Personal Failure or System Failure?

Lowering_The_Bar_Cover_2010.09.22Bill 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.


Recovery Pluralsim

stancesBill White has a new post challenging the recovering community to be more pluralistic and let go of notions that there is one path to recovery:

Embracing recovery pluralism is not an embrace of recovery relativism in which opinions and preferences completely dominate facts. To be tolerant of the varieties of recovery experience is not to say we must blindly accept all proffered approaches to recovery as equal. All must be subject to investigation and all held accountable for recovery outcomes. Recent efforts to define recovery have focused on three essential elements: 1) the resolution of alcohol and other drug problems (most often measured by enduring abstinence), 2) improvements in global health (e.g., physical, emotional, relational health; quality of life and functioning), and 3) positive community reintegration (citizenship). All proposed pathways to recovery must be accountable for the degree to which they facilitate or fail to facilitate change across these three zones of recovery experience. That accountability comes through the experiences of individuals, families, and communities as well as through the rigor of scientific studies. At the moment, no recovery approach has outcomes so high as to warrant the claim of being THE recovery pathway.

Quality of life and death

English: Graveyard in Barnes
English: Graveyard in Barnes (Photo credit: Wikipedia)

A study out of Australia looks at death rates among opioid addicts receiving opioid substitution treatment (OST, for short. It’s methadone.) in New South Wales between 1985-2005. It’s a HUGE sample–43,789 people. If fact, the paper says:

This cohort is likely to represent the majority of opioid dependent people in that State during this period, perhaps as high as 80%.

To my mind, the strongest argument for methadone and buprenorphine has been overdose prevention–that dead addicts can’t recover and drug-free treatment isn’t going to work for everyone at every point in time. If I’m the parent of a heroin addict and they’ve refused drug-free treatment or relapsed after high quality drug free treatment of the adequate dose and duration, maintenance might look like the least bad option. At least they’ll be alive, right? (Of course, my concern is that these drugs have become the first line treatment and access to better options is diminishing.)

So, what did they find in this cohort?

Well,  8.8% of the cohort died. (9.4% of men.)

There were 3,685 deaths in the cohort between 1985 and 2005 for a crude mortality rate of  894 per 100,000py (95% CI: 865, 923) (Table 1).

How did they die?

The majority of deaths were drug-related  (n=1932; 52%), with most of these (n=1574; 82% of all drug-related deaths) coded as accidental opioid deaths. The bulk of remaining deaths were due to unintentional injuries (n=975; 26% of all deaths) and suicide (n=484; 13% of all deaths).

Did they at least live long lives?

Using the Australian life tables approach, there was an estimated 160,055 Years of Potential Life Lost (YPLL) in this cohort, an average of 44 YPLL per person who died, and 29 years of YPLL before age 65 (Table 4). Just under half (45%) of the YPLL were due to accidental opioid-related deaths (an average loss of 46 years of potential life, or 31 years prior to age 65). Motor vehicle accidents accounted for the highest average YPLL, 47 years, or 33 years before age 65.

How does this compare with the rest of the population?

The overall age-, sex- and year-standardised mortality ratio was 6.5 (95% CI: 6.3-6.7) indicating that our cohort had 6.5 times the rate of mortality than that expected in the population.

Is this unique to Australia?

The average of 44 years of potential life lost for each fatality in the cohort highlights the fact that deaths in opioid users often occur at a young age. This was particularly the case for avoidable causes of death such as drug overdose and injuries. The pattern of YPLL was broadly similar to previous analyses of a Californian male cohort (n=581) in the US, followed from 1962 to 1997 (10). Both studies found that opioid overdoses were the largest contributor to YPLL but suicides made a larger contribution to YPLL in our cohort, and homicide a larger contribution in the Californian cohort.

Now, this doesn’t mean that methadone doesn’t reduce death rates. It means that the death rate is still very high.

It also means that quality of life questions shouldn’t be dismissed with snarky quips like, “What kind of QOL do dead people have?“, because methadone patients die in large numbers too.

If you’re thinking that those were the bad old days, before we had buprenorphine, think again. Retention rates for methadone and buprenorphine are not great. When put head to head, methadone has higher retention rates.

I’ll also throw in a reminder from a previous post about were I stand on ORT:

Just to be sure that my position is understood. I’m not advocating the abolition of methadone.

Here’s something I wrote in a previous post: “All I want is a day when addicts are offered recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose.”

Another: “Once again, I’d welcome a day when addicts are offered recovery oriented treatment of an adequate duration and intensity and have the opportunity to choose for themselves.”

It’s also worth noting that there is a link between AA and methadone.