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We're moving!

This blog will be moving over the next week or so, so we'll be quiet for about a week.

Blogger is ending the FTP service this blog uses tomorrow and Dawn Farm's website will soon be updated and will be using Wordpress. Hoped to have the blog moved by tomorrow, oh well. Short of having the move completed, I hoped to have all the details by now, but I don't. :-(

You'll be able to find our new home by visiting www.dawnfarm.org or revisiting this post. (I think I'll be able to update it.) I also plan to update the feedburner feed, so people who use that should not have to do anything.

If all goes well, we'll be back up by next week.

Measuring recovery

The Art of Life Itself has a post linking to 2 documents that compile instruments measuring recovery or some aspect of recovery. (That seemed like a wordy and awkward sentence. I left my brain in bed this morning.)

Tab dump

• Don’t Call It ‘Pot’ in This Circle; It’s a Profession
• Reinventing Yourself: Part 1 — A Neurological Case for Recovering People to Journal
• Thinking About Tomorrow
• When the Country Went Cold Turkey
  

The findings of this study seem to be pretty striking. I haven't had a chance to ready the actual paper to see how robust the outcomes were. They controlled for authoritative parenting style. It seems to suggest that R-rated films  are powerful advertising vehicles for drinking. The third link would seem to support the power of advertising.

• Keeping kids away from R-rated movies may prevent early drinking
• Parental R-Rated Movie Restriction and Early-Onset 
• Alcohol Use*
• Young Drinkers Influenced More by Alcohol Ads than by Athletes' Drinking Behavior

Customer Service?

I decided to do a search for "customer service" and "behavioral health". The results are pathetic. I have a feeling that this says something pretty troubling about behavioral health services.

Alcoholism, Family and the Limits of Love | World of Psychology

Bill White reviews the tv movie airing this Sunday, When Love is Not Enough:

When Love is Not Enough is clearly more than a love story, though it is surely that. Readers of Psych Central and the people they serve will discover in this movie six profound lessons about the impact of alcoholism and alcoholism recovery on intimate relationships and the family.

1. Prolonged cultural misunderstandings about the nature of alcoholism have left a legacy of family shame and secrecy.

2. Alcoholism is a family disease in the sense that it also wounds those closest to the alcohol dependent person; transforms family relationships, roles, rules, and rituals; and isolates the family from potential sources of extended family, social, and community support.

3. The family experience of alcoholism is often one of extreme duality.

4. Family recovery from alcoholism is a turbulent, threatening and life-changing experience.

5. We cannot change another person, only ourselves.

6. The wonder of family recovery.

How much do we know?

Clinical Evidence offers a pie chart that categorizes medical treatments (All medical treatments. This is not specific to addiction.) by their known effectiveness.

Use evidence-based approaches is important in all services, human and otherwise, but it's easy to forget that the concept is not that simple--there are political factors, publication bias, research bias, real world vs. research considerations, individual client factors, practitioner factors, environmental factors, etc. When thinking about evidence-based approaches in the context of behavioral health, it's also easy to lose sight of the larger medical context.

Figure 1 illustrates the percentage of treatments falling into each category. Dividing treatments into categories is never easy hence our reliance on our large team of experienced information specialists, editors, peer reviewers and expert authors. Categorisation always involves a degree of subjective judgement and is sometimes controversial. We do it because users tell us it is helpful, but judged by its own rules the categorisation is certainly of unknown effectiveness and may well have trade offs between benefits and harms. However, the figures above suggest that the research community has a large task ahead and that most decisions about treatments still rest on the individual judgements of clinicians and patients.

End Insanity Of The War on Drugs—Start With Decriminalizing Marijuana at The Federal Level

Ron Paul renews his call for marijuana decriminalization.

I'm not knee jerk about the matter, I don't think anyone should do jail time for simple possession, but these arguments would resonate more with me if they said something to address the social costs of drugs and alcohol. Alcohol prohibition was wrought with serious problems and I would never support its return, but alcohol consumption is tied to no small number of serious social problems and costs. (And it has an industry that's invested in shaping policy, beliefs and attitudes toward those problems and costs.)

