What makes treatment effective?

This will be my post in response to the NY Times’ series on Suboxone.

This post originally ran on 7/19/13 and addressed a lot of our concerns.

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postcard---heroin-lie

I’ve been catching a lot of heat recently for posts about Suboxone and methadone. (For the sake of this post, lets refer to them as opioid replacement therapy, or ORT, for the rest of this post.

One commenter who blogs for an ORT provider challenged my arguments that we should offer everyone the same kind of treatment that we offer doctors and questioned the “it works” argument from ORT advocates. He dismissed the treatment model

Another commenter is an opiate addict who objected to a post about Hazelden’s announcement that they started providing ORT maintenance. She reported suffering greatly from cravings and relapsing after drug-free treatment at Hazelden. She’s been on Suboxone for 50 days and feels like it is a better solution for her.

Another post, that has nothing to do with me, blames abstinence-oriented treatment for the recent overdose death of an actor. (Among the other problems with the article are that she slanders abstinence-based treatment by suggesting that abuse is common. She misleads readers into thinking that ORT is not widely available when federal surveys find that ORT admissions accounted for 26% of all admissions. [Not 26% of opioid addiction admissions. 26% of all addiction treatment admissions.]

So, I thought I’d take a step back and try to address the big picture in one post.

The wrong paradigm?

Red_Drug_Pill---recoveryTo some extent, these arguments remind me of hearing Bill White comment on arguments about cognitive-behavioral therapy vs. motivational interviewing vs. 12 step facilitation. He commented that, “these are all arguments within the acute care paradigm.”

I talk often about the success of health professional recovery programs and their remarkable outcomes. What makes these programs so successful? I’d boil it down to a few factors:

  1. They are recovery-oriented. They treat patients with the expectation that they can fully recover and focus on facilitating and supporting recovery rather than just extinguishing symptoms of addiction.
  2. They have a chronic care model. They continue to provide care and support long after the acute stage of treatment (5 years). They also focus on lifestyle changes the will support recovery and look for ways to embed support for recovery in the patient’s environment.
  3. They provide adequate care. The provide multiple levels of high quality care of the appropriate intensity and duration at different stages of the patient’s recovery.

Many abstinence-oriented treatment providers have provided the first, but not the second and third. (Though one could argue that 12 step facilitation offers a long term recovery maintenance model.) They provide 10 days of inpatient care or 2 weeks of intensive outpatient and offer a passive referral to outpatient care. (Only 2% of all treatment admissions were for long term [more than 30 days] residential.) The end product looks something like a system that treats a heart attack with a few days or weeks of emergency care and then discharges the patient with no long term care plan. (Or, a weak long term care plan.) Then, we’re surprised when the patient has another cardiac event.

Many ORT providers have offered the second element, but not the first or third. The long term nature of ORT could be considered a chronic care model. However, the end product look something like palliative care for a treatable condition. It reduces opiate use (not necessarily other drug use), criminal activity and over dose. But these benefits are only realized as long as the patient is on ORT and drop-out rates are not low. And, ORT research has not been able to demonstrate the improvements in quality of life (employment, relationships, housing, life satisfaction, etc.) that we see in those health professionals who get all three elements. (Also note that opiate addicted health professionals often use VERY large doses and go undetected for long periods of time. Any neurological damage from their use does no appear to interfere with their achieving drug-free recovery in very impressive numbers.)

It’s effective!

photo credit: ntoper
photo credit: ntoper

One of the recurring arguments that I hear is that ORT is effective and there is tons of research that it’s effective. I don’t question that it’s effective at achieving some outcomes–reducing criminal activity, reducing opiate use and reducing overdose. If those are the only outcomes you care about, then you can say it’s effective without any qualifications.

Even with my bias for abstinence-oriented treatment, I can imagine circumstances where ORT might be the least bad option. (For example, if your child had been offered high quality treatment of adequate quality and duration more than once and they continue to relapse and be at high risk for fatal overdose.) A few weeks ago I offered an analogy that attempted to offer an approach to informed consent:

Maybe the choice is something like a person having incapacitating (socially, emotionally, occupationally, spiritually, etc.) and life-threatening but treatable cardiac disease. There are 2 treatments:

  1. A pill that will reduce death and symptoms, but will have marginal impact on QoL (quality of life). Relatively little is known about long term (years) compliance rates for this option, but we do know that discontinuation of the medication leads to “near universal relapse“, so getting off it is extremely difficult. The drug has some cognitive side-effects and may also have some emotional side effects. It is known to reduce risk of death, but not eliminate it.
  2. Diet and exercise can arrest all symptoms, prevent death and provide full recovery, returning the patient to a normal QoL. This is the option we use for medical professionals and they have great outcomes. Long-term compliance is the challenge and failure to comply is likely to result in relapse and may lead to death. However, we have lots of strategies and social support for making and maintaining these changes.

