support that speed and facilitate recovery initiation, buttress ongoing recovery maintenance, enhance quality of personal and family life in long-term recovery, and provide the community space (physical, psychological, social and spiritual) where recovery and sustained health can flourish.  Anything less is a set-up for failure.

via Personal Failure or System Failure? | Blog & New Postings | William L. White.

Related articles

• What makes treatment effective? (addictionandrecoverynews.wordpress.com)
• All in how you look at it (iretablog.org)
• Community Recovery Capital (addictionandrecoverynews.wordpress.com)
• …let us work together (addictionandrecoverynews.wordpress.com)
• no hint of opinion here (addictionandrecoverynews.wordpress.com)
• Recovery vs. Disease Management: The Core of the Argument (hopeworkscommunity.wordpress.com)

 

The Unintended Consequences Of Medical “Maximalism”

Health (Photo credit: 401(K) 2013)

The Health Affairs blog questions the American Heart Association’s maximalist approach with the use of statins. The issues sound familiar.

The policy implications of these guidelines are staggering. Estimates show that if these recommendations are fully implemented, close to a third of all Americans will be placed on a statin. But these developments beg the question: Is this the right policy? Is taking a statin the most effective way for the millions of Americans who are at risk of heart disease to reduce their risk?

When appropriately prescribed, evidence substantiates that statins do reduce heart attack risk, but how do they compare to other interventions? We know that lower cholesterol is better, and we know that statins help to reduce heart disease risk, but we also know that the most effective way to reduce heart disease is not necessarily by taking more pills in ever-increasing doses – it’s to engage in lifestyle change. The best way to reduce risk is by losing weight if overweight, quitting smoking if a smoker, exercising if sedentary, and eating a Mediterranean style diet. Over the past few decades, we have gotten less active, we weigh more, and we eat too much unhealthy food. The new guidelines may have the unintended consequence of de-emphasizing the things that we know reduce risk the most in favor of treatments that are less effective.

Lifestyle change is also emphasized in the guidelines, but it can be very difficult to change deeply embedded behaviors, no matter how unhealthy they may be. When people are unable or unwilling to make those changes, frustrated clinicians looking for another solution often turn to medication as the easy answer for their patients. But a blanket prescription that everyone who has heart disease, or who is at risk for it, take a statin may encourage those most at risk to be lulled into a false sense of security. As cholesterol numbers go down, patients may no longer feel at risk, but the truth is a lot more complicated. For individuals who fall into the four benefit groups, then, yes, the drugs will likely lower their risk of a heart attack; but they will still likely have a heart attack at some point in their life. Medications cannot effectively insulate us from the results of our unhealthy choices.

The parallels are not perfect, as exemplified by his emphasis on choice in his closing, but the parallels are close enough to make clear that addiction treatment providers are not alone with our questions about medical maximalism vs. lifestyle changes.

Guidelines like those released last month reinforce how far society and our health care system have swung away from prevention and towards the medical model, which treats disease, but often does an inadequate job of promoting public health. Lifestyle change won’t help everyone. Some may still need to take a statin, even after they change their lifestyle. But for many, making healthier choices is enough. As medical science advances, we will continue to have better drugs, and the tendency of providers might be to expand their use. But the solutions to many of the ills that plague large numbers of Americans—high blood pressure, high cholesterol, diabetes, and the heart disease that they cause—do not lie in taking more and more pills to treat more of our preventable chronic conditions. They lie in motivating the millions of Americans who are currently living an unhealthy lifestyle to make better choices.

While experts in other areas of health may neglect promoting lifestyle changes, I suspect most would acknowledge that, for most people, lifestyle changes are either the preferred way to resolve the chronic health problem, the front line response, or be a prominent feature of every treatment plan. In opiate addiction, the field has swung so far in the maximalist direction that we’ve gotten to the point where we can’t even agree on that.

David Katz addresses the questions this discussion begs:

As far as I’m concerned, the entire debate about statins is part of our societal static. It’s a background noise of cultural misdirection that favors the conflated interests of Big Food and Big Pharma while ignoring the compelling, consistent, signal of what lifestyle as medicine could do for us all.

We could prevent all those heart attacks, and more, without putting statins in the drinking water. We could add years to life, and life to years, and save rather than spend money doing it – if lifestyle were our preferred medicine. The signal has been there for literal decades that minimally 80 percent of all heart disease could be eliminated by lifestyle means readily at our disposal. There is a case that, but for rare anomalies, heart disease as we know it could be virtually eradicated by those same lifestyle means. And the same lifestyle medicine that could do this job would slash our risk for every other bad outcome as well, while enhancing energy, cultivating vitality, and contributing to overall quality of life. And unlike our statins, we could share these benefits with those we love.

