Sentences to ponder

Medical marijuana dispensary on Ventura Boulev...
Medical marijuana dispensary on Ventura Boulevard in Los Angeles, California, U.S.A. (Photo credit: Wikipedia)

Mark Kleiman shares typically thoughtful and serious thoughts about legalizing cannabis. Too bad thoughtful and serious is so rare where cannabis policy is concerned.

2. Everything has advantages and disadvantages. Cannabis legalization will reduce criminal revenue, intrusive enforcement, arrest, incarceration, and disorder around illicit markets, and enhance personal liberty, consumer choice, and respect for the law, and probably reduce bloodshed in Mexico. It might foster safer and more beneficial practices of cannabis use.

3. Legalization will certainly increase drug abuse, including heavy use by minors. Every adult is a potential source of leakage to minors. And if we insist on making minors consume illicitly-produced pot, we reserve 20-25% of the market for criminals. Much better to tolerate leakage and have a grey-market supply to minors like the current system that provides them with alcohol.

4. The polarized nature of the debate means that both sides wind up spending lots of time denying the obvious.

via How to legalize cannabis « The Reality-Based Community.

Tribes of the Recovering Community

Celebrate_RecoveryCelebrate Recovery appears to be the most popular faith-based recovery group in the U.S. It’s Christian and evangelical and it’s not limited to people with drug and alcohol problems. Some members use it as a sole source of recovery support, others use it as an adjunct to 12 step recovery.

Celebrate Recovery is a biblical and balanced program that helps us overcome our hurts, hang-ups, and habits.  It is based on the actual words of Jesus rather than psychological theory.  20 years ago, Saddleback Church launched Celebrate Recovery with 43 people. It was designed as a program to help those struggling with hurts, habits and hang-ups by showing them the loving power of Jesus Christ through a recovery process. Celebrate Recovery has helped more than 17000 people at Saddleback, attracting over 70% of its members from outside the church. Eighty-five percent of the people who go through the program stay with the church and nearly half serve as church volunteers.

(The “Tribes of the recovering community” series is intended to demonstrate the diversity within the recovering community. I have no first hand knowledge of most of the tribes, so inclusion in this series should not be considered an endorsement.)

Pediatric use of buprenorphine

Adolescent_MedicineDrugfree.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.

Tribes of the Recovering Community

303451_192353640882543_1968585459_aThis week’s tribe is Millati Islami:

Millati Islami is a fellowship of men and women, joined together on the “Path of Peace”.  We share our experiences, strengths, and hopes while recovering from our active addiction to mind and mood altering substances.

We have sought to integrate the treatment requirements of both Al-Islam and the Twelve Step approach to recovery into a simultaneous program. Our personal thanks and appreciation goes to the Narcotics Anonymous and Alcoholics Anonymous programs from which we borrowed. Just as Narcotics Anonymous was founded out of its need to be non-specific with regard to substance, so Millati Islami was born out of our need to be religiously specific with regard to spiritual principles.

Millati Islami, by G-d’s will, (masha-Allah) offers a fresh perspective on age old ideas for treating our fallen human conditions. We pray further that it will serve as a model for successfully understanding and addressing the special problems encountered as recovering Muslims and substance abusers in a predominately non-Muslim society.

(The “Tribes of the recovering community” series is intended to demonstrate the diversity within the recovering community.I have no first hand knowledge of most of the tribes, so inclusion in this series should not be considered an endorsement.)

 

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.

we can heal

hopeJennifer Matesa has a new piece up at the recently reincarnated The Fix. It’s a response to the recent NY Times series on Suboxone and goes directly after the underlying assumption and its implications for her.

Reckitt can get away with convincing doctors that addicts need to be maintained on Suboxone because—as the Times story notes—common belief holds that painkiller addicts can never be drug-free. We’re told we’ve permanently screwed up our neurology. Popular thinking goes: Once you junkies take drugs, you might as well stay on drugs for life.

To support this belief, Reckitt and its growing army of reps offer twisted interpretations of research studies and anecdotal evidence about addiction and Suboxone. They claim studies “prove” that replacing painkillers with buprenorphine (the opioid drug in Suboxone) helps us stay “clean.” Ditch the old drug for the new drug and we stop shooting, snorting, stealing, doctor-shopping, tricking.

. . .

If my “Sub doc” had believed—as so many doctors do—that somebody like me could never be drug-free, I’d without a doubt still be on drugs today. Hell, which of us inside active addiction believes we can do without drugs? I’d also be experiencing nasty side-effects for which people who read my addiction-and-recovery blog write in asking for help.

For me, what’s so important about her voice is that she’s one addict speaking directly to other addicts around the chorus of experts chanting, “research shows that maintenance treatments are the most effective treatments we have.” She’s offering hope that other addicts don’t have to limit themselves to the definition of success that these experts offer (reduced death, disease and drug use).

She’s also become a collector of stories about the lived experience of people who have tried Suboxone and found it to be incompatible with full recovery and very difficult to discontinue.

Just like doctors who can’t detox their patients off painkillers, most doctors who prescribe Suboxone don’t know how to help their patients quit. So the patients wind up asking me to be their doctor. One woman recently begged me to manage her detox in exchange for payment. I declined, but I was left shocked at the desperation of some folks out there to live a drug-free life, so much so that they will contact a total stranger and offer cash for an amateur detox. This speaks to the sorry state of treatment (not to mention the general health-care system) in this country.

These folks read my blog, they know I got off drugs including Suboxone, and they can see I’m living a productive drug-free life. I write them back, but I can’t be their doctor. The best I can do is keep writing stories like these, and letting policymakers, researchers, and practitioners know that they need to open their minds about how well most addicts can live, how much we can heal.

Recovery capital and capital

blindjusticeartFrom 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.

Tribes of the recovering community – Calix Society

calixlogo

This week’s tribe is the Calix Society.

Calix is an association of Catholic alcoholics who are maintaining their sobriety through affiliation with and participation in the Fellowship of Alcoholics Anonymous. Our first concern is to interest Catholics with an alcoholic problem in the virtue of total abstinence. Our second stated purpose is to promote the spiritual development of our membership. Our gathering today is an effort in this direction. Our conversation and our association together should be a source of inspiration and encouragement to each other, geared to our growth toward spiritual maturity. Our participation in all other spiritual activities of Calix, such as the frequent celebration of the Liturgy, reception of the Sacraments, personal prayer and meditation, Holy Hours, Days of Recollection and retreats, aid us in our third objective, namely, to strive for the sanctification of the whole personality of each member. We welcome other alcoholics, not members of our faith, or any others, non-alcoholics, who are concerned with the illness of alcoholism and wish to join with us in prayer for our stated purposes.

(The “Tribes of the recovering community” series is intended to demonstrate the diversity within the recovering community.I have no first hand knowledge of most of the tribes, so inclusion in this series should not be considered an endorsement.)

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.

*   *   *

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.

*   *   *

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.