Oxford House in Michigan

Glad to see Oxford Houses making their way into Michigan.

Science and moral truth

This post by Sam Harris gets at something that I suspect is at the crux of much of the disagreement over harm reduction. He argues that there are objectively true answers to moral questions.

There is undoubtedly a great deal of truth in what he says, but the potential for excessive certitude is troubling. It feels like it creates more ground for people to indulge moral vanity rather than less. He introduces a contrast between there being no answers in practice vs, no answers in principle, but it point is to emphasize that there is a correct answer.

He seems to define the correct answer to moral problems as the answer that contributes most to human happiness and thriving--so, he appears to be arguing for a form of utilitarianism, probably a form of rule utilitarianism. It seems, to me, that you can't avoid subjective judgement when we get into defining happiness and thriving and what conditions or acts create happiness and thriving, however we choose to define them.


Related posts:

• Heroin anyone?
• Science can answer moral questions
• Limitations of Utilitarianism
• Politics, Science and Harm Reduction

The Harper government and the Insite flim-flam

I decided not to comment on this today, but here I am. Why do I find this so grating? I think it's the certitude.

I understand the anger of the writer. Government officials trying to construct evidence to support biases or politically convenient positions is frustrating. It sounds like the RCMP dealt with their concerns in a pretty indirect and dishonest manner.

What I find grating is the assumption that one position is bias-free and has objective truth on its side. Science can only answer the questions it's asked. I'm willing to cede that Insite's existence results in fewer ODs, more treatment referrals and fewer discarded syringes when compared to DOING NOTHING.

Doesn't that beg some important questions? If we're spending $3,000,000, aren't there a lot of things we could do to achieve the same outcomes? Who's to say that those outcomes are the most important, or that they address the most important problems?

Further, the writer never really addresses the questions raised in the opposing papers. He seems to just dismiss them as worthless because they were not published in peer-reviewed journals. Why?

It seems like more political theater--both sides seem to assume the matter is a no-brainer and that anyone who disagrees is brain-dead.

Smart readers

Loran Archer left the following comment on the previous post:

Lifetime DSM-IV alcohol dependence in the NIAAA NESARC survey is not a chronic condition. It a broad spectrum of disorders ranging from mild dependence (3 to 9 lifetime symptoms), moderate dependence (10 to 14 lifetime symptoms)and severe dependence (15+ lifetime symptoms).

The 63% with mild and moderate lifetime symptoms do not self-identify as alcoholics and would not be identified by others as alcoholics. If they attend AA 53% will drop out.

The mild/moderate and the severe dependent populations are categorically different types of drinkers. 

In an earlier study of AA access and continuance, A model of access to and continuance in Alcoholics Anonymous http://knol.google.com/k/a-model-of-access-to-and-continuance-in-alcoholics-anonymous# , I describe the differences.

His link is an AMAZING resource. He has two Knol articles:

• A model of access to and continuance in Alcoholics Anonymous
• Pathways to abstinence: Impact of Alcoholics Anonymous

I've never seen such a clear summary of research on AA attendance and abstinence among AA attendees (and dropouts).

The first paper reports on the people who try AA, who continues, who does not and possible reasons.

The second looks at abstinence rates among people who have attended AA.

It looks at data from only one study and some of the numbers are not huge due to low numbers of subjects with any prior AA attendance, and it won't satisfy critics who will only accept randomized controlled trial, but it seems to me like a pretty strong response to a lot of the twelve-step facilitation criticism.

From the conclusions of the paper on abstinence:

The abstinence recovery rate for Americans with high severity alcohol disorders who continue to attend AA ranges from a low of 45%, age 18-29, to a high of 84%, age 50+ years.

The findings of this study support the findings of Kaskutas et al that "disengagement from AA does not necessarly translate to a return to drinking". The rates of abstinence, over 60%, in the 40+ years high severity AA drop outs are similar to the rate of abstinence, 63%, in the 30-39 year age high severity group who continued in AA.. The findings suggest that a substantial portion of the "AA drop outs" attain sobriety or abstinence after a period of AA membership and maintain their abstinence without AA attendance.