As I've said before, a problem-free alcohol and drug policy is not possible. There will be problems with any policy. The question is which problems are we willing to live with and what can we do to mitigate them.

Tab Dump

• An Alcoholic’s Savior: God, Belladonna or Both? (Not news, but interesting. May say something about Bill Wilson's openness to LSD later in life.)
• Losing a voice of reason against ‘war on drugs’
  
• Soft war on drugs: Portugal shows how drug addiction, when treated as an illness and not as a crime, can be controlled effectively.
• Tanning bed usage can be as addictive as cannabis and alcohol (Ugh! I've said before that I worry about some of the neuroscience of drug addiction being replicated with all sorts of other compulsive behaviors. I don't believe that this will prove those behaviors are brain diseases or that addiction is not. Just that we understand less about the mechanisms of addiction than we think we do.)
• Reason.tv: 3 Reasons to Legalize Pot Now! (I find the first half of number one to be a terrible reason for legalization.)
• Why is Disulfiram Superior to Acamprosate in the Routine Clinical Setting? (Given the underwhelming evidence for disulfiram, what does this say about acomprosate? Can't get the full text yet.)

I give my autistic son pot

News from the medical marijuana front lines .

More on McLellan's departure

More on McLellan's departure.

Why Drug Addicts Are Getting Sterilized for Cash

Another story on Project Prevention. I've blogged about them before here and here.

What does it say that Time inserted this into the story?

(See the best and worst moms of all time.)

I think it speaks volumes about about the attitudes and stigma that this kind of program taps.

Think for a minute about the about the opening paragraphs:

When Joanne Chavarria's grandmother died last summer, she coped by turning to the bottle. "I started to drink. And then I started to smoke some weed. And then I started doing meth," says the 32-year old from Merced, California. Chavarria, who began abusing drugs at the age of 12, was eight months pregnant at the time. Last August, she gave birth to drug-addicted twins, and California's Child Protective Services took the infants, and Chavarria's three other children, into custody.

As with other addicts, the road to recovery for Chavarria began with counseling and a drug rehabilitation program. Less orthodox, however, was her decision to undergo a tubal ligation. "Addicts in my situation need to get their tubes tied," she says. "When you stop having kids it makes you think about what else you can do in life."

Chavarria had the procedure done after meeting with Project Prevention, a North Carolina-based charity that gives drug addicts $300 if they go on long-term birth control or undergo sterilization. The aim of Barbara Harris, 57, the organization's controversial founder, is to prevent addicts from having children they can't care for and reduce the number of babies born exposed to drugs.

"Last summer"?!?!?!

This article is dated April 17!

More concerns about DSM-V criteria

This concern speaks to some of my thoughts.

Others are more concerned, arguing that abuse should be thought of as a behavior and dependence as a disease, and by combining them it becomes easier for payers to deny clinically appropriate care. Even worse, it might signal a shift to the idea that any professional with "behavioral" health training would be eligible.

It's worth noting that is not an argument for the status quo. I've never been comfortable with abuse as a disorder.

The Joylessness of Drug Addiction

From Addiction Inbox:

The act of “liking” something is controlled by the forebrain and brain stem. If you receive a pleasant reward, your reaction is to “like” it. If, however, you are anticipating a reward, and are, in fact, engaging in behaviors motivated by that anticipation, it can be said that you “want” it. The wholly different act of wanting something strongly is a mesolimbic dopamine-serotonin phenomenon. We like to receive gifts, for example, but we want food, sex, and drugs. As Nesse and Berridge put it, “The ‘liking’ system is activated by receiving the reward, while the ‘wanting’ system anticipates reward and motivates instrumental behaviors. When these two systems are exposed to drugs, the “wanting” system motivates persistent pursuit of drugs that no longer give pleasure, thus offering an explanation for a core paradox in addiction.”