The catch is that you can’t do both because option 1 appears to interfere with the benefits of option 2.

Fixing treatment

Hazelden Monument2_2WEBHazelden’s adoption of ORT has provided fuel to a lot of these arguments.

Hazelden was confronted with poor outcomes for their opiate addicted patients. They saw a problem and decided to act.

One option would have been to declare that a 30 day model for opiate addiction treatment is doomed to fail and build a recovery-oriented, chronic care system that delivers high quality care of the appropriate intensity and duration.

ORT seems to be the easier response, particularly with the market and cultural currents flowing in that direction.

Bill White has argued that ORT can be compatible with a recovery orientation. I’m skeptical, but I’m watching and am willing to learn from any success they have.

However, if you can get what the doctor’s having, why would you want anything else? And, shouldn’t we want every patient to get the same kind of care the doctor would get if she were the patient? If you can’t get that, you’ve got some tough decisions to make.

I’m looking for others to implement the health professional model with others, finding ways to build upon it and make it less expensive, as we have.

UPDATE: In an email exchange with a friend who disagrees, I clarified Hazelden’s options, as I see them. If it were Dawn Farm, I’d imagine we’d look at things like:

  • improving our aftercare referral process–asking ourselves if we can make better active linkages to communities of recovery;
  • evaluating whether the intensity, duration and quality of our aftercare recommendations were appropriate;
  • embedding recovery coaching in cities around the country to provide assertive recovery support;
  • improving post-treatment recovery monitoring and re-intervention.

no hint of opinion here

SecondOpinion400

To me, the most important line in the NY Times Suboxone series was this one, “[Dr. Sullivan] considered opioid addiction “a hopeless disease'”.

We believe that maintenance approaches are rooted in the belief that most opiate addicts are not capable of recovering in the same manner that doctors recover.

Most of the arguments for maintenance treatments focus on reduced harm and its relative risks, very few focus on quality of life or achieving full recovery.

It’s also worth remembering that Suboxone compliance rates aren’t what they used to be.

The post below was originally published on 6/26/13. I decided to repost it to accompany the posts from the last few days.

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From an article about a new report on medications for opiate treatment:

The report also examined studies that evaluated buprenorphine, methadone, injectable naltrexone, and oral naltrexone and concluded a benefit in patient outcomes as well as costs.

“I can say with no hint of opinion here, it’s simple fact, they are all effective,” McLellan said. “They’re effective not just in reducing opioid use, they’re effective in so many other ways that are important to societies and families.”

Effective. It’s a fact. No opinion here. Hmmm.

Effective at what? These drugs are effective at reducing opiate use. If that outcome is all one wants, they may be a good option.

The problem is that it’s a palliative response, when we know that full recovery is possible if the right resources are made available. (Of course these treatment approaches are not the ones physicians choose for themselves and their peers.)

Let’s see what the report says about another outcome that might speak more directly to quality of life, say, employment [emphasis mine]:

These studies have also measured various types of related outcomes such as reductions non-opioid drug use, employment and criminal activity. Here the literature is quite mixed and appears to be a result of the particular patient population, the clinical approach of the methadone maintenance program and the available counseling and social services provided.

and

As with methadone, the literature is quite mixed with regard to reducing non-opioid drug use, improving employment and reducing crime.

and

He also found improvements within the methadone maintenance group across various time periods on HIV risk behaviors, employment and criminal justice involvement. [My note: In this study, employment increased from approximately 21% to approximately 31%.]

So…while there’s little doubt that these medications reduce opiate use and overdose deaths, the quality of life evidence is considerably weaker.

With the increases in opiate ODs, I understand families and individuals struggling with these decisions. I struggle to come up with the best analogy for informed consent. Maybe something like this?