The problem with DSM dependence

This NIAAA feature points out a big problem with the DSM diagnosis alcohol dependence. The diagnosis is intended to capture people with chronic problems and the NIAAA article suggests that as many as 70% have one episode that lasts less than 4 years and that 75%  of those who "recover" do so without any treatment. This leaves 30% having more than two or more epsiodes. The former group appears to be people who go through a period of heaving drinking (most often as young adults) and then moderate or stop drinking on their own.

This begs all sorts of questions, such as:

• Should these two groups be in one diagnostic category? 
• I what ways are these categorically different types of drinkers? Do they respond to different treatments? Do they require different treatment goals? (abstinence vs. moderation) 
• Do these people who "recover" think of themselves of recovering? Should they?
• Are there ways for clinicians to distinguish between these two types? Are the people with more severe forms more likely have the chronic form? Are there patterns in terms of the diagnostic criteria that are met for the 2 groups? (I suspect that the loss of control criteria are more frequently met for the people with the chronic type.)
• When we read stories about the number of people who need treatment and don't receive it, are those 70% included? (yes) What does this mean for those kinds of statistics?

[via Adi Jaffe]

Washington Post redux

Another take down of the Washington Post op-ed has been posted here.

Bye Bye Bereavement Exclusion?

A NYT op-ed reports that the APA is close to either dropping the bereavement exclusion from the Major Depression diagnostic criteria or adding something like Bereavement Related Depression.

I too find this troubling and see no way to characterize this other than an attempt to pathologize a normal human process.

One of the advocates left a comment on a post a couple of years ago. One of the links he left was a counter argument against the concerns identical to those expressed in this NYT op-ed. Among his counter arguments was this:

There are no convincing data showing that the bereavement exclusion for the diagnosis of major depression protects against “pathologizing” normal grief,

Really? The title of his response is "DSM5 Criteria Won’t “Medicalize” Grief, if Clinicians Understand Grief". Isn't the DSM a manual of DISORDERS?

Does someone who is grieving have a disorder? Even if they have the same symptoms as someone with a disorder? Is context unimportant? Does someone who experiences intense anxiety in the days following a traumatic event have an anxiety disorder until proven otherwise? How about a patient detoxing from alcohol or benzodiazapines?

No.

Symptoms do not equal diagnosis.

UPDATE: What does this mean? It does not mean we ignore those symptoms. We can respond to the person's suffering without treating them as though they are ill in some way. We can also recognize that the vast majority of grieving people will get their needs met from their family and community and that these natural supports should be the first line response. We can recognize them as at risk for depression and intervene if they are not experiencing gradual relief of their depressive symptoms.

Insite's dollars and cents

This article seeks to answer an important question about Insite. (Vancouver's injection center.) How much does the program save in health care costs?

The argue that the $3 million annual investment in Insite saves nearly $18 million due to and estimated 84 avoided HIV infections.

This begs the question, what else could be done with $3 million that would also prevent 84 HIV infections?

Dawn Farm's annual budget is just over $3 million. We'll serve more than 2000 people this year in 140 transitional housing beds, 49 long term residential treatment beds, 18 detox beds, outpatient services and corrections outreaches. This is pure speculation, but I suspect that in a high-HIV environment like Vancouver, I suspect we'd prevent at least as many infections and save much more by moving people into recovery.

Which is a better investment of scarce resources?

If low-threshold drug-free treatment and recovery support services were proven to provide a similar or better return on investment (as measured by reductions in disease transmission), would Insite supporters resist shifting resources toward those programs? I suspect they would. If so, then it's not just about HIV, is it? What then? Values?

Reflections on the state of the field

Highlights from an interview between 2 of the most important figures in the field.

On the relationship between psychiatric symptoms and AOD use:

Bill White: One of your early interests there was the relationship between patients’ drug choices and particular types of psychiatric disorders. How did that interest develop?

Dr. McLellan: Well, once again, there was no planning involved. I was a junior faculty member at the Coatesville Veteran’s Administration Medical Center. At that time, they had about 3,000 residential beds that were constantly filled with people who had psychiatric illness, really quite severe psychiatric illness. This was the era of the first patients’ rights movement, and it fell to me to evaluate a random sample of patients and ask them confidentially about their satisfaction with all manner of things, like their treatment, the food, the doctors and all of that. Well, in the course of this, I was able to insert some additional questions about whether there had been any drug use in their history. And indeed, there was. More importantly, many of them were actively involved in using alcohol and other drugs right on the campus. I was amazed by that—showing my naïveté—so that was the first report; but the second report was a little more interesting.

