Kicking methadone in the U.K.

A great story of recovery and the professionals who didn't believe that it was possible. We get calls from people with the same experience here in the U.S., they want to get off methadone and the clinic treats it as noncompliance. They often feel that their only options are to get back on heroin or con a doctor into an opiate prescription, switch to the heroin or opiate Rx, and then detox themselves from the heroin or Rx opiates.

...I decided to look into rehab options. I met with my CAU key worker, explained that I wanted to get off the methadone as I wasn't using heroin anymore, and go to a rehab, I was told in no uncertain terms that she thought I wasn't ready for rehab and the local authority wouldn't be funding it.

As it happens that was probably for the best as I found a rehab myself, funded by housing benefit in Cardiff, that had a place for me. So I left hospital and went straight into LivingStones Rehab. I wanted to discuss reducing my methadone, so at this point I went to see my key worker again, really chuffed to be able to give my first negative urine sample(negative for heroin), She said that's great but I'd like to increase your methadone dose, just in case. I couldn't believe it, why raise it? I'd stopped taking heroin, was in a stable environment, with support and they wanted to raise my dose? After a lengthy discussion, she agreed to not increasing it but would have none of it when it came to talk of reducing it.

So I decided to write my own reduction plan, as I was on weekly pickup it was possible for me to measure it myself and discard the remainder. I decided on 10% drops every week, until I was completely off it. I let my key worker know my plan, accepted the flack she gave me and got on with it.

Every time I went in for an appointment after that I ended up being chastised for reducing myself,it was going smoothly but she still wouldn't agree to reducing as I wanted and would only drop it to the level I was on that day, so by the next week I was having to measure it and throw away the excess again. No matter what I said or how I explained it, the CAU would not reduce it for me, worse than that they put every barrier possible in front of me. This went on for months, in fact it wasn't until I was on 8ml/day that they realised I was serious about coming off methadone for good and actually started to reduce it for me when I asked.

Alcohol,The Brain & Insulin

One explanation for "wet brain"?

Teens Who Abuse Alcohol Or Drugs Are More Likely To Die Young

More reason to take teen drug use seriously. (Just don't hype it.)

"The fact that these were, to an extent, predictable deaths raises additional concerns about the hazards of alcohol and drug problems in teens and young adults," said Duncan B. Clark, M.D., Ph.D., associate professor of psychiatry and pharmaceutical sciences at the University of Pittsburgh School of Medicine and director of the Pittsburgh Adolescent Alcohol Research Center at the Western Psychiatric Institute and Clinic of UPMC.

Teens who abuse alcohol or drugs are more likely to die in early adulthood, according to a study by University of Pittsburgh researchers published in the current issue of the Journal of Adolescent Health.
...
The researchers studied 870 white and African-American adolescents, ages 12 through 18, recruited from both clinical and community settings. The subjects were followed for up to eight years, starting in 1990.

Among the 870 adolescents, researchers noted 21 deaths, or about 2 percent of the group, at an average age of nearly 25 years. Fourteen of those deaths occurred in males with SUDs, or more than 10 percent of that group. Among African-American males with SUDs, 23 percent had died by the age of 25. Males with SUDs in this study group had a mortality rate far in excess of the rate of 137 per 100,000 reported for young adult males in the U.S. general population.

Socioeconomic status was not a significant predictor of survival time. Causes of death for the young adults in the study ranged from homicide and suicide to drug overdose and motor vehicle accidents.

What drug poses the greatest threat?

This map shows how local law enforcement answered the question, "What drug poses the greatest threat to your area?" Blue is cocaine, red is methamphetamine, amber is heroin, and green is marijuana.

This map is from the National Drug Threat Survey. Even though I'm aware of the regional differences in drug use, it's still striking every time I see something like this. I'm surprised that there were not more mentions of heroin.
[hat tip: Addiction Inbox]

Pot potency commentary

A challenge to the ONDCP hype about pot potency. I support policies intended to keep kids from using drugs, but the ONDCP would really help themselves if they were less sensational and more honest. The result of this hype is that kids learn quickly that the ONDCP and CASA are not a reliable sources of information so they stop listening to anti-drug messages--then who are they listening to?

