It Isn't All About Evidence-Based Practice

This article from Counselor does a good job pointing out some of the limitations of the push for evidence based practices.

The whole issue is a double-edged sword. Measuring your own outcomes is a good thing, but it's no small burden for a treatment provider. (Imagine if every doctor had to measure their outcomes.) The adoption of and evidence-based practice (with some measures to assure fidelity) could relieve providers of this burden, but it comes at the cost of autonomy--which no one likes. Providers also hate that the process for identifying evidence-based practices is so political. (Consider the case of MRT.)

Note the straw man hit job by the journalist in the comments:

Yeah, I'm skeptical of this resistance as well: the reason there's such a push for evidence-based practice is because the non-evidence-based practices in addiction-- like harsh confrontation, humiliation, one-true-wayism (particularly insistence that the alternative to AA is jailsinstitutionsdeath: way to give hope, guys!)-- are not only ineffective but harmful.

These practices are antithetical to therapeutic alliance and to most of the other things you say are important for treatment.

All evidence-based practices incorporate "best practices" like emphasizing therapeutic alliance and empathy and opposing one-true-way stuff-- so it's really rather absurd to argue against EBT's by saying that those things matter.

If the non-evidence-based stuff did that, this wouldn't be a huge issue, but it doesn't and harmful and ineffective practices continue to be widely utilized.

How did this turn into a sarcastic 12 step bashing moment? (By the way, 12 Step Facilitation is an evidence-based practice.) Why does she insist on painting treatment providers with such a broad brush?

Besides, a quick google search of the author of the article finds that that the guy wrote a book on controlled drinking--hardly a 12 step nazi. Another important point is that one of the biggest critics of the push for the adoption of evidence-based practices is Scott Miller--not a 12 stepper in ANY way. In fact, he's the biggest advocate of the notion that the therapeutic alliance is for more important than the treatment model and he uses lots of evidence to support his arguments--not just anecdotes and slurs against people who think differently.

So much for the false notion that questioning the push for adoption of evidence based practices means your a mindless, abusive treatment provider who can't bring yourself to give up "harsh confrontation, humiliation, one-true-wayism"!

NRT linked to cancer?

Do nicotine replacement gum and lozenges cause mouth and throat cancer? Of course, they'd still be lower risk than tobacco but it's an argument against long term maintenance on NRT.

Teens and marijuana self-medication

My inbox has been bombarded with stories based on this study. The qualitative study consisted of 20 (Yes, 20.) kids who were a subset of 63 and their reported reasons for smoking pot. These 20 were a subset of 63 pot smoking kids participating in a larger study. A quick read of the study reveals that the authors uncritically accept the premise that marijuana is an effective treatment for a myriad of problems and their citations reflect a bias for self-medication theories. The study looks like a conclusion in search of evidence. The reported reasons for use of marijuana by these kids included depression (6), stress/anxiety (12), sleep problems (9), focus/concentration (3) and physical pain (5). There was no confirmation of any prior diagnosis or treatment and no assessment and diagnosis as part of the study.

That a qualitative study of a subset of 20 kids has gotten so much attention and led to headlines like, "Teens Use Pot to Treat Health Problems", "Some teens smoke pot for medical needs", "Herbal Remedy: Teens Often Use Cannabis For Relief, Not Recreation, Study Finds" and "Some teens smoke pot for their health" is ridiculous. Of course, this will influence the assumptions of researchers and clinicians and yield more of the same.

Speaking of Kleiman...

From Foreign Policy:

There are two distinct "drug problems." First -- logically, not in importance -- is the damage that drug toxicity, intoxication, and addiction can do to people who consume drugs, and lead them to do to other people. That we might call the "drug problem" proper.

. . . illicit markets sometimes generate violence and disorder, and the higher prices they create stimulate income-producing crime by some drug users. The enforcement effort also generates harm: arrest, incarceration, bribery, gunfights between enforcers and dealers. The problem of the illicit market constitutes the second "drug problem."

. . . Both no-brainer "solutions" to the drug problem --"a drug-free society" and "ending the drug war" -- are equally delusional. The two drug problems are both here to stay. Let's learn to deal with that fact.