Because I had interviewed these individuals without any kind of background, I later went and looked up their diagnoses. It turned out that their diagnoses were quite related to the kinds of drugs that they had been using. People who were diagnosed as depressed were often using a variety of depressant or tranquilizing drugs. People who were diagnosed with schizophrenia had histories of using amphetamine—there was very little cocaine use at that time. The people with alcohol and opiate use backgrounds had a variety of diagnoses. I wrote an early paper on this possible relationship.

This led me to ask such questions of current patients, many of whom had been coming to the Veteran’s Administration for a number of years. By tracing back their early psychiatric test results, I found over a six year period, in a sample of people who had returned to treatment every year for six years, that there was a progressive development of psychiatric problems that mirrored the actions of the drugs they were using. Particularly interesting were the changes in psychiatric diagnoses among people who used amphetamine/methamphetamine over a six year period. They moved from being treated primarily in the drug unit, to being treated in the psychiatric unit, and finally, into locked wards. It looked as though, after some period of time, the symptoms that were purely drug-related and temporary ultimately ended up being permanent or semi-permanent. The same thing happened with people who used combinations of alcohol and depressants. Depression—significant, serious depression—was sustained. Also interesting, we saw no major changes in the psychiatric problems of people who used opiates or alcohol.

As a point of potential interest to young researchers, I wrote these findings and tried to present them to the American Psychological Association, and they turned it down flat.

On thinking about multiple problem clients:

Some problems cause substance use; some problems result from substance use; and some simply emerge along with substance use as the result of genetic, personality or environmental conditions. This was one of the most important things I ever learned about addiction. Like many of the people I meet in my current job, I too thought that if you just reduce the drug use, all the other “drug related” problems would disappear. This was, and still is, a very naïve view. Worse, it has been a very big force in the way the original—and some of the existing—treatment programs were conceptualized, designed, funded and evaluated.

On service integration and the future of the field:

In this policy environment that I’m in now, one of the emerging themes is integrating addiction treatment into mainstream healthcare. I know a lot of readers are going to get very worried about that. They know the bad old days when addiction was treated under the mental health umbrella and was viewed as merely a symptom of an underlying depression or personality disorder and never given the emphasis it properly required. I hope that doesn’t come back, but here’s the other truth: addiction treatment as a field is currently reaching only a tiny fraction of the people it should reach.

Addiction is causing and is complicating a lot of medical disorders. Mainstream healthcare has never really paid the attention it should have to addiction related problems in the mainstream healthcare system. Meanwhile, as addiction treatment has become more segregated, budgets have been reduced virtually every year since I’ve been working in this field. I know of no kind of treatment, education or public enterprise that is best when it is segregated. So we’re trying very hard to bring addiction treatment—particularly screening and early intervention with mild to moderate substance use disorders—into lots more healthcare settings, particularly primary care and family medicine centers. Importantly, I am talking less about “addiction,” than about the less severe and less chronic forms of substance use—unhealthy use, problematic use, etc. We’re trying to develop more and more varied kinds of treatments: treatments that will involve medications, treatments that will involve families; treatments that will involve whole communities. We are hoping that different types of treatments for mild to moderate substance use problems, delivered within the same context as the rest of medical care, are more attractive and engaging to those who will not even consider treatment now.

Prayer and drinking

Not a study of alcoholics, but may offer some insight into a mechanism of change:

... they randomized students (all of them religious believers) to two groups. One group was asked to pray every day for their friends and family (they had to pick 5). The other group was asked simply to think positive thoughts daily about their friends and family.

By the end of the study, four weeks later, the 'good thoughts' group were drinking nearly twice as much alcohol as the 'prayer' group.

So it seems that making nominally religious people actively engage in their beliefs can discourage them from drinking. But why?

Lambert has two theories. First is that prayer may help to improve your relationships with others (that's something Lambert has shown in an earlier study). And if relationships are stronger, then you'll have less need to turn to drink to overcome social barriers.

His second theory is that spirituality and alcohol consumption are alternative routes to relieve the 'burden of self'. This is the idea that, particularly in Western cultures, people are under high pressure to succeed as individuals. By turning to prayer, people may have less need to turn to the bottle.