Maybe the choice is something like a person having incapacitating (socially, emotionally, occupationally, spiritually, etc.) and life-threatening but treatable cardiac disease. There are 2 treatments:

  1. A pill that will reduce death and symptoms, but will have marginal impact on QoL (quality of life). Relatively little is known about long term (years) compliance rates for this option, but we do know that discontinuation of the medication leads to “near universal relapse“, so getting off it is extremely difficult. The drug has some cognitive side-effects and may also have some emotional side effects. It is known to reduce risk of death, but not eliminate it.
  2. Diet and exercise can arrest all symptoms, prevent death and provide full recovery, returning the patient to a normal QoL. This is the option we use for medical professionals and they have great outcomes. Long-term compliance is the challenge and failure to comply is likely to result in relapse and may lead to death. However, we have lots of strategies and social support for making and maintaining these changes.

The catch is that you can’t do both because option 1 appears to interfere with the benefits of option 2.

NYT Reax

SecondOpinion400This blog has a point of view. We’re not fans of maintenance. (Though we still think Suboxone can be a very useful detox tool.)

If you want to read defenses of Suboxone, you can find a couple here:

The best critical response is from addictiondoctor.org, though he’s not making a recovery argument. He’s really making a harm reduction argument.

It’s key to remember that there is an epidemic of opioid overdose deaths in this country largely fueled by the unrestricted access to long active high potency full opioid agonists in “pain clinics” around the country. It’s strikingly ironic that in the midst of this, there is controversy about a long acting partial agonist that is much safer and has been used in hundreds of thousands of people to stop the compulsive use. What is even more ironic is that the use of Suboxone is limited while any physician can prescribe nearly limitless quantities of the more deadly full opioid agonists.

The NY Times published a few reactions to its Suboxone series.

There were a couple of letters from physicians writing in support of Suboxone.

There was also a letter from a recovering person.

Thank you for exposing the dark side of the recovery and pharmaceutical industries’ approach to addiction. I’m dropping my own anonymity today.

It took me 14 years of fits and starts to finally earn a decade of continuous sobriety. To stay sober I need four meetings a week.

I see buprenorphine sweeping through the recovery population. It’s obvious that newbies and kids are suffering from it the most.

And, a physician who used to be a fan, but is no longer.

As one of the earliest of the Pennsylvania physicians approved to prescribe buprenorphine, I was part of a wave of optimism. After decades of helping addiction patients struggle to save their lives, I was initially quite heartened with the results of buprenorphine. Now, the “bloom is off the rose” as I, too, see the patterns of abuse and diversion.

There were lots of reader comments that were positive and negative about Suboxone. Here’s one that captures what we hear from a lot of addicts and families seeking help getting off of Suboxone:

My son has been an opiate addict for years. Through countless detoxes and rehabilitations he found himself on suboxone. What isn’t discussed is that this is a controlled substance that is hardest of all to withdraw from. It is an opiate. My son on suboxone continued addict-type behavior. Sure, he was functioning a bit better but not good enough. He was listless, with no attention span and without any sense of urgency to taking care of himself. My wife and I realized this is a pervasive horrible substitute for sobriety and we told my son we would not support it any longer. He still struggles to find a lasting sobriety. Opiate addiction is all the evils everyone talks about and I don’t need to repeat them. But suboxone is not the answer to finding true sobriety. Doctors are too keen to provide this as a solution but it continues one’s addiction not only to the opiate but to the behaviour that si typical of addicts. We pray and continue to support ways to help my son find a true sobriety, but one opiate substitute for another is not the answer.

Here’s a comment from our facebook page:

Suboxone is perfect for keeping the addict trapped in the dark place of turmoil that so many of us are in when we are first clean. I’m not sick but I still need a steady supply of drugs just to sleep. I have no healthy ego because my life still sucks and no coping skills outside of self destructive survival behaviors that kept me alive on the street. The addict eventually has to choose between a life with little to no quality or one where they have the relief of temporary highs. You can’t get off drugs by staying on drugs. Suboxone is no different than when I got off heroin and methadone In 97 and then spent 17 yrs drinking myself to death culminating in a suicide before getting sober last year. I was off the “bad drugs”And on the one that’s acceptable.

a spectrum of apples, oranges, lemons, plums?

DSM_5_2Howard Wetsman picks apart the spectrum approach of the DSM5

Making a spectrum out of the illnesses that have been put in the substance use category of DSM IV is like making a spectrum out of an apple, an orange, a lemon, a lime, a blue fruit (if there was one) and a plum. You’d have the colors but your mixing different things. Sometimes a metaphor can be taken too far.

