Most popular posts of 2015 – #3 – The treatment system is failing opiate addicts

Doha15Stories like this are getting a lot of attention lately:

State Sen. Chris Eaton is planning to introduce legislation to encourage opiate treatment providers and doctors to break with an abstinence-based model and embrace evidence-based practices for treating addiction, the Minnesota Democrat told The Huffington Post.

I want to make it clear that I know nothing of Senator Eaton and am not questioning her motives.

If this was really motivated by a desire to spread evidence-based treatments, there’d be another, more interesting debate brewing.

That debate would be whether Senator Eaton should introduce legislation requiring that Physician Health Programs (PHP) start treating addicted health professionals with maintenance medications.

I doubt Senator Eaton wants that. I doubt she even knows much about Physician Health Programs. Her source of information about opioid addiction treatment was the Huffington Post article that painted abstinence-based treatment as hopelessly anti-evidence and ineffective while painting maintenance medications as THE answer to this problems that’s been with us for ages.

Why would she want to change opiate addiction treatment for the general population, but not for doctors? Because the treatment system for the general population is failing addicts and their families while the Physician Health Programs are producing outstanding outcomes.

Is the difference that one is abstinence-based while the other uses maintenance medications? No.

The difference is that PHPs get treatment and recovery support of an adequate quality, intensity and duration while the general population does not.

Debra Jay identified 8 essential ingredients in PHPs:

  1. Positive rewards and negative consequences
  2. Frequent random drug testing
  3. 12 step involvement and an abstinence expectation
  4. Viable role models and recovery mentors
  5. Modified lifestyles
  6. Active and sustained monitoring
  7. Active management of relapse
  8. Continuing care approach

PHPs provide treatment, recovery support and monitoring for up to 5 years and 85% of participants have no relapses. Of the 15% who relapse, most of them have only one relapse over that 5 year period.

Will maintenance medications improve treatment for the general population? It’s hard to imagine they will when they have the same retention problems that abstinence-based treatments have. Further, most of the treatment delivered with maintenance medications suffers from the same problem as abstinence-based treatment– inadequate quality, intensity and duration. (By duration, I mean the accompanying behavioral support as well as retention on the medication.)

So . . . this solution really focuses on the wrong problem.

The problem isn’t that treatment is abstinence-based. The problem is that abstinence-based and maintenance treatments too often do not provide adequate quality, intensity and duration.

So, why advocate to spread access to a treatment we won’t use on addicted physicians rather than spread access the gold standard of care that addicted physicians receive? That’s the danger of advocacy journalism that is dressed up as objective reporting.

I’m grateful to work in a place the works so hard to increase access to treatment and recovery support of an adequate quality, intensity and duration.

Prisons or spas?

housing3The Huffington Post continues its longform advocacy journalism on the issue of medication assisted treatment.

Jason Cherkis puts his attention on a real issue of rural access to medication assisted treatment by sharing the story of a South Dakota man who travels 350 miles to get his buprenorphine prescription.

Anyone who wants access to this treatment should have access to it and should not have to drive hundreds of miles.

Unfortunately, in making this case, he repeats some of the mistakes of earlier articles.

Parts of it read like a Reckitt Benckiser marketing pitch.

In the U.S., buprenorphine is mainly sold under the brand name Suboxone, in which form it’s combined with naloxone, the drug that can reverse the effects of an overdose. If someone tries to misuse Suboxone by injecting it, the predominant effect will be that of the naloxone, not the buprenorphine. It’s an important safety feature; think of it like an airbag for those with fierce cravings.

spa-300x225Other parts sound like a hit piece on drug-free treatment approaches.

But the U.S. drug treatment system — which is mostly a hodgepodge of abstinence-only and 12-step-based facilities that resemble either minimum-security prisons or tropical spas — has for the most part ignored the medical science and been slow to embrace medication-assisted treatment, as The Huffington Post reported in January.

There is no doubt that there are programs that resemble prisons and others that resemble spas. However, this dichotomy is no more true than stating buprenorphine maintenance programs are mostly a hodgepodge of  programs that resemble amoral pill-mills or medical maximalists who believe the sole solution to every problem is a new pill.

Now, why did the writer frame the issue this way and fail to also advocate for access to the gold standard treatment? If you care about addicts and you care about choice and you’re an objective reporter, wouldn’t this make sense? There’s plenty to criticize on the treatment system and reasonable people can disagree on treatment approaches, but why be so dismissive of one approach (Without questioning whether common problems are issues related to the type of treatment or the execution.) and so uncritically embracing of the other.