Another legalization op-ed

This time in the Wall Street Journal. More of the same. The growing chorus of voices calling for legalization, regulation and taxation makes one ask, where are the other Kleimans calling for something other than the status quo or legalization?

More on Portugal

More on Portugal's drug policy. Again, it's worth noting that Cato is a Libertarian think tank and has a strong point of view on the issue:

Limitations of Utilitarianism

A post about the limitation of Utilitarianism uses drug policy as an example:

But the big problem, the world-breaking problem, is that sticking everything good and bad about something into one big bin and making decisions based on whether it's a net positive or a net negative is an unsubtle, leaky heuristic completely unsuitable for complicated problems.

...

In the hopes of using theism less often, a bunch of Less Wrongers have agreed that the War on Drugs would make a good stock example of irrationality. So, why is the War on Drugs so popular? I think it's because drugs are obviously BAD. They addict people, break up their families, destroy their health, drive them into poverty, and eventually kill them. If we've got to have a category "drugs"³, and we've got to call it either "good" or "bad", then "bad" is clearly the way to go. And if drugs are bad, getting rid of them would be good! Right?

So how do we avoid all of these problems?

I said at the very beginning that I think we should switch to solving moral problems through utilitarianism. But we can't do that directly. If we ask utilitarianism "Are drugs good or bad?" it returns: CATEGORY ERROR. Good for it.

Utilitarianism can only be applied to states, actions, or decisions, and it can only return a comparative result. [emphasis mine]

Utilitarianism is often cited in support of harm reduction programs that I object to (I don't object to all, or even most, harm reduction programs.) and drug legalization. However, as this post argues, the real question is, "X is better than what?"

The argument is limited by which options the person making the argument has chosen to compare. Too often, this lends itself to straw man arguments and reduces complex problems to false binary decisions.

[via Andrew Sullivan]

Out of your head

A nonalcoholic writer writes about a month of sobriety:

I am not an alcoholic. I don’t get sick, fall down or start my day with tots of whiskey. But I do love wine. I am entranced by the socio-historical and chemical properties of the vine. It is, for me, an intellectual pursuit–albeit one that is also literally intoxicating.

The threshold of addiction is a foggy place. You more or less know when you’re dependent, and you know when you're independent. But most of us stumble around somewhere in between: we’ll just have one more; we don’t need it, we just like it; we could stop anytime. My social life runs on alcohol like a bicycle on its tyres: it could keep moving without it, but the ride would be bumpy and uncomfortable and I would worry about looking foolish.

So I decided to give up drinking for a month. How hard could it be? Not that I thought it would be easy: not only do I enjoy drinking, but also I am good at it. I merrily buy fine wine and hold it well. Yet given my lack of discipline, going completely without seemed easier than moderation. I believe La Rochefoucauld had it right when he said, "Moderation is the feebleness and sloth of the soul, whereas ambition is the warmth and activity of it."

    Supportive friend:  "Seriously? For a whole month? Wow. You should write about it. People love to read about the misery of others."

    Less supportive friend:  "In January? Are you mad? What other joys are there at this time of year?"

    Even less supportive friend:  "I’m just off out for a lovely evening of dinner, chat and lots of red wine. Oh, and martinis. Envious?"

So I did it. It’s not difficult. Just dull. I felt unsociable. I missed the glow of self-satisfaction that alcohol brings, and the clear division it offers between work and recreation.
...
So what else did I learn after a month of stone-cold sobriety? That it's over-rated. There is a reason why people drink proportionally more the less they like themselves: alcohol takes you, as so much slang for drunkenness has it, out of your head. I’m no self-loathing Hemingway or Parker, but a month is a long time in your own uninterrupted company. Nobody wants to spend that much time with me--not even me. This is despite the fact that I found abstinence to be good for my self-esteem, not the other way round. People keep asking me if I feel healthier. I don't, particularly. But I do feel smug.

Wow. What a great job explaining the difficulty of quitting drinking for someone who simply likes drinking--for someone whose brain hasn't even been hijacking to seeking alcohol as a survival need.

It also does a great job of explaining some of the ways in which a tribe within mainstream culture can offer many of the same barriers that are face by people who identify with a tribe the culture of addiction.