Personally, I think something else is going on here. By making people pray every day, what you are doing is reminding people constantly of their religion. It's called priming. And by doing that, you remind them of their cultural expectations - and also remind them that god is watching them.

Rehab doesn't work

The Washington Post published an opinion piece on addiction treatment and AA. I can't help but think of Emerson:

Well, most men have bound their eyes with one or another handkerchief, and attached themselves to some one of these communities of opinion. This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars. Their every truth is not quite true. Their two is not the real two, their four not the real four: so that every word they say chagrins us and we know not where to begin to set them right.

Where to begin? How about the beginning?

the 12-step model pioneered by Alcoholics Anonymous that almost all facilities rely upon

Really? "almost all . . . rely"? How many is "almost all"? What constitutes "relying"? Surely, most treatment programs make referrals to 12 step programs, but I'd say relatively few "rely" on 12 step programs and owe much more to CBT based relapse prevention and motivational interviewing. Most seem to view 12 step involvement as a potentially helpful adjunct rather than something core or central to treatment. Of course, there are programs that rely on 12 step programs (Dawn Farm could be characterized this way, though we do integrate other approaches.), but to say that "almost all" "rely" on them is difficult to swallow.

We have little indication that this treatment is effective.

Just not true. (The link offers reams of evidence.)

When an alcoholic goes to rehab but does not recover, it is he who is said to have failed. But it is rehab that is failing alcoholics.

Blaming the patient for relapse is definitely a historical failing of addiction treatment providers. However, these attitudes have dramatically improved, and this problem is not unique to addiction treatment. Doctors are only beginning to look at ways to improve compliance with treatment for chronic disease and use of prescription medications? Haven't they too historically blamed patients for failing to take their meds, exercise, follow diets, etc.? This doesn't excuse this failure of addiction treatment providers, but it provides some important context.

And the way we attempt to treat alcoholism isn't just ineffective, it's ruinously expensive: Promises Treatment Centers' Malibu facility, where Lohan reportedly went for her second round of rehab, in 2007, has stunning vistas, gourmet food, poolside lounging and acupuncture. It costs a reported $48,000 a month.

We think this is just as bad as he does. There are too many people who are cashing in on treatment. But what about nonprofits like Dawn Farm?

Even nonprofit facilities that don't cater to Hollywood types are too costly for most people. At the 61-year-old Hazelden center in Minnesota, which bills itself as "one of the world's largest and most respected private not-for-profit alcohol and drug addiction treatment centers," a typical 28-day stay costs $26,000.

So these are the only 2 tiers of treatment providers? Come on. We charge around $2700 per month. Does he not know that most treatment programs programs/episodes cost nowhere near $26,000? Why would he leave uninformed readers with the impression that these programs are the norm?

And when they do report a success rate, be it 30 percent or 100, a closer look almost always reveals problems. That 100 percent rate turns out to apply only to those who "successfully completed" the program.

Fair criticism. Many programs engage in this practice. It's, at least in part, an artifact of the acute care model where the expectation is that one time-limited treatment episode with produce full and permanent remission. I suspect that Dr. Johnson rejects the acute care model and you'd think that he'd address this fallacy in these kinds of "success rates"--that, not only are they often deceptive, but their premise is faulty.

A recent review by the Cochrane Library, a health-care research group, of studies on alcohol treatment conducted between 1966 and 2005 states its results plainly: "No experimental studies unequivocally demonstrated the effectiveness of AA or TSF [12-step facilitation] approaches for reducing alcohol dependence or problems."

I've posted about Cochrane before, the most germane is a summary of a Sara Zemore presentation last year:

She very effectively rebutted the Cochrane Review from a few years ago by making the following points. (These are based on notes I took and are incomplete. Hopefully they post video so that you can see her complete rebuttal for yourself.)

• It was limited only to randomized trials and ignored the overwhelming observational evidence. 
• It included one of Zemore's studies which was NOT a randomized study of AA. 
• She acknowledged that the randomized evidence is ambiguous. 
• Randomized trials of AA are hard to do because some subjects in other groups end up participating in AA. This happened in Project MATCH. 
• The Cochrane Review did not find Twelve-step Facilitation ineffective. It found it no more effective that CBT and MET. (The summary from the abstract says, "The available experimental studies did not demonstrate the effectiveness of AA or other 12-step approaches in reducing alcohol use and achieving abstinence compared with other treatments, but there were some limitations with these studies.")
• Finally, she cited 4 randomized studies of Twelve-step Facilitation: The outpatient arm of Project MATCH, a study by her colleague Kaskutas, and two others that I missed. 

