Recovery-oriented Methadone Maintenance, part 5

Bill cites a methadone advocate making an important distinction--treating dependence vs. treating addiction.

The stigma attached to methadone is also shaped by the expectations of methadone treatment as a system of care. Methadone advocate Walter Ginter comments on such expectations:

Patients, former patients, staff, policy makers, and the public expect the methadone treatment program to treat addiction. While that is a reasonable expectation, it is not what Opioid Treatment Programs (OTPs) do. OTPs treat opiate dependence, and they do it very well. Most patients on an adequate dose of methadone do not continue to use opiates. However, opiate addiction is more than dependence on opiates; it is dependence combined with a series of behaviors. OTPs (with a few exceptions) do not treat the behavioral aspects of addiction. The behavioral aspects are not treated by a medication but rather by counseling, therapy, peer recovery supports, and 12-step groups. As long as well-intentioned people go around saying that “methadone is recovery,” it is going to continue to be misunderstood. Methadone is a medication, a tool, even a pathway, but it is not recovery. Recovery is a way of living one’s life. It doesn’t come in a bottle.547

Recovery-oriented Methadone Maintenance, part 4

Bill summarizes criticism of MM as follows:

Critics of medication-assisted treatment, many of whom were competing for cultural and economic ownership of the problem of heroin addiction, alleged that MM: 1) substitutes one drug/addiction for another; 2) conveys a societal attitude of permissiveness toward drug use; 3) fails to address the characterological or social roots of heroin addiction; 4) cognitively, emotionally, and behaviorally impairs MM patients; 5) is a tool of racial oppression and genocide; 6) is financially exploitive; and 7) as a result of these factors, is morally unacceptable.

He later states:

We concluded in the first two articles that it was time we as a country and a professional field stopped debating the morality of methadone maintenance and focused our energies instead on elevating the quality of methadone maintenance treatment.

I didn't see where another kind of objection is addressed. What about the concern that MM is a manifestation of stigma? That it's based on the premise that drug-free recovery is not possible for opiate addicts (or, certain kinds of opiate addicts)? That it's a form of treatment that doctors never use for their addicted colleagues? That it's born from the failure of drug-free treatment of inadequate intensity, duration and quality and, when we choose to address those inadequacies, outcomes for opiate addicts are very, very good.

Whenever I'm talking with a professional helper about a loved one, one of my first questions is, "What are our options?" followed by, "What would you do if this was your child/parent/spouse?" That's where we determine the ideal course of action and second best options. I'd like to have this conversation with people who have been exposed to the best of both approaches to treatment.

Recovery-oriented=Soviet-style?

Seems the recovery movement in the U.K. has hit a nerve. PeaPod reports:

Writing in SCANbites (not the latest fast food on offer at McDonald’s, but the newsletter of the Specialist Clinical Addiction Network) he [Dr Colin Drummond] rails against what he sees as a politically motivated attempt to force doctors to practise in non-evidence-based ways.

He is ambivalent about the recovery agenda. Praising its potential on one hand, but worried that at its worst “it can be an ideological dogma, imposed by a vociferous minority driven by hegemonic, or, worse, financial motives; a stone’s throw from simple minded translation into daft new Soviet-style targets for treatment delivery”.

Hegemony means the predominant influence, as of a state, region or group over others. A bit like the influence of psychiatrists, say, over the addiction field. 

Recovery-oriented Methadone Maintenance, part 3

Bill White on efforts to broaden the definition of recovery:

Consistent with Newman’s and Dole’s views are definitions of recovery that focus on health and functionality without reference to cessation of medical use of methadone. The examples below illustrate such definitions:

Recovery is the process of pursuing a fulfilling and contributing life regardless of the difficulties one has faced. It involves not only the restoration but continued enhancement of a positive identity and personally meaningful connections and roles in one’s community. Recovery is facilitated by relationships and environments that provide hope, empowerment, choices and opportunities that promote people reaching their full potential as individuals and community members.194

Recovery is a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles.195

The process of recovery from problematic substance use is characterised by voluntary sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.196

Stabilized MM patients would meet these criteria for recovery if they were demonstrating progress toward increased health and functionality. The “sustained control over substance use” in the UK recovery definition is broad enough to include multiple pathways of alcohol and other drug (AOD) problem resolution—traditionally defined abstinence, decelerated patterns of AOD use that no longer meet criteria for a substance use disorder, and medication-assisted recovery—as long as the other criteria of health and positive community participation are met. Similar in spirit to the UK definition were suggestions to the authors from some methadone patients that a broadened definition of recovery is needed.