But for the most part, we as individuals, and collectively as a culture, seem deaf to this signal. We watch our peers and parents succumb to heart disease, and wring our hands. We fret over the same fate overtaking us. We get prescriptions for drugs we wish we didn’t have to take, worry about serious side effects, suffer through minor ones, grumble about copays, and implicate ourselves in the unmanageable burden of “health” care costs.

via The Unintended Consequences Of The New Statin Guidelines – Health Affairs Blog.

Related articles

• Op-Ed Contributors: Don’t Give More Patients Statins (nytimes.com)
• Do the benefits of statin drugs to prevent cardiovascular disease outweigh the risks? (bangordailynews.com)
• The statin debate ignores the signal of lifestyle as medicine (kevinmd.com)
• Shift In Cholesterol Advice Could Double Statin Use (npr.org)
• It’s time to question the new guidelines on cholesterol drugs – The Globe and Mail (theglobeandmail.com)

Learning Non-Reaction in Recovery

Make Me Laugh (Photo credit: Wikipedia)

Anna David shares her 10th step work with us. One of my favorite things in recovery is that way many people with solid recovery share their 10th step stuff with us in a way that provokes laughter with them. This laughter, which in other contexts could be cutting or toxic,  somehow fosters insight, fellowship and growth.

I cannot afford to continue to have the reactions that I do.

The fact is, even at 13 years of sobriety, I’m a big reactor. You could argue that part of this is good: I have a near childlike exuberance for things at times. Yay, I’m fun! But you could also argue that most of this is bad—and when I say bad, I mean bad for me more than anyone or anything else. At the end of last week, I had a few stressful things come up—things that a person with a very calm sensibility might have taken in, nodded at and gone about their business.

…

A related epiphany: I still pretty much think the rules don’t apply to me, that I shouldn’t have to put up with certain things. Part of this is the result of the way I was raised and things that happened that showed me I didn’t have to follow the rules but at this point it doesn’t matter why I’m like that; the point is that believing this only causes me pain. Right now I have a piano player who lives above me, a guy I’ve attempted to reason with about how much his musical theater act upstairs at all hours interferes with my wellbeing and ability to work. We’ve come to no resolution. But the one thing I’m realizing that I haven’t tried is to just see if I can tolerate it—to see if I can remind myself when I hear it that this is the risk you take when living in an apartment building, that I can move out when my lease is up (and always, from now on, take an upper unit) and that I can leave when the noise gets to be intolerable. I’ve noticed that I jump right to This is a disaster which makes me believe I need a dramatic solution, skipping through humbly trying out various ways of making a situation more tolerable.

via Learning Non-Reaction in RecoveryAfter Party Chat.

Community Recovery Capital

Forest Collage (Photo credit: zebble)

This weekend is the fist time I recall seeing Bill White discuss the concept of community recovery capital. I’ve heard him discuss community recovery and the ecology of recovery, but I think I must have missed community recovery capital.

The prognosis for community recovery is influenced by the ratio between problem prevalence, severity, and complexity and the level of community recovery capital (the scope and quality of resources that can be mobilized to initiate and sustain a community recovery and revitalization process).

There are multiple pathways and styles of community recovery and renewal, with most including emergence of a new recovery-based community identity (story).

Sustainable community recovery engages multiple community institutions in a process whose results can be measured in reductions of community pathology, but are best measured in long-term increases in community recovery capital.

Community recovery elevates the prognosis for personal/family recovery by elevating external recovery capital; creating the physical, psychological and cultural space where recovery can flourish; and increasing the density of recovery carriers (persons who convey infectious hope and guidance for recovery initiation/maintenance) within the community.

This is exciting to me because it has the potential to mitigate the concerns I raised last week about the potential for recovery capital to become a proxy for class.
Here’s Bill describing the concept of a healing forest:

One of the most riveting metaphors emerging from the Native American Wellbriety movement is that of the Healing Forest (Coyhis & White, 2002). In this metaphor, the clinical treatment of addiction is seen as analogous to digging up a sick and dying tree, transplanting it into an environment of rich soil, sunshine, water, and fertilizer only to return it to its original deprived location once its health has been restored and subsequently lost again. What is called for in this metaphor is treating the soil—creating a Healing Forest within which the health of the individual, family, neighborhood, community, and beyond are simultaneously elevated. The Healing Forest is a community in recovery.

Related articles

• Recovery capital and capital (addictionandrecoverynews.wordpress.com)
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Pediatric use of buprenorphine

Drugfree.org has a piece advocating more use of buprenorphine with children.

