He said, I should retire from life and avoid stress. I have come to call my psychiatrist’s pronouncement a “prognosis of doom”. He was condemning me to a life of handicaptivity wherein I was expected to take high dose neuroleptics, avoid stress, retire from life and I was not even 18 years old! My psychiatrist did not understand that boredom is stressful! A life devoid of meaning and purpose is stressful! A vegetative life is stressful. A life in handicaptivity, lived out within the confines of the human services landscape, where the only people who spend time with you, are people who are paid to be with you – that is stressful! Living on disability checks from the government is stressful.
When I was diagnosed I needed hopeful messages and role models. I needed to hear that there were pathways into a better future for me. I needed to connect with others who had been diagnosed with schizophrenia and who had recovered lives of meaning and purpose. I needed to find others who had completed college and who had jobs and who got married and had families, and had an apartment and a car.
Why is hope important to recovery? Because hope is the root of life’s energy. In order to recover, I had to turn away from the wish that psychiatrists could fix me. I had to turn away from the myth that psychiatric treatments could cure me. Instead, I had to mobilize all of the energy I had. I had to become an active partner in my recovery. I had to learn to work collaboratively with my treatment team and to draw strength from the wisdom of my peers. I had to begin striving for my goals, not when I was “all better”, but from day one. I had to believe that there was a life for me beyond the confines of the mental health system. That is hope. Hope is the tenacious pursuit of pathways to a better life, despite the odds. Without hope, there is no recovery.
Amen. Please go and read the whole post at her blog and spend some time poking around her posts.
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.
* * *
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 alladdiction treatment admissions.]
So, I thought I’d take a step back and try to address the big picture in one post.
The wrong paradigm?
To 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.”
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.
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.
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
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:
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 emotionalside effects. It is known to reduce risk of death, but not eliminate it.
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.
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.
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 alladdiction treatment admissions.]
So, I thought I’d take a step back and try to address the big picture in one post.
The wrong paradigm?
To 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.”
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.
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.
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
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:
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 emotionalside effects. It is known to reduce risk of death, but not eliminate it.
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.
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.
Yes, cannabis has medical value for some people. And yes, the sustained effort of the federal government to make medical cannabis research as difficult as possible is a national disgrace.
As of October 2012, a total of 903 physicians had recommended medical marijuana for the 108,000 patients holding valid red cards. Twelve physicians recommended medical marijuana for 50 percent of those patients, including one physician with more than 8,400 patients on the Registry.
Some physicians have recommended what appear to be higher-than-reasonable amounts of medical marijuana. In one case, a physician recommended 501 plants for a patient. In another case, a physician recommended 75 ounces of useable marijuana for the patient.
Do the arithmetic on 8400 patients for one physician. Assume a 50 40-hour workweeks and zero time spent on administrative tasks. That’s a little bit less than 15 minutes per customer. Medical practice? No. Just dope dealing.
He adds:
The strategy of using quasi-medical legalization as a means of normalizing consumption and moving the political acceptability of full commercial legalization has been a great success … And I’m not unhappy with the outcome. … Still, the whole deal – and especially the role of the “kush docs” – makes me a little sick to my stomach.
Crain’s Detroit has an article on the state’s medical marijuana business from the grow side to the physicians. The article says that there have been 344,000 patient applications in the state since 2009 and that doctors often charge around $150 to certify patients, that’s $51,600,000 in revenue for the docs. Here’s a little from the article about one of them:
“I discovered the medical benefits of marijuana in 2007 when I was doing suboxone therapy for narcotics addiction,” said Townsend, who holds a bachelor’s degree in biological sciences from Michigan State University and a medical degree from the Southeastern College of Osteopathic Medicine in North Miami Beach, Fla.
“I began to notice that as I was weaning people off of narcotic pain medications, those that were using marijuana illegally, and then with medical marijuana cards after 2008, weaned very, very well.”
After seeing thousands of patients over the past five years, Townsend has concluded that marijuana has a deserved place in a doctor’s black bag.
“I discovered that people were coming off using handfuls of Vicodin a month — high doses of Vicodin every day — strictly through the use of medical marijuana,” said Townsend, who termed himself one of the biggest advocates for it in the state — but never has used it.
“It’s very good for the treatment of Crohn’s disease, excellent for nausea, very useful for treatment of glaucoma and Parkinson’s disease,” he said. “I’ve seen it stop a seizure in front of me.”
Of the approximately 30,000 active doctors in Michigan, only about 1,900 have written a single medical marijuana certification, Townsend said. When analyzed further a year ago, 55 doctors in Michigan wrote 70 percent of the certifications, with Townsend being in that group.
55 docs wrote 70%? Let’s see, 70% of $51.6 million is $36,120,000 and let’s divide that by 55 docs. That’s $656,727.27 per doc!
I wonder what other kinds of care they provide to these patients?
This has gotten a lot of press. There’s naloxone distribution doubt this will reduce overdose deaths. However, some pretty important questions remain:
What happens after the overdose?
What services/interventions might have prevented the overdose in the first place?
The article references placing defibrillators in public places. What happens after someone is saved by one of those defibrillators? An ambulance comes and takes them to receivetreatment. (Often treatment that costs tens of thousands of dollars.)
0 = Number of times the word “treatment/treat/treatable” appears in the article
0 = Number of times the word “recovery/recover” appears in the article
So … dead addict don’t recover, but why do we seem to care so little about treating what nearly killed the patient?