Social economics

Social economists are playing a larger role in drug policy discussions. There may be a lot of good reasons for them to have a place at the table, but this post, while not about addiction, does a great job illustrating why I believe social economists shouldn't be given too much sway.

They offer an intellectually stimulating perspective on many social problems that has the potential to stimulate some creative thinking, but they offer a very one dimensional perspective that seems indifferent to many elements of the social context.

The Historical Essence of Addiction Counseling

It struck me today that so many of the disagreements related to drug policy and services boil down to disagreements about the nature of the problem. Here's Bill White on the historical essence of addiction counseling:

If AOD problems could be solved by physically unraveling the person-drug relationship, only physicians and nurses trained in the mechanics of detoxification would be needed to address these problems. If AOD problems were simply a symptom of untreated psychiatric illness, more psychiatrists, not addiction counselors would be needed. If these problems were only a reflection of grief, trauma, family disturbance, economic distress, or cultural oppression, we would need psychologists, social workers, vocational counselors, and social activists rather than addiction counselors. Historically, other professions conveyed to the addict that other problems were the source of addiction and their resolution was the pathway to recovery. Addiction counseling was built on the failure of this premise. The addiction counselor offered a distinctly different view: "All that you have been and will be flows from the problem of addiction and how you respond or fail to respond to it."

Addiction counseling as a profession rests on the proposition that AOD problems reach a point of self-contained independence from their initiating roots and that direct knowledge of addiction, its specialized treatment, and the processes of long-term recovery provide the most viable instrument for healing and wholeness.

Opioid Maintenance Therapy Saves Lives

It's important to note the context of this finding. When your options are sub-optimal treatment, no treatment, or opioid maintenance, opioid maintenance saves lives. Findings like this get published, and we learn that, in the context of crappy options, which option is the least crappy. This option gets categorized as "the best option" or as an evidence-based practice. No one stops to suggest that, maybe, we should change the context.

Opioid-dependent patients are 13 times more likely to die than their age- and sex-matched peers in the general population. To examine predictors of long-term mortality, Australian researchers conducted a 10-year follow-up study of 405 heroin-dependent patients who had participated in a randomized trial comparing methadone and buprenorphine.

• Overall mortality was 8.8 deaths per 1000 person-years of follow-up (0.66 during opioid maintenance treatment and 14.3 while out of treatment).
• Each additional opioid maintenance treatment episode lasting more than 7 days decreased mortality by 28%.
• Subjects who were using more heroin at baseline had a 12% lower mortality rate overall, likely because they spent more time in opioid maintenance treatment.

Comments:
Often overlooked in the controversy over opioid substitution therapy is the reality that opioid dependence has a high fatality rate. The current study highlights that opioid maintenance treatment saves lives. The selection of the treatment episode as greater than 7 days strongly suggests that opioid maintenance, not detoxification, reduces mortality. The time is right to promulgate opioid maintenance therapy with either buprenorphine or methadone as the standard-of-care, first-line treatment for opioid dependence.
Peter D. Friedmann, MD, MPH

Reference:
Gibson A, Degenhardt L, Mattick RP, et al. Exposure to opioid maintenance treatment reduces long-term mortality. Addiction. 2008;103(3):462–468.

This weed is the sh*t!!!

Literally. Salmonella too!

More on recovery in the U.K.

UPDATE: The author of the post linked to below believes that she was taken out of context. Her blog appears to be down at the moment. She was responding to this proposed definition of recovery:

‘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.’

I believed that this would have been clear in the context of this blog (The previous post was on this subject and provided the definition.) and the link back to her blog. My apologies if this wasn't clear.

--------------------

A harm reduction advocate in the U.K. wrestles with the idea of a system organized around recovery:

So, hang on, if I'm a substance user who voluntarily controls my own substance use but who chooses not to have participation in the "rights and roles and responsibilities of society" I can't be in recovery? Who says so? What you going to do? Make voting and working and watching Eastenders mandatory for all ex users? Recovery is what I define it as.