 

What’s with all of the posts about methadone and buprenorphine?

SAMHSA-recovery-definitionI’ve been doing a lot of posts on methadone and buprenorphine lately. It’s not that I think they are evil and should be banned.

It’s just that, if your knowledge was limited to what’s in media reports, you’d believe that medications like buprenorphine and methadone are the only responsible treatment, that they are inaccessible, and that any abstinence-based treatment is dangerous and only advocated by flat-earth zealots.

There’s evidence to support the use of these meds. But, the evidence is not as strong as many would lead readers to believe, and most of the studies do not measure the kinds of outcomes that addicts and their families are looking for.

So, these posts are intended to demonstrate these truths–that many studies with “positive” outcomes would not be considered positive by most people in real-world situations, that negative outcomes exist, that they are not the only “science-based” approach, and reasonable people can disagree with their characterizations of maintenance as “the most effective” treatment approach.

More important than maintenance vs abstinence?

Now, it’s pretty clear to anyone who reads this blog that I believe the preferred treatment approach should be something modeled on Physician Health Programs (PHP), and that it should be available to all addicts. (I also believe that addicts should get good informed consent and have the right to choose their treatment approach.)

A sad fact is, for far too many people, their choices are inadequate medication-free treatment or inadequate medications assisted treatment (MAT). Given these choices, for a lot of people, inadequate MAT is probably less bad than inadequate medication-free treatment.

This has caused me to think about something Bill White said about another treatment argument:

Arguments over whether persons in inpatient addiction treatment should stay twenty-eight days or five days, whether outpatient treatment should be five sessions or twenty sessions, or consist of Twelve Step Facilitation or Cognitive Behavioral therapy are all arguments inside this acute care paradigm.

I wouldn’t make this argument, but one could argue that the medication-free element of PHP’s is not a critical element in their success–that it’s the elements focused on chronic disease management (or, recovery management) that are most important.

Bill White articulated a model for Recovery Management. Here are the 7 elements of his model:

There are seven elements to a comprehensive program of recovery management:

1) Client Empowerment (enfranchising persons in recovery to participate in the planning, design, delivery and evaluation of behavioral health services and to advocate for prorecovery policies and programs in the wider community),

2) Needs Assessment (identifying the needs and strengths of individuals/families experiencing severe behavioral health disorders with a particular emphasis on eliciting first-person voices of consumers and family members),

3) Recovery Resource Development (creating the physical, psychological and social space within a community in which recovery can occur; creating a full continuum of treatment and recovery support services; linking personal, professional and indigenous community resources into recovery management teams; and guiding the individual/family into relationship with a larger community of shared experience.),

4) Recovery Education and Training (enhancing the recovery-based knowledge and skills of people/families in recovery, service providers, and the larger community,

5) On-going Monitoring and Support (continuity of contact and support over time)

6) Evidenced-based Treatment and Support Services (developing services that remove barriers to recovery and enhancing “recovery capital”3 ; “trading out” less effective treatment and recovery support services for approaches that have a greater foundation of scientific support; pursuing a recovery research agenda to elucidate the structures/pathways, styles and stages of long-term recovery), and

7) Recovery Advocacy (advocating for social and institutional policies that counter stigma and discrimination and promote recovery from severe behavioral health disorders).

Don’t believe the hype

hype-marketing

About that Huffington Post article covering Obama’s addiction speech a few weeks ago.

ALLEGATION FACT FACT
A Huffington Post investigation published in January found that the treatment industry overwhelmingly resists a medication-assisted model based on decades-old beliefs about sobriety that have been passed down by those in recovery, but have never been rigorously tested. Suboxone is the number 39 drug in the US and has sales of more than $1.4 billion.* Federal surveys find that opioid replacement treatment (one form of medication assisted treatment) admissions accounted for 27.8%** of all admissions. [Not 27.8% of opioid addiction admissions. 27.8% of ALL addiction treatment admissions.]

More on the Huffington Post’s drug policy reporting here.

* note that this is only for the brand Suboxone and does not include Subutex and generics.

** This post originally reported that maintenance admissions accounted for 26%. It was 26% in 2009. More recent numbers are now available and the updated reports says that maintenance admission accounted for 27.8% of all admission in 2011.