First there is the assumption that the substance use disorders actually hold together and are separate from other disorders in the DSM. It is an assumption and not one that is supported by the evidence of recent studies. DSM is concerned with behavior, not with biology. Illness is biology from which behavior can manifest, but it’s the biology that comes first. So before we look at the substance use disorders and say they can be made into a spectrum we have to see if they are separate from other things that look like addiction (overeating, compulsive sex, compulsive gambling, etc.) and are the same as each other (that substance abuse is the same as addiction, only less of a problem).

The evidence I’ve seen suggests that it can’t be done. Biologically, addiction to opioids and addiction to sugar binging have more in common than addiction to opioids and abuse of opioids. There are a lot of reasons that people with normal brains choose to do stupid things with drugs, but there’s a real commonality about why people with addiction use. That commonality extends beyond drugs to anything that makes the reward system go “Bam.” When we try to put people with normal brains who abuse substances in addiction treatment they don’t understand what we’re talking about. When we try to put addicts in treatment with people with normal brains they get confused and try to “use like a normal person.”

Read the rest of the post here.

 

Living on the bottom

NMLG-cover300-201x300Debra Jay addresses the belief that families should let an addicted family member hit bottom:

Hitting bottom is an old idea, still imposed upon families as if it were an absolute. Many families sadly believe that they must wait for alcoholics to hit bottom before there is any hope for recovery. They rarely stop to consider that this belief sentences them to years of unhappiness and devastation. No one ever mentions the fact that alcoholics and addicts don’t take the trip to the bottom alone–the family goes with them. Families are never warned that the journey to the bottom takes even the smallest children.

. . .

“Bottoms” can be temporary. Alcoholics resist getting sober even when things are going badly in their lives. They are good at weathering storms. Perhaps they’ll swear off alcohol for a while, but as soon as things cool down, they begin drinking again. The addicted brain can’t make lasting connections between alcohol and the problems it causes. Once the problems go away, alcohol is their best friend again. Addiction is both invisible and sacred to alcoholics: they deny its existence yet sacrifice everything to it.

Addicts don’t want to cause trouble or hurt the people they love. Quite the contrary: they struggle to be the person they think they still are, the person they were before the addiction took hold. They can’t make sense of their own actions. As their addiction progresses and troubles mount, they work harder to manage their lives, but addiction never lets anyone lead a life free of trouble. There are always problems, big and small. Bad behavior, poor decisions and emotional upheaval are all symptoms of this disease that affects both the brain and soul. Families are confused, too. Not understanding what is happening to their loved ones, they mutter: “When will she learn?” But addicts can’t learn because addiction keeps tightening its grip, demanding complete allegiance.

Sentences to ponder

by karola riegler photography
by karola riegler photography

Nearly one-third of U.S. veterans who are given psychiatric medications by their doctors do not have a diagnosed mental health problem

Many vets given psychiatric drugs without diagnosis | Reuters

AA is asinine?

foreignThe Boston Globe has a piece on why Russians haven’t embraced AA:

…the group-therapy dynamic collides with a skepticism about the possibility of ordinary people curing each other of anything. “The idea that another drunk can help you is asinine to most Russians,” said Alexandre Laudet, a social psychologist who has researched Russian alcoholism.

Then there’s the problem of opening up to strangers. The AA method works in part through trust in people you’ve never met before, and coming clean to them about one’s most shameful secrets.

With Rise Of Painkiller Abuse, A Closer Look At Heroin

English: Pre-war Bayer heroin bottle, original...
English: Pre-war Bayer heroin bottle, originally containing 5 grams of Heroin substance. (Photo credit: Wikipedia)

 

The number of people who had used heroin in the previous year increased between 2007 and 2012, from 373,000 to 669,000. Meanwhile, federal data from 2011 finds that nearly 80 percent of people who had used heroin in the past year had also previously abused prescription painkillers classified as opioids.

 

via With Rise Of Painkiller Abuse, A Closer Look At Heroin : NPR.

 

Recovery and Harm Reduction

English: Liberty Bell in Philadelphia
English: Liberty Bell in Philadelphia (Photo credit: Wikipedia)

Bill White has a new paper on Recovery and Harm Reduction in Philadelphia. Here’s a quote he offered in a blog post introducing the paper:

Traditional harm reduction programs have pioneered low threshold services, but they have often also been characterized by low expectations.  Our vision is to expand low threshold services that at the same time elevate peoples’ sense of what is possible for them.  We do this by exposing them to living proof that recovery is possible even under the most difficult of circumstances, confirming that there are people who will walk this path with them, and offering stage-appropriate services to support people in their journeys from addiction to recovery. Arthur C. Evans, Jr., PhD, Commissioner, Philadelphia Department of Behavioral Health and Intellectual disAbility Services, 2013

This reminds me of posts I’ve written about “recovery-oriented harm reduction” over the years. 