Or say I want to participate in the "three R's" of society but every 6 months or so I have a binge. Am I not in Recovery? Don't I have any say in deciding that?

For me, defining Recovery as a process to be controlled by the individual, but then imposing a whole set of values and outcomes upon what "characterises" that recovery is to miss the point. You have to let me judge what my Recovery is. It is not up to you to normalise me. These are my choices, my hopes and my decisions. You make them yours, then you do exactly what those early mental health activists feared. You create "a cosmetic initiative that maintains the dependence of individuals on the system".

I suppose I understand the apprehension, that a recovery-oriented system just being a new set of parameters for doing the same old thing--controlling people. We've certainly had the experience of seeing systems earnestly describe themselves as recovery-oriented when, in practice, they still blame clients for the client's "failure to change" when, in truth, the system failed to provide the support the client needed. Also, there is some history of recovery advocates (before they were called recovery advocates) imposing one narrow path as THE way to recover.

Before I get into my reactions, let me say that I mean no disrespect. I see her blog post as a constructive attempt to articulate her concerns rather than dismiss or attack.

However, there's a way in which I bristle at the statement above. I think it paints a caricature of recovery advocates and addicts. The statement suggests that those who advocate recovery may be invested in forcing some sort of conformity onto addicts. I also believe that it hints at a view of addiction of a nonconformist lifestyle choice rather than an illness characterized by loss of control. The truth, in my experience, is that they're suffering terribly due to their addiction and often don't dare to hope for recovery. Once we impart some hope for recovery, (by offering success stories, hope-engendering relationships, respect and love) they want recovery. They may be concerned that we're asking them to give up their identity and become conformist but this is quickly dismissed by experiencing the recovering community first hand--it could hardly be characterized as conformist.

My response to the concern would be that a recovery-oriented system doesn't force anything, Can a client choose to use every six months and consider themselves in recovery? Sure. They're free to do whatever they want. Would I consider this recovery? If the binge is unintentional, I might characterize this as serial recovery but continue to work toward a more stable recovery. If the binge is planned, ("I'll just go on a binge once every 6 months!") I suppose I would not consider that recovery. I believe that part of recovery is participating in self-care to maintain recovery. However, if a person is capable of "tying one on" once every six months in a way that does not create problems in their life, I wouldn't consider that person an addict. My reaction is not some sort of moral reflex. I'd have the same reaction to a diabetic who goes on a sugar binge every six months and lands in the hospital. That person would not be in recovery from their diabetes. Now, does my judgment that this hypothetical is not recovery mean that I would try to coerce the client into my definition of recovery or abandon them? No. My response to this would be to try to be a fellow traveler and recognize that this is the client's journey.

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.

That is not to say that we cannot as professionals, service users and policy makers do what they did in mental health and begin to explore what we need to do to support Recovery, to define the conditions in which opportunities for people to achieve Recovery are optimised, or to find new ways of working which return the power to the service user and rebalance old inequalities. This is how Recovery became the dominant philosophy in the UK mental health field. I spent some time with an old friend last week who has spent years as a service manager working towards Recovery oriented mental health services. She told me that in the late 90's and early part of the century Recovery rapidly gained credence in mental health. Through the work of user groups and coalitions, the developmental work of NIMHE and other organisations across the field, and through live projects and action research, consensus was built around the Recovery model. She said the biggest challenge she faced was in changing the staff culture. No longer were people there to make decisions for people, to impose their will on people or even to ‘lead by example’. Staff had to find a new role, one that was about first of all helping people define their own ideas of what Recovery would mean – whether that was feeling completely well, or finding something they owned and understood in their own experience of illness (for example having a positive experience of hearing voices). But once that challenge had been dealt with, she said the battle was not over. Key for the success of the Recovery model was the ability of staff to empower service users to access the help and support they needed in the community.

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
  

1000 posts

My last post with my 1000th post. This blog started out as a way for me to share information with Dawn Farm employees and now has 150 to 300 readers a day. Thanks for your interest.