The treatment system is failing opiate addicts

Doha15Stories like this are getting a lot of attention lately:

State Sen. Chris Eaton is planning to introduce legislation to encourage opiate treatment providers and doctors to break with an abstinence-based model and embrace evidence-based practices for treating addiction, the Minnesota Democrat told The Huffington Post.

I want to make it clear that I know nothing of Senator Eaton and am not questioning her motives.

If this was really motivated by a desire to spread evidence-based treatments, there’d be another, more interesting debate brewing.

That debate would be whether Senator Eaton should introduce legislation requiring that Physician Health Programs (PHP) start treating addicted health professionals with maintenance medications.

I doubt Senator Eaton wants that. I doubt she even knows much about Physician Health Programs. Her source of information about opioid addiction treatment was the Huffington Post article that painted abstinence-based treatment as hopelessly anti-evidence and ineffective while painting maintenance medications as THE answer to this problems that’s been with us for ages.

Why would she want to change opiate addiction treatment for the general population, but not for doctors? Because the treatment system for the general population is failing addicts and their families while the Physician Health Programs are producing outstanding outcomes.

Is the difference that one is abstinence-based while the other uses maintenance medications? No.

The difference is that PHPs get treatment and recovery support of an adequate quality, intensity and duration while the general population does not.

Debra Jay identified 8 essential ingredients in PHPs:

  1. Positive rewards and negative consequences
  2. Frequent random drug testing
  3. 12 step involvement and an abstinence expectation
  4. Viable role models and recovery mentors
  5. Modified lifestyles
  6. Active and sustained monitoring
  7. Active management of relapse
  8. Continuing care approach

PHPs provide treatment, recovery support and monitoring for up to 5 years and 85% of participants have no relapses. Of the 15% who relapse, most of them have only one relapse over that 5 year period.

Will maintenance medications improve treatment for the general population? It’s hard to imagine they will when they have the same retention problems that abstinence-based treatments have. Further, most of the treatment delivered with maintenance medications suffers from the same problem as abstinence-based treatment– inadequate quality, intensity and duration. (By duration, I mean the accompanying behavioral support as well as retention on the medication.)

So . . . this solution really focuses on the wrong problem.

The problem isn’t that treatment is abstinence-based. The problem is that abstinence-based and maintenance treatments too often do not provide adequate quality, intensity and duration.

So, why advocate to spread access to a treatment we won’t use on addicted physicians rather than spread access the gold standard of care that addicted physicians receive? That’s the danger of advocacy journalism that is dressed up as objective reporting.

I’m grateful to work in a place the works so hard to increase access to treatment and recovery support of an adequate quality, intensity and duration.

The medical establishment’s “best hope for addicts”

Lowering_The_Bar_Cover_2010.09.22I’m sure this piece is going to get a lot of attention. “A treatment that actually works” is the subtitle for the article.

I’m not going to write a lengthy response, but I have written a lot on the subject.

First, how effective is it for someone like the subject of the article? Well, two recent studies are not very promising.

Second, what does “actually works” mean? Works to do what?

The reader needs to stop and ask, “What do I want for the addict?” (Our interest might be for a loved one, out of altrusim or as a tax paying community member.) Am I looking for a reduction is drug use, criminal activity and disease transmission? Or, do I want more for them?  Is my goal for them a full recovery and a return to full participation in family, community, academic and professional life?

When they say, “it works”, we need to ask if it works to facilitate this kind of full recovery.

Finally, let’s take a look at this statement: “The medical establishment had come to view Suboxone as the best hope for addicts like Patrick.”

addicts like Patrick.

What about addicts like members of the medical establishment? They do not view Suboxone as “the best hope” for their addicted colleagues. They have a better approach and enjoy outstanding outcomes. They get long term, high quality, abstinence focused treatment, long term recovery monitoring and support, and rapid re-intervention in the event of a relapse.

Why is that kind of treatment not considered the “best hope” for addicts like Patrick?

UPDATE:

The “they’d still be alive” theme merits a response. Here’s a post I wrote on the argument that Philip Seymour Hoffman would be alive if he was prescribed Suboxone. (Preview: 1) He had Suboxone in his apartment. 2) Even if Suboxone helps prevent ODs, you have to take it to be protected. And, as pointed out above, huge numbers of patients stop taking it.)