The only way we will ever be able to move addiction treatment to a chronic disease model is if we take the “abstains from alcohol and other intoxicating drugs” out of the recovery definition, or at least stop making it the deciding factor for the status of being “in recovery”… I think we need to make it one of many goals rather than the focus. This would help us achieve the focus of every other chronic disease treatment: QUALITY OF LIFE and the reduction of symptoms…We have got to stop thinking of recovery as ALL or NOTHING.”

Personally, something about the patient's statement is more compelling than any of the others. I think a lot of people in drug-free recovery would be open to thinking about abstinence as a goal when defining recovery. "One of many" may be a problem because it makes it sounds like it would reduce abstinence to an item on a checklist when, for many of us, without abstinence there is NO recovery--an insufficient, but necessary condition for recovery.

With abstinence being so central to our recovery, it certainly feels like defining recovery as something for which abstinence is not necessary leaves it feeling like an incomplete definition. One of the factors that binds us together is the shared experience of searching for chemical solutions to our addiction problem and having to face the reality there is no chemical solution to our problem. If someone can find one, our hats are off to them, but their experience and our experience are qualitatively different. Not better or worse, but different. The journey may be similar, but it's not the same. Does that make any sense?

This isn't to dismiss recovery-oriented MM, but is it realistic to expect people in drug-free recovery and medication-assisted recovery to identify as one community? We might get there, but we've got a long way to go and a lot of mental barriers to navigate. Many of those barriers were created to protect our recovery and our identity as recovering people. I associate stigma with "otherness". Addicts have long faced being defined as "the other" and recovering people have constructed our own positive sense of otherness. We talk about "normal people" and that we different from people who manage to moderate or find recovery through faith communities. Would embracing MM patients erode this protective differential identity? It also begs the question, why have MM patients been unable to create their own communities of recovery?

The Big Picture on marijuana

The Big Picture (one of my favorite blogs) has a marijuana gallery.

Warning--if you're recovery is a little shaky, you might want to skip it. A few images of people using marijuana.

Recovery-oriented Methadone Maintenance, part 2

Here Bill describes the devolution that troubled early advocates of MM:

The regulation and mass diffusion of MM in the 1970s and 1980s was accompanied by changes in treatment philosophy and clinical protocols. The most significant of these changes in terms of recovery orientation included a shift in emphasis from personal recovery to reduction of social harm; increased preoccupation with regulatory compliance; widening variation in the quality of MM programs; the reduction of average methadone doses to subtherapeutic levels; arbitrary limits on the length of MM treatment; pressure on patients to taper and end MM treatment; the erosion of ancillary medical, psychiatric, and social services; and a decreased emphasis on therapeutic alliance between MM staff and MM patients. The definition of recovery during this period shifted from a focus on global health and functioning to an almost exclusive preoccupation with abstinence—then defined as including cessation of methadone pharmacotherapy. The public face of MM became defined by the worst MM clinics and the least stabilized MM patients.

Recovery-oriented Methadone Maintenance

Bill White has a new monograph out on recovery oriented methadone maintenance (MM). There's something in it please everyone and something in it to anger everyone. He takes the position that MM is an essential part of the treatment continuum but is hard on MM in its current form.

I'm very busy with a couple of projects but I plan to try and post some highlights every day for the next several days. Here's the first.

Here Bill descibes the disappointment of methadone pioneers at what they see as a devolution of MM:

Dr. Dole later spoke of the “stagnation of treatment” that occurred throughout the 1970s and 1980s.87 He was particularly incensed at the depersonalization of MM and the loss of partnership with patients in MM: “the contempt with which many regulators and program administrators have treated their patients seems to me scandalous.”

The strength of the early programs as designed by Marie Nyswander was in their sensitivity to individual human problems. The stupidity of thinking that just giving methadone will solve a complicated problem seems to me beyond comprehension.

Dole was not the only early MM pioneer who criticized the evolution of MM in the 1970s. In 1976, Dr. Robert Newman, who led the expansion of MM in New York City, declared:

Methadone maintenance treatment, with its unique, proven record of both effectiveness and safety, no longer exists. One can only hope that it is not too late to reassess that which has been cast aside, and to resurrect a form of treatment which has helped so many, and which could help many more.90

Other critics, including Dr. Stephen Kandall, concurred with Newman and further argued that:

Political forces reduced methadone to an inexpensive, stripped down way to “control” a generation of addicts without having to provide essential rehabilitative services… 91

Tab Dump

• Rangers Use Ginger Ale in Celebration as Way to Include Josh Hamilton
• The Marijuana Number That Was Too Good to Check
• I lost ten years of my life as a middle class, NHS sponsored drug addict...
• Shelter alters its handling of substance abuse

Amazing

From a recent Bill White speech:

Today, I received an email that 200 recovering people and their families marched the streets of Tokyo this week in Japan’s first ever recovery march. Today, we stand, here and abroad, reaching across geographical, political, racial, and cultural barriers, to mobilize our growing numbers and influence. Today, we stand to reach our goal of engaging those who still suffer and creating a world in which recovery is supported and celebrated. Today, we stand to remind ourselves and to send a message to those still wounded: Recovery is contagious.