Advertisement for curing morphine addictions from Overland Monthly, January 1900 (Photo credit: Wikipedia)
I blogged before about the availability of opiates for pain management and the need to try to limit their diversion. While others have complained about draconian limitations on the prescribing of opiates and being too afraid to treat pain, I pointed out the explosion in opiate prescriptions and overdoses. It’s a complex problem that demands a solution that balances the needs of pain patients with the public health risks of easily available opiates.
Here’s a new study looking at the issue [emphasis mine]:
While overdose death rates related to heroin, cocaine, sedative hypnotics, and psychostimulants increased between 1999 and 2009, deaths related to pharmaceutical opioids increased most dramatically, nearly 4-fold. In 2000, the Joint Commission on the Accreditation of Health Care Organizations introduced new standards for pain management which focused on increased awareness of patient’s right to pain relief which contributed to an increase in prescribing of opioid analgesics (Phillips, 2000 and Federation of State Medical Boards of the US, 1998). The average milligrams of morphine prescribed per patient per year increased more than 600% from 1997 to 2007, which led to an increased availability of pharmaceutical opioids for illicit use (US Department of Justice, 2012). From 1999 to 2007, substance abuse treatment admissions for pharmaceutical opioid abuse increased nearly 4-fold and emergency department visit rates related to pharmaceutical opioids increased 111% from 2004 to 2008; visit rates were highest for oxycodone, hydrocodone, and methadone (SAMHSA, 2009a, SAMHSA, 2009b and SAMHSA, 2011). Risks associated with pharmaceutical opioid related overdose included taking high daily doses of opioids and seeking care from multiple healthcare providers to obtain many prescriptions (Paulozzi et al., 2012 and Hall et al., 2008). “Doctor shopping” has also been associated with opioid diversion and illicit use (SAMHSA, 2010 and Rigg et al., 2012). National survey data showed that 75% of pharmaceutical opioid users were using opioids prescribed to someone else (Substance Abuse and Mental Health Services Administration, 2010).
Rates of undiagnosed attention deficit hyperactivity disorder in London drug and alcohol detoxification units
Background
ADHD is a common childhood onset mental health disorder that persists into adulthood in two-thirds of cases. One of the most prevalent and impairing comorbidities of ADHD in adults are substance use disorders. We estimate rates of ADHD in patients with substance abuse disorders and delineate impairment in the co-morbid group.
Method
Screening for ADHD followed by a research diagnostic interview in people attending in-patient drug and alcohol detoxification units.
Results
We estimated prevalence of undiagnosed ADHD within substance use disorder in-patients in South London around 12%. Those individuals with substance use disorders and ADHD had significantly higher self-rated impairments across several domains of daily life; and higher rates of substance abuse and alcohol consumption, suicide attempts, and depression recorded in their case records.
Conclusions
This study demonstrates the high rates of untreated ADHD within substance use disorder populations and the association of ADHD in such patients with greater levels of impairment. These are likely to be a source of additional impairment to patients and represent an increased burden on clinical services.
More than 76 million people worldwide have alcohol problems, and another 15 million have drug problems. Motivational interviewing (MI) is a psychological treatment that aims to help people cut down or stop using drugs and alcohol. The drug abuser and counsellor typically meet between one and four times for about one hour each time. The counsellor expresses that he or she understands how the clients feel about their problem and supports the clients in making their own decisions. He or she does not try to convince the client to change anything, but discusses with the client possible consequences of changing or staying the same. Finally, they discuss the clients’ goals and where they are today relative to these goals. We searched for studies that had included people with alcohol or drug problems and that had divided them by chance into MI or a control group that either received nothing or some other treatment. We included only studies that had checked video or sound recordings of the therapies in order to be certain that what was given really was MI. The results in this review are based on 59 studies. The results show that people who have received MI have reduced their use of substances more than people who have not received any treatment. However, it seems that other active treatments, treatment as usual and being assessed and receiving feedback can be as effective as motivational interviewing. There was not enough data to conclude about the effects of MI on retention in treatment, readiness to change, or repeat convictions.The quality of the research forces us to be careful about our conclusions, and new research may change them.
This is a great example of a major flaw in research. There are so many assumptions in every study. One wrong assumption can lead to bad findings. For example, that motivational interviewing is an especially effective and sufficient intervention to treat alcoholism.
MI is being integrated into treatment for all sorts of medical problems, chronic health problems in particular, where part of treatment is recruiting the patient into participating in a treatment that is known to be effective but often suffers from low rates of patient compliance.
The difference here is that researchers seem to be interested in replacing existing treatments for addiction with MI.
One big problem here is that this inserts the assumption that alcoholism is resolved be increasing motivation to quit or reduce drinking.
I believe that these assumptions may be correct for low severity alcohol problems and that MI may be an effective intervention for these problems.
I also believe that MI is probably a valuable tool for more severe alcohol problems, but, in these cases, its proper use is to get patients to accept and participate in treatments that are known to be effective when patients comply. Twelve step facilitation, for example.
Why is there this push for MI as a replacement treatment rather than a treatment inducement tool? Does this constitute a bias on the part of researchers? I don’t know, but note that I’m not the one tossing out the baby with the bath water. I’m suggesting MI might be very important but that they are just asking the wrong questions. It’s also a little ironic that the push to use MI to replace other treatments actually weakens the case for MI having an important role in treating alcoholism.
Pat Deegan reflects on her own experience an shares about the need for hope in recovery:
To 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.”
Hazelden’s adoption of ORT
Unreal. Someone’s got an awful lot of faith in their diagnostic skills. 
Cochrane conducts 
Addiction & Recovery News 