Medication-Assisted Treatment (MAT) for opioid dependence is a science-based and proven-effective option for teens and young adults. It should be administered with age appropriate psychosocial therapy and drug testing. Unfortunately, it has been subject to controversy and stigma. Yet the neuroscience of addiction and cravings helps explain why MAT, when properly used and overseen, can be truly life saving for adolescents, young adults, and their families. I see it working all the time. When kids come into treatment, their lives are just chaotic. Parents are desperate — they don’t know what to do or where to turn. The most important thing is to bring stability into the situation, and the best way to do that is with medication.

Ugh!

So now we’re expanding the notion of incapacitating long-term brain changes to adolescents? Who have been using in what quantities? And, for how long? (Apparantly the only people with brains that aren’t permanently disabled by opiate addiction are health professionals. They get abstinence focused treatment and have outstanding outcomes.)

My first thought about the piece was, “Hey, at least he provides some actual numbers.” However, upon closer examination, though the numbers give the appearance of an accountable professional engaging in informed consent, something’s not kosher here.

In our highly-structured program at Boston Children’s Hospital about a third of the children remain completely free from any alcohol and drug use. About another third remain free from opioid use but they might have an occasional slip on alcohol or marijuana. (We tend to not approve of that behavior and keep working with them). And the remaining third, particularly early on, will try opioids once or twice. But even after those early slips they show dramatic improvement over time.

Unfortunately, he doesn’t provide any timeframe. AND, stop and think about the numbers he offered:

• 1/3 free of alcohol and drug use
• 1/3 use no opioids but occasionally use alcohol or marijuana
• 1/3 use opioids “once or twice”

1/3 + 1/3 + 1/3 = 100%

He is saying that approximately 100% will not use opioids 3 or more times? This is an eminent physician at a prestigious institution. He has been a Principal Investigator of studies on adolescent substance abuse funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration, and the Robert Wood Johnson Foundation.

This assertion is so obviously implausible that it should provoke deep skepticism about the people upheld as experts, the funding priorities of government agencies and the biases built into what become “evidence-based practices.” (Remember “no hint of opinion“?)

As you read the comments, you’ll find people complaining about the methadone not being included. (Methadone for adolescents!)

You’ll find one comment, from a physician, explaining that, “Dr. Knight works with adolescents, with most of his patients under age 16, where methadone cannot legally be used (under 18 can be used with parental consent).”

The author’s finger wagging, very certain tone is regarding the use of Suboxone with patients under the age of 16.

I can imagine circumstances where the best path is not crystal clear (I’m thinking of youth that are highly resistant to treatment and at high risk for fatal OD.) but the question any family has to ask is, “How do we want my loved one to return too us?”

Here are Earl Hightower and Anna David:

AD: Should the parents just accept the first recommendation or should they ask for more?
EH: I think the first question they should ask should be one they ask themselves, which is how they want their son to return.

AD: What does that mean?

EH: Well, the majority of the treatment centers out there are 12-step based, which means that the goal for them is for their clients to achieve abstinence. This would be the choice to make if the parents want to get their son back in the same condition that he was in before he got on drugs: drug-free.

AD: But you can’t say for certain that a 19-year-old who was doing Oxy for nine months is definitely an addict who will need 12-step.

EH: You can’t. Maybe he was just dabbling; treatment would be able to help determine that. But maybe treatment will prove something else—maybe treatment will prove that this wasn’t an isolated incident. Maybe he’ll get in there and confess that he’s been using pot since he was 12 and maybe other conversations will turn up the fact that there’s a genetic predisposition toward addiction in the family. And if that’s the case, I believe he will need community-based support in staying clean once he returns home. It could go either way: good ongoing clinical assessment is the backbone of early treatment to determine the direction of care.

AD: But not all rehabs recommend 12-step or even full abstinence.

EH: Yes. And that’s why parents—people—need to know is that if an addict is going to a facility which subscribes to medication-assisted treatment and recovery, the goal is different. Loved ones need to know what medication-assisted treatment really means, which is that treatment will be radically re-defined and their child could be put on a medication which he would remain on for a long time, if not the rest of his life.

AD: So that’s what you mean when you talk about parents asking themselves how they want their child to return.

EH: Yes. But I can tell you from 30 years of doing this work that most parents want their child to come home drug-free—or they at least they want a shot at that. But some members of the treatment community will tell parents—or the addicts themselves—that we have to let go of this notion of abstinence and move more in the direction of medication-assisted treatment. And that means that people who could thrive without being on anything at all are leaving treatment centers on very powerful opiate replacement drugs.