From one of those posts:

Recovery is all about freedom. The freedom to live one’s life in the way one chooses without being a slave to addiction or being controlled by treatment or criminal justice systems.

This is the key. We’ve struggled mightily with maintaining a professional culture that is focused on recovery. It often conflicts with human nature and the instincts of professional helpers, so we have to accept that it will be a constant struggle. On the subject, we contributed to this paper.

I’ve been thinking about a model of recovery-oriented harm reduction that would address the historic failings of abstinence-oriented and harm reduction services. The idea is that it would provide recovery (for addicts only) as an organizing and unifying construct for treatment and harm reduction services. Admittedly, these judgments of the historic failings are my own and represent the perspective of a Midwestern U.S. recovery-oriented provider:

  • an emphasis on client choice–no coercion
  • all drug use is not addiction
  • addiction is an illness characterized by loss of control
  • for those with addiction, full recovery is the ideal outcome
  • the concept of recovery is inclusive — can include partial, serial, etc.
  • recovery is possible for any addict<
  • all services should communicate hope for recovery–recognizing that hope-based interventions are essential for enhancing motivation to recover
  • incremental and radical change should be supported and affirmed
  • while incremental changes are validated and supported, they are not to be treated as an end-point
  • such a system would aggressively deal with countertransference–some people may impose their own recovery path on clients, others might enjoy vicarious nonconformity through clients

I’ve also admired Scott Kellogg’s writing on gradualism. Here’s a quote from a story about him a few years back:

A Gestalt-trained therapist, Kellogg holds some views that seem to place him closer to the harm reductionist’s way of looking at substance use and recovery. He questions treatment center practices that appear to profess abstinence at the risk of losing many clients before they can start making progress. He states his belief that “there’s a crisis in our treatment world because many people don’t like treatment.”

Yet he also says his perspective goes against the tenets held by many harm reductionists. He is most impatient with the attitude in some needle exchange programs and similar initiatives that “we would never tell people what to do.” Offering a shower, a sandwich and a clean needle and then repeating the process time and again are fine in the short term, but at some point you need to help build a life after you’ve saved one, he suggests.

A chronic illness?

addiction
addiction (Photo credit: Alan Cleaver)

Bill White responds to a recent article that has gotten a lot of attention by Gene Heyman, a disease model critic. Heyman (and a couple of other recent articles) question whether it’s accurate to call addiction a chronic illness.

If there is anything that the full scope of modern research on the resolution of AOD problems is revealing, it is that the dichotomous profiles of community and clinical populations represent the ultimate apples and oranges comparison within the alcohol and other drug problems arena.

Conclusions drawn from studies of persons in addiction treatment cannot be indiscriminately applied to the wider pool of AOD problems in the community, nor can findings from community studies be indiscriminately applied to the population of treatment seekers.

Adults and adolescents entering specialized addiction treatment are distinguished by:

1) greater personal vulnerability (e.g., male gender, family history of substance use disorders, child maltreatment, early pubertal maturation, early age of onset of AOD use, personality disorder during early adolescence, less than high school education,  substance-using peers, and greater cumulative lifetime adversities),

2) greater problem severity (e.g., longer duration of use, dependence, polysubstance use, abuse symptoms co-occurring with substance dependence;  opiate dependence),

3) greater problem intensity (frequency, quantity, high-risk methods of ingestion, and high-risk contexts,

4) greater AOD-related consequences (e.g., greater AOD-related legal problems),

5) higher rates of developmental trauma and post-traumatic stress disorder,

6) higher co-occurrence of other medical/psychiatric illness,

7) more significant personal and environmental obstacles to recovery, and

8) lower levels of recovery capital–internal and external resources available to initiate and sustain long-term recovery.

Bill points out the real world consequences of these arguments.

This is not merely an academic question.  Are families reading the headlined summaries of such reviews to conclude that the prolonged addiction of their family member results from moral and character defects of self-control that prevent “maturing out” of such problems that most people, according to these reports, achieve?  Should such chronicity render one unworthy of family and community support?

Read the rest here.