This anecdote about Japan is really impressive. Here's a little context:

• Japan has a lot of people--127,000,000. About 40% of the U.S. population.
• AA has been around for decades and membership estimates range from 4000 to 5000.
• Danshukai is the largest mutual aid group. It's membership consists of alcoholics and their families and is estimated to be around 10,000.
• AA membership in the U.S. is estimated to be around 1,000,000 people.

The recovering community in Japan is tiny and stigmatized. For them to bring together 200 members to march in public is quite an accomplishment.

Moving back into the shadows

A friend directed me to this comment about the recovering community and prevention workers:

We recently held a United for Prevention - Celebrating Recovery event and it is our 4th year of celebrating recovery in our local community. Youth challenged law enforcement to a back yard game of kick ball... "kicking it for recovery" was on the back of law enforcement t-shirts and "Life At Its Best... Add Nothing... Play Sober" was on the back of the youth t-shirts. The recovery community was there and I know this because some of our greatest volunteers quietly try to slide in unnoticed - out of the shadow of shame as Penny puts it. We gave away the t-shirts as they were provided by our local mental health provider - and the most popular one I might add was "Play Sober".... you could tell that the message resonated for young, old, middle-aged and yes - particularly with the recovery community. One of my friends in recovery commented "it would have been nice if this message had been around many years ago".... 

It is now October and September Recovery Month has come and gone... and as our friends in recovery start to move back into the shadows... I challenge those of you in prevention to reach out and find ways to keep them engaged ... they are your greatest advocates! And remember, the shadows often bring us our most beautiful flowers and offer a calm ending to our day as the sun sets... treasures worth celebrating!

Drug Legalization and Tax Revenue

Ugghh!

I hate this argument for legalization. I also think it's the wrong way to go about it if legalization were to come to pass.

Think for a moment about the power of the alcohol and tobacco lobbies. (In Michigan it's been impossible to raise liquor taxes.) Think about their marketing power. Think about their place in our culture.

Is that what we want for marijuana?

I fear that capitalism, legalization and out political system are likely to be an ugly combination.

If we were to legalize, I like Mark Kleiman's proposal to keep sale illegal and legalize people growing their own on a limited scale.

Salience

I've posted before about the role of salience in addiction. This is a great illustration:

More on recovery without abstinence

Oops. I meant to add more to that last post and didn't.

The commonly held belief about addiction is that addicts won't seek help without a gun held to their heads. Our experience just shatters that.

I meant to introduce the quote with the statement that Dawn Farm would say exactly the same thing. More than ever, I have faith that, given a menu that includes good options, addicts will migrate toward recovery--whatever that looks like for them. Some may be able to quit heroin and continue to drink while achieving the same quality of life as another who chooses to abstain completely. I believe that the former person is the exception to the rule and that it's a risky experiment--if this path doesn't work, they may not survive or their illness may progress in a manner that makes it more difficult to stabilize and achieve recovery the next time around. However, if a person chooses to pursue this path after reviewing the risks, it's their choice to make. What I fear is programs or systems that don't offer hope for recovery, don't offer accurate information, don't offer treatment/support of adequate duration and intensity and celebrate any positive change without encouraging addicts to keep moving in the direction of full recovery--whatever that means to them.

Recovery without abstinence

I'm not about to start recommending this as a path to recovery, but I really like the tone of this guy. Fascinating story.

The commonly held belief about addiction is that addicts won't seek help without a gun held to their heads. Our experience just shatters that.

The book that started it all

"more than 5 pounds"

only $13 a pound! 

That's cheaper than Starbucks Anniversary Blend!

Let's hope they offer a cheaper version in the near future. (They offer a more expensive version.)

Social network mapping and recovery facilitation

This begs some fascinating questions.

Could targeting specific roles in the culture of addiction bring others into recovery with them--a kind of domino effect?

How many of your friends drink alcohol? How many might say they used alcohol problematically? What about illicit drugs? Probably a smaller proportion of the people you know take drugs, but perhaps a few have experienced problems with drug use at some point in the life.

For the 160 current and former drug users who took part in the RSA’s User-Centred Drug Services Project survey, answers to these questions are, I presume, rather different to yours. ...30 per cent said that all of the people they know use drugs, with most of them using problematically. Similarly, around a third reported that all of the people they know used alcohol, and around half of them had problems because of it.