Related articles

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• NYT Reax (addictionandrecoverynews.wordpress.com)
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Precovery

Bill White introduces a new concept, precovery:

Precovery involves several simultaneous processes:  physical depletion of the drug’s once esteemed value, cognitive disillusionment with the using lifestyle (a “crystallization of discontent” resulting from a pro/con analysis of “the life”), growing emotional distress and self-repugnance, spiritual hunger for greater meaning and purpose in life, breakthroughs in perception of self and world, and (perhaps most catalytic in terms of reaching the recovery initiation tipping point) exposure to recovery carriers–people who offer living proof of the potential for a meaningful life in long-term recovery.  These precovery processes reflect a combustive collision between pain and hope.

Unfortunately, it can often take decades for these processes to unfold naturally.  If there is a conceptual breakthrough of note in addictions field in recent years, it is that such processes can be strategically stimulated and accelerated.  Today, enormous efforts are being expended to accelerate precovery processes for cancer, heart disease, diabetes, asthma, and other chronic disorders.  We as a culture are not waiting for people to seek help at the latest stages of these disorders at a time their painful and potentially fatal consequences can no longer be ignored.  We are identifying these disorders early, engaging those with these disorders in assertive treatment and sustained recovery monitoring and support processes.  Isn’t it time we did the same for addiction?

This made me think of Debra Jay and her efforts to continue refining, improving and expanding the role of family interventions.

Recovery capital and capital

From the UK Advisory Council on the Misuse of Drugs second report of the recovery committee [emphasis mine]:

…our optimism about recovery should be tempered. Evidence suggests that different groups are more or less likely to achieve recovery outcomes. For some people, with high levels of recovery capital (e.g. good education, secure positive relationships, a job), recovery may be easier. For others, with little recovery capital or dependent on some types of drugs (especially heroin), recovery can be much more difficult and many will not be able to achieve substantial recovery outcomes.

It’s great that people are discussing recovery and looking at outcomes, but I have a few important concerns.

At what point does recovery capital become a proxy for class?

I’m increasingly concerned that recovery capital is becoming a proxy for social class. Whenever I discuss health professional outcomes, the typical response is something like, “Yeah, well, they have a lot more recovery capital than most opiate addicts.” The implication is that health professionals (and people like them) are capable of achieving drug-free full recovery while other opiate addicts are not. This is particularly troubling as maintenance becomes the de facto treatment for opiate addiction and significant financial resources become more important for accessing drug-free treatment of adequate duration and intensity. (Like health professionals get.)

This question brings John Rawls and his “original position” to mind.

In the original position, the parties select principles that will determine the basic structure of the society they will live in. This choice is made from behind a veil of ignorance, which would deprive participants of information about their particular characteristics: his or her ethnicity, social status, gender and, crucially, Conception of the Good (an individual’s idea of how to lead a good life). This forces participants to select principles impartially and rationally.

We have a situation where the experts provide one kind of treatment to their peers and another kind of treatment to the rest of their patients. If these experts had to assume the original position and operate from behind the veil of ignorance–if they were to be reborn an addict of unknown class, race, gender, economic status, etc–what would they want the de facto treatment to be?

If it’s not maintenance, then we have a social justice problem.

Evidence for what?

The other important question concerns the evidence. I have several questions about discussions about evidence.

• How many of these experts view opiate addiction as a hopeless condition?
• Do the experts and evidence address quality of life?
• How many of the experts have an anti 12-step bias or anti-recovery bias?
• How many of the experts receive payments from drug companies or have other financial interests in the drugs they are researching?
• Do the experts recognize the limitations of evidence in making policy?
• Are we getting all of the evidence?
• What influence is PHARMA wielding?
• Evidence for what outcomes?

Related articles

• …let us work together (addictionandrecoverynews.wordpress.com)
• Two more defenses of Suboxone (addictionandrecoverynews.wordpress.com)
• no hint of opinion here (addictionandrecoverynews.wordpress.com)
• What makes treatment effective? (addictionandrecoverynews.wordpress.com)

Knowing laughter

In The Gifts of Imperfection, Brene Brown describes “knowing laughter”

In I Thought It Was Just Me, I refer to the kind of laughter that helps us heal as knowing laughter. Laughter is a spiritual form of communing; without words we can say to one another, “I’m with you. I get it.”

True laughter is not the use of humor as self-deprecation or deflection; it’s not the kind of painful laughter we sometimes hide behind. Knowing laughter embodies the relief and connection we experience when we realize the power of sharing our stories—we’re not laughing at each other but with each other.

It reminds me of Ernie Kurtz’s writing about laughter at meetings

The laughter that takes place at an AA meeting is not laughter at the speaker, it is laughter at self. This is why it is so healing. Any genuine Twelve-Step meeting will have laughter, the humor that comes from the embrace of this image of imperfection.