Pot and cancer tumors

In case you heard that recent story about marijuana as a potential treatment for cancer tumors and wondered what to make of it, here's an apparent expert offering their view on it.

New ONDCP appointment

Obama's Drug Czar nominee seems to be well on his way to confirmation and now we learn that A. Thomas McLellan has been nominated for Deputy Director of the ONDCP. McLellan founded the Treatment Research Institute, co-authored a landmark paper making the argument that addiction is a chronic illness and, more recently, has been working closely with Bill White and others on implementing a recovery-oriented system of care in Philadelphia. (Here's something that they wrote together.)

This seems to be very good news. Hopefully they'll get the latitude that they need to initiate meaningful reforms.

Why do they stay?

A little off topic, but this is a great post on why victims of domestic violence often stay with the perpetrator.

5 Years After: Portugal's Drug Decriminalization Policy Shows Positive Results

This offers a very important opportunity to examine the effects of decriminalization. In terms of public health, the effects appear to have been very good. I'd be interested to watch indicators like age of first use, overall use rates, treatment admission rates, other crimes that are often drug-related, other harms that are often drug related (child welfare, etc.) and if there are any adverse or positive effects on specific communities. Aside from the legal status of the drug, it would be great to see a country shift its emphasis from criminalization of addicts to a wellness or recovery facilitation approach.

Keep in mind that the source has an avowed bias.

Abstinence too dangerous?

Interesting reading about professional helpers' fear of abstinence at wired in to recovery.

Peapod says, "While the ‘it’s too dangerous to try for abstinence’ argument is widespread in treatment settings, my own belief is that it is a rationalisation for maintaining the status quo."

I think it goes beyond the status quo issue. The context is much different here in the States, harm reduction and methadone are not dominant here, but there are very similar sentiments among those providers here. I believe that it comes down to a few common core beliefs in many (not all) workers in these field:

• that addicts can't or won't achieve full recover
• that drug use (including addiction) is voluntary or a lifestyle choice and that the liberty to choose drug use should trump other values
  
• to encourage recovery is to moralize

These discussions always remind me of a friend describing an NA t-shirt from a conference years ago. The shirt says, "The lie is exposed--we can recover."

Sober housing

Bill White reflects on the historical significance of sober housing (and recovery support services in general):

Congress has just mandated that health insurance companies must cover mental illness and substance abuse with the same standards they use to pay for other illnesses (The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (PL 107- 1434)). Passage of this legislation is, in some ways, a step “back to the future” since many health insurance companies in the 1970s and early 1980s covered addiction treatment as they covered payment for other illnesses. Such reimbursement was restricted or eliminated in the late 1980s and early 1990s because of treatment industry excesses (e.g., inappropriate admissions, excessive lengths of stay) and growing alarm about patterns of chronic relapse and treatment recycling. It is important in the face of this new legislation that the treatment field avoids replication of this earlier history. The use of Oxford Houses and other non-clinical, peer-based recovery support services can enhance the likelihood of recovery without relapse and can help prevent the future loss of the parity that has just been legislatively restored. 

Polishing a terd

Hythiam Announces Results Of Two Double-Blind, Placebo-Controlled Studies On Impact Of Prometa(R) Treatment Program For Alcohol Dependence

Marijuana derangement syndrome

Mark Kleiman debunks the some of the latest pro-legalization hysteria. (Read Kleiman's entire post.)

I asked Andrew Sullivan to publish the number of incarcerations for marijuana possession in quantities consistent with personal use. (Because I honestly didn't know and he give lip service to bringing rationality to matter.) Rather, he's opted to go with the umpteenth installment of "The Cannabis Closet". (Why does such a smart guy embrace this crap? Does he feel the same way about people saying, "Dude, I'm gonna pound a case a beer tonight. I've got a beautiful beer bong that can hold 72oz and deliver it in 4 seconds!"?) I don't really care if he wants to spark up every night, but the he celebrates it is getting pretty grating.

Kleiman reports that there are 30,000 inmates whose worst offense was marijuana crime. Another site reports that the number is 37,500, with 15,400 of them convicted of possession rather than trafficking. Too many, worthy of attention for reform, but not what the hyperbole would lead one to believe. Keep in mind that there is a lot of distance between current practices and legalization.