Onward...

AA itself has released success rates at times, but these numbers are based only on voluntary self-reports by alcoholics who maintain their ties to AA -- not exactly a representative sample.

Even taken at face value, the numbers are not impressive. In a 1990 summary of five membership surveys from 1977 through 1989, AA reported that 81 percent of alcoholics who began attending meetings stopped within one month. At any one time, only 5 percent of those still attending had been doing so for a year.

A few things. First, he acknowledges that this is not scientific survey. It's fair to say that many AA members and allied professionals have little faith in the accuracy of these surveys. Second, did it really report that 81% of alcoholics stopped attending? How were they identified as alcoholics? A common concern among AA members is that courts send non-alcoholics to AA because of an alcohol related offense. Third, here's the report on the most recent survey. It doesn't include dropout info, but does that paint the same picture he paints?

As for his comparison to spontaneous recovery, I've got a few questions. The rate he cites seems very high and begs a couple of questions. First, how stable is this recovery? Second, how rigorous was the screening for DSM dependence? Did they let people slip in who were not chronic or experiencing loss of control? Finally, we've already cast doubt on his portrayal of AAs effectiveness.

Many proponents of AA cite Project MATCH ... After eight years and $27 million, the study concluded that the techniques were equally effective. 

Actually, Project MATCH found few differences in overall effectiveness, but 12 step facilitation was superior for the most severe alcoholics and people with heavy drinking social networks.

Although AA doubtless helps some people, it is not magic.

AA is not magic. It does not work for everyone. It should not be the only option available to people with alcohol problems. However, this is damning with faint praise. AA has been part of the path to recovery for millions of American alcoholics. Not to mention the drug addicts that have been helped by 12 step programs. Why is he so dismissive of this? Are there approaches that have played an important role in more recoveries?

I have seen, in my work with alcoholics, how its philosophy can be harmful to patients who chronically relapse: AA holds that, once a person starts to slip, he or she is powerless to stop.

This is known as the "Abstinence Violation Effect" theory. It's commonly cited in criticism of the disease model, and it makes intuitive sense, but there's little evidence to support it. Studies looking for this effect have often failed to find it.

Equally troubling, AA maintains that when an alcoholic fails, it is his fault, not the program's. As outlined in the organization's namesake bible, "Alcoholics Anonymous" (also known as "The Big Book"): "Those who do not recover are those who cannot or will not give themselves completely to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates . . . they seem to have been born that way." This message can be devastating.

This is a fair criticism. It's also fair to point out that treatment is not AA (and AA is not treatment). Treatment providers who are dropping the acute care mindset don't hold these attitudes or allow them into the treatment milieu. It's also worth pointing out that AA has a pretty loving and accepting toward active alcoholics and its literature humbly acknowledges the limitations of their knowledge. I also can't help but notice Dr. Johnson's choice of words in introducing the quote--bible. Most people refer to it as AA's text. Why did he choose such a culturally loaded term? Does it intimate a bias?

Finally, it's worth noting that in the AA participation fits exceptionally well with a chronic disease management approach. Medical professionals who try to help patients with diabetes and heart disease make behavioral changes would live would love a free, easily accessible, thriving community organized around supporting patients in making behavioral changes to support recovery and reduce the risk of relapse. Why doesn't Dr. Johnson?

I asked a lot of questions in this post and one might interpret them as passive-aggressive. Let me be more clear. I believe that Dr. Johnson doesn't like AA and I believe his piece paints treatment and AA in the worst possible light, primarily by using half-truths. Most troubling (and maybe most telling) is that he offers no alternative. AA is not magic, it does not work for everyone, there should be a menu of options, and research into other treatments should continue, but AA and treatment do work. We don't say bypass surgery doesn't work because some people have more blockages and heart attacks. We don't say diet and exercise aren't good treatment for type 2 diabetes and heart disease because too many people don't follow through. Why hold AA and addiction treatment to another standard?