Tag Archives: United States

The Unintended Consequences Of Medical “Maximalism”

Health

Health (Photo credit: 401(K) 2013)

The Health Affairs blog questions the American Heart Association’s maximalist approach with the use of statins. The issues sound familiar.

The policy implications of these guidelines are staggering. Estimates show that if these recommendations are fully implemented, close to a third of all Americans will be placed on a statin. But these developments beg the question: Is this the right policy? Is taking a statin the most effective way for the millions of Americans who are at risk of heart disease to reduce their risk?

When appropriately prescribed, evidence substantiates that statins do reduce heart attack risk, but how do they compare to other interventions? We know that lower cholesterol is better, and we know that statins help to reduce heart disease risk, but we also know that the most effective way to reduce heart disease is not necessarily by taking more pills in ever-increasing doses – it’s to engage in lifestyle change. The best way to reduce risk is by losing weight if overweight, quitting smoking if a smoker, exercising if sedentary, and eating a Mediterranean style diet. Over the past few decades, we have gotten less active, we weigh more, and we eat too much unhealthy food. The new guidelines may have the unintended consequence of de-emphasizing the things that we know reduce risk the most in favor of treatments that are less effective.

Lifestyle change is also emphasized in the guidelines, but it can be very difficult to change deeply embedded behaviors, no matter how unhealthy they may be. When people are unable or unwilling to make those changes, frustrated clinicians looking for another solution often turn to medication as the easy answer for their patients. But a blanket prescription that everyone who has heart disease, or who is at risk for it, take a statin may encourage those most at risk to be lulled into a false sense of security. As cholesterol numbers go down, patients may no longer feel at risk, but the truth is a lot more complicated. For individuals who fall into the four benefit groups, then, yes, the drugs will likely lower their risk of a heart attack; but they will still likely have a heart attack at some point in their life. Medications cannot effectively insulate us from the results of our unhealthy choices.

The parallels are not perfect, as exemplified by his emphasis on choice in his closing, but the parallels are close enough to make clear that addiction treatment providers are not alone with our questions about medical maximalism vs. lifestyle changes.

Guidelines like those released last month reinforce how far society and our health care system have swung away from prevention and towards the medical model, which treats disease, but often does an inadequate job of promoting public health. Lifestyle change won’t help everyone. Some may still need to take a statin, even after they change their lifestyle. But for many, making healthier choices is enough. As medical science advances, we will continue to have better drugs, and the tendency of providers might be to expand their use. But the solutions to many of the ills that plague large numbers of Americans—high blood pressure, high cholesterol, diabetes, and the heart disease that they cause—do not lie in taking more and more pills to treat more of our preventable chronic conditions. They lie in motivating the millions of Americans who are currently living an unhealthy lifestyle to make better choices.

While experts in other areas of health may neglect promoting lifestyle changes, I suspect most would acknowledge that, for most people, lifestyle changes are either the preferred way to resolve the chronic health problem, the front line response, or be a prominent feature of every treatment plan. In opiate addiction, the field has swung so far in the maximalist direction that we’ve gotten to the point where we can’t even agree on that.

David Katz addresses the questions this discussion begs:

As far as I’m concerned, the entire debate about statins is part of our societal static. It’s a background noise of cultural misdirection that favors the conflated interests of Big Food and Big Pharma while ignoring the compelling, consistent, signal of what lifestyle as medicine could do for us all.

We could prevent all those heart attacks, and more, without putting statins in the drinking water. We could add years to life, and life to years, and save rather than spend money doing it – if lifestyle were our preferred medicine. The signal has been there for literal decades that minimally 80 percent of all heart disease could be eliminated by lifestyle means readily at our disposal. There is a case that, but for rare anomalies, heart disease as we know it could be virtually eradicated by those same lifestyle means. And the same lifestyle medicine that could do this job would slash our risk for every other bad outcome as well, while enhancing energy, cultivating vitality, and contributing to overall quality of life. And unlike our statins, we could share these benefits with those we love.

But for the most part, we as individuals, and collectively as a culture, seem deaf to this signal. We watch our peers and parents succumb to heart disease, and wring our hands. We fret over the same fate overtaking us. We get prescriptions for drugs we wish we didn’t have to take, worry about serious side effects, suffer through minor ones, grumble about copays, and implicate ourselves in the unmanageable burden of “health” care costs.

via The Unintended Consequences Of The New Statin Guidelines – Health Affairs Blog.