McLellan Resigning as ONDCP Deputy Director

Too bad. He's had a lot of family stuff going on. Sounds like a terrible time to start this kind of job. I wish him all the best.

Medical care in recovery

We're working on improving linkages between our clients and primary medical care. We've borrowed from these guidelines and have been discussing this with local primary care physicians. 

I drafted the document below for clients and I'm interested in your thoughts. Keep in mind that I'm trying to keep it brief so that people will actually read it. Please post comments or email me with your comments.

Thanks!

UPDATE: A few updates throughout the day. The most recent version can be viewed here.

=============

Medical care in recovery

It's been said that the doctors office can be one of the most dangerous places for a recovering alcoholic or drug addict.

Here are a couple of data points from studies on the subject:

• 29.5% of patients said their physicians knew about their addiction and prescribed psychoactive drugs such as sedatives or Valium, which could cause additional problems. (Source)
• 94% of primary care physicians fail to diagnose substance abuse when presented with early symptoms of alcohol abuse in an adult patient. (Source)
• In a study of third-year medical students, only 19% recognized alcoholism during a mock chart review examination, even though the alcoholism diagnosis, a family history of alcoholism, and a 10-year history of extensive alcohol use were included prominently throughout the chart. (Source)
• A national survey of residency program directors found only 56% of the programs require training in substance use disorders. Even when training is required, very little is provided—median curriculum hours ranged from 3 to 12. (Source)

We've seen countless relapses begin with a visit to the doctor's office. It can happen even when the recovering person is clear about their recovery status. We've heard time and time again from recovering people who go to the doctor for something like pain or sleep problems and the doctor insists that a drug like vicodin, ambien or ultram is "mild" or "safe".

For this reason (and a couple others) it's important to recruit your doctor to support your recovery. 

Reasons to make your doctor a recovery ally

1. To help assure that your doctor will not prescribe you anything that might put your recovery at risk.
   
2. To help assure that you won't make a bad decision when you're scared, unhappy and/or in pain. When we're suffering we're at risk for making poor choices, we just want the pain to stop, we feel like we're going to go crazy if we don't get some sleep or if the anxiety doesn't stop. Everyone wants a quick, easy fix when their suffering, but the consequences are much more dire for us. This doesn't mean that we shouldn't take our symptoms seriously, we just need to be careful not to put our recovery at risk.
   
3. To help your doctor with diagnosis and treatment. Some symptoms of addiction (even in abstinence) can look like other medical and psychiatric problems. You want to be sure that the right problem is being treated. Your doctor can't make the right diagnosis if they don't have all the relevant information.
   
4. Addiction is a chronic illness and requires long term care, monitoring and support--longer than Dawn Farm can provide.
   
   Here's one way to think about it. If you get cancer, say Hodgkins, you are likely to go through a course of chemotherapy and radiation. If all goes well, within a period of months there will be no signs of cancer left in your body. Does your cancer treatment stop there? Let's hope not! Your doctor will probably want you to get periodic body scans for a period of around 5 years to be sure that a relapse is not occurring. If there is a relapse, the patient gets more treatment before the cancer get too bad. Why 5 years? Because recovery from the cancer is not considered stable until relapse rates drop below 15% and it takes about 5 years that to occur. It just so happens that it takes about 5 years for alcoholism relapse rates to drop below 15% and about 7 years for opiate addiction relapse rates to drop below 15%.
   
   For this reason is makes sense to make sure that you are getting recovery monitoring and support for a period of at least 5 years. A primary care physician is an ideal person to provide this monitoring and support.
   
5. It's your recovery and you're responsible for protecting it. There is tons of research that suggests this is important and there are thousands of stories that speak to its importance. 