...The average probability of smoking, for example, is found to be 61 per cent higher if a friend smokes (one degree of separation), 29 per cent higher at two degrees of separation, and 11 per cent higher at three degrees of separation.

A recent RSA paper on problem drug use suggests that recovery may be ‘contagious’ in the same way. This is an important insight, but problematic: if all of the people you know take drugs, how do you get out of this networked influence that entrenches drug use? A study (external PDF) of drug user networks in Connecticut found that, on average, 85 per cent of the people in a drug user’s personal social network (or ego-network) used drugs. Piecing together the community-wide drug using network, the researchers found clustering of drug users into African American, Puerto Rican and White communities. Interestingly, the mapping also revealed who the key influencers were in the drug using network;  those ‘nodes’ at the centre of the network most strongly connected to large numbers of other users.

The RSA is extending its work on drugs to look at how we might similarly map drug using networks in Peterborough, with a view to identifying and working with these potential ‘recovery champions’ to transmit recovery through the network. There is good reason to try this: intervention programmes to tackle smoking and alcohol use that deliberately employ peer effects and social network ‘modification’ are found to be more effective than those that do not.

Stigma Unaffected by Acceptance of Disease Model, Study Finds

This doesn't surprise me. So much of what fuels stigma is fear. Calling addiction an illness or disease doesn't really get at the question, "Am I and my loved ones safe with you around us?"

Psychiatric fads

Allen Frances, Chair of the DSM-IV Task Force, deconstructs the  phenomena of psychiatric fads:

To become a fad, a psychiatric diagnosis requires 3 preconditions: a pressing need, an engaging story, and influential prophets. The pressing need arises from the fact that disturbed and disturbing kids are very often encountered in clinical, school, and correctional settings. They suffer and cause suffering to those around them--making themselves noticeable to families, doctors, and teachers. Everyone feels enormous pressure to do something. Previous diagnoses (especially conduct or oppositional disorder) provided little hope and no call to action. In contrast, a diagnosis of childhood Bipolar Disorder creates a justification for medication and for expanded school services. The medications have broad and nonspecific effects that are often helpful in reducing anger, even if the diagnosis is inaccurate. 

The "epidemic" of childhood Bipolar Disorder fed off the engaging storyline that it: 

1. Is extremely common
2. Was previously greatly under-diagnosed
3. Presents differently in children because of developmental factors
4. Can explain the variety of childhood emotional dysregulation
5. Has diverse presenting symptoms (eg, irritability, anger, agitation, aggression, distractibility, hyperactivity, and conduct problems)

The prophets were "thought leading" researchers who encouraged child psychiatrists to ignore the standard bipolar criteria and instead to make the diagnosis in a free-form, over-inclusive way. Then enter the pharmaceutical industry-- not very good at discovering new drugs, but extremely adept at finding new markets for existing ones. The expanded reach of childhood Bipolar Disorder created an inviting target. The bandwagon was further advanced by advocacy groups, the media, the internet, and numerous books aimed at suffering parents. 

[hat tip: David Mee-Lee]

Hope

This comment on a previous post caught my attention:

Drugoholism is a field, a combination of various processes, internal and external. "As the twig is bent the branch doth grow." is an old adage. I have realised that IN PRACTICE this is true for many. At times the only PRACTICAL solution, apart from the exceptional few is amelioration.

I'm reminded of this post from a few years ago:

Ideas like this are rooted in despair, rather than hope. (see here, here, here) We get overwhelmed by the problem. (here) We're too cheap to offer adequate help. (here) We don't believe that these people can recover. We think they have no chance. We're scared that they'll hurt us and get us sick. (here)  So, we offer them these kinds of interventions. Often, these programs represented in the name of choice, (here) when, the addicts themselves, want better from us. (here, here) They actually want to get well, but often lose hope that it's possible for them. The system starts patting them on the head an encouraging them to be more realistic. (here, here, here) What they need from professional helpers is for us to lend them our hope to cultivate some of their own. (here, here) They need a system that stops talking about if they recovery and starts talking about when they recover. (here)

"If you want to treat an illness that has no easy cure, first of all, treat them with hope." --George Vaillant

Smoking and recovery

PeaPod just posted on one of my pet causes--smoking among recovering people.

The situation is very similar in the U.S. and we are trying hard to address this within Dawn Farm for a few key reasons:

• In Michigan, 23% of the population smokes while 85% of our clients smoke.
• Addicts and alcoholics have a harder time quitting than other smokers.
• Addicts and alcoholics experience greater physical harm from smoking than other smokers.
• Quitting smoking at the initiation of recovery is associated with improved treatment outcomes. Quitting smoking is good for recovery.
• 15% of nonsmokers who enter programs that allow smoking become smokers by the time they leave treatment.   

One of our handouts is available here.

A slidecast is available here.