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Filed under Controversies, Dawn Farm, Harm Reduction, Policy, Research, Treatment

Community Recovery Capital

Forest Collage

Forest Collage (Photo credit: zebble)

This weekend is the fist time I recall seeing Bill White discuss the concept of community recovery capital. I’ve heard him discuss community recovery and the ecology of recovery, but I think I must have missed community recovery capital.

The prognosis for community recovery is influenced by the ratio between problem prevalence, severity, and complexity and the level of community recovery capital (the scope and quality of resources that can be mobilized to initiate and sustain a community recovery and revitalization process).

There are multiple pathways and styles of community recovery and renewal, with most including emergence of a new recovery-based community identity (story).

Sustainable community recovery engages multiple community institutions in a process whose results can be measured in reductions of community pathology, but are best measured in long-term increases in community recovery capital.

Community recovery elevates the prognosis for personal/family recovery by elevating external recovery capital; creating the physical, psychological and cultural space where recovery can flourish; and increasing the density of recovery carriers (persons who convey infectious hope and guidance for recovery initiation/maintenance) within the community.

This is exciting to me because it has the potential to mitigate the concerns I raised last week about the potential for recovery capital to become a proxy for class.
Here’s Bill describing the concept of a healing forest:

One of the most riveting metaphors emerging from the Native American Wellbriety movement is that of the Healing Forest (Coyhis & White, 2002). In this metaphor, the clinical treatment of addiction is seen as analogous to digging up a sick and dying tree, transplanting it into an environment of rich soil, sunshine, water, and fertilizer only to return it to its original deprived location once its health has been restored and subsequently lost again. What is called for in this metaphor is treating the soil—creating a Healing Forest within which the health of the individual, family, neighborhood, community, and beyond are simultaneously elevated. The Healing Forest is a community in recovery.

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Drug Overdose Deaths Are Increasing Pretty Much Everywhere

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These images speak for themselves. Here are a couple of important sentences:

Between 1999 and 2009, drug poisoning deaths grew by 394 percent in rural areas and 279 percent for large metropolitan areas, according to the CDC’s county-level look at the data.

According to the CDC, roughly 60 percent of all OD deaths in 2010 were caused by prescription drugs, with three-fourths of those cases involving painkillers.

The work of advocates like these is growing more important.

Blue indicates a lower overdose rate and red indicates a higher rate (13+ per 100,000)

Blue indicates a lower overdose death rate and red indicates a higher overdose death rate (13+ per 100,000)

 

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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.

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Addiction Treatment With a Dark Side

money-pillsThe NY Times has a new piece on Suboxone.

First, on its blockbuster status:

Suboxone is the blockbuster drug most people have never heard of. Surpassing well-known medications like Viagra and Adderall, it generated $1.55 billion in United States sales last year, its success fueled by an exploding opioid abuse epidemic and the embrace of federal officials who helped finance its development and promoted it as a safer, less stigmatized alternative to methadone.

But more than a decade after Suboxone went on the market, and with the Affordable Care Act poised to bring many more addicts into treatment, the high hopes have been tempered by a messy reality. Buprenorphine has become both medication and dope . . .

Next, on the dark side of the business:

Many buprenorphine doctors are addiction experts capable, they say, of treating far more than the federal limit of 100 patients. But because of that limit, an unmet demand for treatment has created a commercial opportunity for prescribers, attracting some with histories of overprescribing the very pain pills that made their patients into addicts.

A relatively high proportion of buprenorphine doctors have troubled records, a Times examination of the federal “buprenorphine physician locator” found. In West Virginia, one hub of the opioid epidemic, the doctors listed are five times as likely to have been disciplined as doctors in general; in Maine, another center, they are 14 times as likely.

Nationally, at least 1,350 of 12,780 buprenorphine doctors have been sanctioned for offenses that include excessive narcotics prescribing, insurance fraud, sexual misconduct and practicing medicine while impaired. Some have been suspended or arrested, leaving patients in the lurch.

Statistics released in the last year show sharp increases in buprenorphine seizures by law enforcement, in reports to poison centers, in emergency room visits for the nonmedical use of the drug and in pediatric hospitalizations for accidental ingestions as small as a lick.

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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]

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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.

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