What you can do

First, if you do not already have a doctor, choose a doctor that know something about addiction and recovery. We recommend the following:

Academic Internal Medicine 5333 McAuley Drive, Suite 4015 Ypsilanti, MI 48197 734.712.5300 (Sliding scale down to $0)	Corner Health Center 47 N. Huron Ypsilanti, MI 48197 734.484.3600 (22 and younger. Sliding scale down to $0)
Pain Recovery Solutions 4870 Clark Road Ypsilanti, MI 48197-1104 734.434.6600	Integrated Health Care 1290 South Main Street Chelsea, MI 48118-1454 734.475.1107

Second, make an appointment for a checkup. We have prepared a letter that you can send your doctor before your visit or bring with you to your appointment. It may seem corny or unnecessary, but it's important that it's in your file. You may end up working with other doctors and, let's face it, they are probably not going to remember.

Third, have your counselor prepare a release that allows your doctor and treatment staff to coordinate your care. Your counselor will then send them a letter letting them know that we are happy to help if they have any questions.

Fourth, bring it up with your doctor and let them know you'll welcome them asking how your recovery is going.

Fifth, keep in mind that it's likely you'll have to remind them when you come in for medical visits.

One more thought

All of this also applies to visits to the dentist too! It's easy to let your guard down and overlook the risks in a dental office then find yourself with a prescription for vicodin or offered nitrous oxide.

All of this may seem like overkill, but is it really? We're vigilant about all sorts of other things in our lives. All of us organize our lives around protecting things that are important to us, whether it's our job, family, health, creative outlets, faith--whatever. So much depends on our recovery. Shouldn't we be just as vigilant in protecting it?

The Future of AA, NA and Other Recovery Mutual Aid Organizations

Bill White's latest is up on Counselor Magazine's website. Two of the most interesting moments come in a section on the "Emerging science of recovery"

Science also will spark controversies by challenging prevailing beliefs of recovery fellowship members. Research on the potential value of medication-assisted recovery is challenging and softening many AA members’ views about medication. One of the most controversial issues within NA in the coming decade will be the science-driven push to re-evaluate local group policies on methadone and other medications (e.g., denial of the right of more than 265,000 persons in methadone maintenance in the United States to speak at NA meetings, chair a meeting, or head a service committee—even by individuals with prolonged stabilization, no secondary drug use, and achievement of global health and positive citizenship.) Some will attempt to avoid this debate by declaring that scientific studies on methadone maintenance are an “outside issue,” but the growing weight of science will exert enormous pressure on NA as an institution, as it will all recovery mutual aid fellowships.

All recovery mutual aid societies will be scientifically evaluated in the coming decades on such dimensions as accessibility, attraction, engagement (affiliation and retention rates), short- and long-term effects on the course of AOD problems, effects on global health and functioning and the potential social cost offsets from such participation. Some groups will face this scrutiny and actually achieve heightened scientific credibility (as has happened with AA in the past decade); others will not withstand the effects of such scrutiny.

An issue most critical to the survival of recovery mutual aid groups is the question of how long members should continue to participate. While 12 Step fellowships have implicitly encouraged sustained if not lifelong participation, many of the alternatives to 12 Step Fellowships do not expect sustained member participation. Among the latter, members are expected to avail themselves of sufficient support to initiate stable recovery and then leave and get on with their lives.

Science is actually revealing that this latter position may work at an individual level. Recent studies of AA reveal a population of positively disengaged individuals who initiated recovery within AA, then later ceased active participation but continued to sustain their sobriety and emotional health over time (Kaskutas, Ammon, Delucchi et al., 2005). An interesting outcome of this finding is that the actual societal impact of AA may have been grossly underestimated, as its contributions have generally been measured by its active membership numbers—a figure that ignores the existence of this larger community of people positively affected by but no longer actively participating in AA. The same is likely true for other recovery fellowships.

Interestingly, the “participate as long as and for only as long as you need to” policy may work at a personal level for many individuals but may doom a recovery mutual aid group’s organizational viability. The future of any recovery mutual aid organization rests on its leadership development and long-term meeting maintenance capacity. The personal recovery outcomes of a recovery support group will not always distinguish those groups that will survive and thrive from those that will stagnate and die or regress to the status of a small ideological cult or commercial platform.