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.

Who’s guarding the hen house?

money-pillsFrom the NY Times:

Addiction experts protested loudly when the Food and Drug Administration approved a powerful new opioid painkiller last month, saying that it would set off a wave of abuse much as OxyContin did when it first appeared.

An F.D.A. panel had earlier voted, 11 to 2, against approval of the drug, Zohydro, in part because unlike current versions of OxyContin, it is not made in a formulation designed to deter abuse.

Now a new issue is being raised about Zohydro. The drug will be manufactured by the same company, Alkermes, that makes a popular medication called Vivitrol, used to treat patients addicted to painkillers or alcohol.

In addition, the company provides financial support to a leading professional group that represents substance abuse experts, the American Society of Addiction Medicine.

Hmm. Let’s see,

  • they profit from a drug that will produce addiction;
  • they profit from a drug to treat addiction;
  • they manage to get their drug approved over a very lop-sided FDA panel objections;
  • they fund the American Society of Addiction Medicine (ASAM);
  • they funded the publication of a portion of the ASAM Patient Placement Criteria, which is the dominant framework for treatment placement decisions;
  • another of ASAM’s sponsors makes billions off of a medication with “near universal relapse” when they try to taper patients off it (It’s worth noting that the feds have also invested heavily in promoting Suboxone.);
  • ASAM engages in advocacy for the products these companies produce;
  • ASAM’s professional status and power places it in the position of conferring legitimacy and illegitimacy to treatments and policies;
  • people who questions these treatments and policies are dismissed as crackpots who reject empiricism.

Who makes policy?

[hat tip: Love First]

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.

DSM 5 Substance Use Disorders: A Concise Summary

DSM_5_2Terry Gorski has a nice summary of substance use disorders in the DSM-5.

Here’s his analysis at the end of the post:

The DSM 5 is criticized for combining the the DSM IV categories of substance dependence (addiction marked by a pattern of compulsive use or loss of control) and substance abuse disorders (using in a manner that causes problems but does not have a pattern of compulsive use). The 2011 definition of addiction by the American Society of Addiction Medicine (ASAM) is consistent with DSM IV but not DSM 5.

The DSM IV, like the ASAM definition is based upon the idea that there is a DIFFERENCE IN KIND between substance abuse and dependence/addiction.

The DSM 5 is inconsistent with the ASAM definition because it is based upon the idea that there is only A DIFFERENCE IN DEGREE between abuse and addiction based upon the number of symptoms.

This is a critical difference in the underlying theory of addiction between the DSM IV and DSM 5 and a break in the progressive development of the fundamental concept if addiction which began with the DSM III.

 

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.

 

A drug to treat cocaine addiction?

Structure of cocaine
Structure of cocaine (Photo credit: Wikipedia)

A recent study on the use of topiramate for cocaine addiction has been getting a lot of attention. Most of the coverage draws only from the researchers press release.

“Using an intent-to-treat analysis, the researchers found that topiramate was more efficacious than placebo at increasing the participants’ weekly proportion of cocaine nonuse days and in increasing the likelihood that participants would have cocaine-free weeks,” the university said Friday in a statement.

Similarly, Johnson’s team found a significant association between topiramate and both a decrease in craving for the drug and an improvement in the subjects’ overall level of functioning in comparison to a placebo.

Here are a few things you should know.

  1. What does “more efficacious than placebo” mean? It means that the number of days subjects did not use cocaine increased to 13.3% or 8.9%. (Depending on how you calculate it.) So, subjects still used cocaine 86.7% or 91.1% of days.
  2.  There a history of concerns about the manufacturer of the drug promoting off-label use of the drug.
  3. The lead researcher left his last post after losing a whistleblower lawsuit. One of his projects had been accused improperly charging the federal government for time spent on a study. He also attacked the character of the whistleblower.
  4. The lead researcher has a financial interest in topiramate.

I’m sure we’ll come up with effective drugs some day, but I’m skeptical that this is one of them.

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.