UPDATE: I neglect to mention that any commentary I make that's worth reading is due to the staff and clients of Dawn Farm. We talk every day about barriers to recovery, great and small, everything from international policy to helping a client in financial crisis get food for his dog.

Thanks for your hard work, thoughtfulness and inspiration. You make it easy to get out of bed every day and join you in helping people not just end their suffering, but transform their lives in truly incredible and inspiring ways.

A very U.K. definition of recovery

‘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.’

A definition only a committee could love. Seriously though, it's good that England is re-examining its treatment system, trying to be more client centered, and trying to develop a vision of recovery. Also, I recognize how difficult the task is. Agreeing on a definition of recovery in an organization would be difficult, let alone across organizations and systems.

Two things leap out at me. The word maximize seems to hedge and leave some room for clinical pessimism. The other thing I found striking is the use of the phrase "sustained control". It's hard to imagine an American consensus statement with that phrase. In fact, one of the participants stated, "very uneasy with the words recovery and sobriety – it all sounded very American", bu that they are "words everyone understands." The concepts of powerlessness from 12 step groups, and loss of control from the DSM are pretty widely accepted here. It's worth noting that sustained control could mean abstinence or non-problematic use.

It seems to me that an important determinant of the definition of recovery would be the definition of the problem. My impression is that the disease concept is not widely accepted and drug problems are thought to be lifestyle choices.

Why Is Mom in Rehab?

The New York Times on recent increases in treatment admissions for 40+ year old women:

The actress Tatum O’Neal was arrested recently on charges of buying crack cocaine from a man on the street near her New York City home. She is a 44-year-old mother of three. She has spent years in and out of drug abuse treatment (which she chronicled in her 2004 memoir), and according to her publicist she will continue to “attend meetings” for drug and alcohol abuse.

Ms. O’Neal illustrates a disturbing trend among those being admitted to substance abuse treatment services: a growing percentage of older women are being treated for harder drugs.

Data from the Substance Abuse and Mental Health Services Administration revealed that the total number of admissions to treatment services from 1996 to 2005 (the last year for which detailed data are available) stayed about the same among people under 40, but jumped 52 percent among those 40 and older. Of the 40 and older group, the rise in admissions among men was 44 percent. Among women, it was 82 percent.

Early Drinking and Adult Alcohol Dependence Increases Among Americans

I've posted before on the relationship between early drinking and dependence later in life. Here's a summary of another study on the subject:

A study of individuals born between 1934 and 1983 found that more Americans began drinking alcohol at an early age over the decades, especially women, and that those who did drink at a younger age were more likely to be alcohol-dependent as adults.

Reuters reported June 9 that researcher Richard A. Grucza of the Washington University School of Medicine and colleagues said that the study doesn't prove that early drinking leads to dependence, "but what [it] does show is that early drinking does not simply reflect a genetic vulnerability to alcohol dependence."

Earlier onset of drinking and increased alcohol dependence in adulthood was true for both men and women, but the changes were more significant in women. Women who were born between 1934 and 1943 began drinking at age 22, on average, while those who were born after 1963 started drinking at an average age of 17. The rate of lifetime alcohol dependence was 9 percent among women born between 1934 and 1943 but rose to 22 percent among those born after 1963.

Grucza noted that while the study found that the decrease in women's average age of first alcohol use and rise in alcohol dependence occurred over the course of a few decades, human "genes don't change in that amount of time."

New Report Finds Highest-Ever Levels Of THC in U.S. Marijuana

It's so hard to believe anything that these guys say. I seem to remember them saying the same kind of thing in 2000. (And, their new chart certainly doesn't support that claim.) One thing that makes this a little more credible is that we're getting similar reports from other countries.

Program Treats Addicts in Health Care

Amazing what happens when you provide treatment in an adequate dose and intensity, and provide long term monitoring.

Family history and alcoholism

It appears that looking beyond parents is important in assessing familial risk for developing alcohol problems.

Obama and McCain on drug policy

Read it here. The 10 second version is that Obama has a decent sized list of predictable progressive pledges and McCain was an early champion of tobacco policy reform and has said little on drug policy recently. The article does look at McCain's positions that are indirectly related to drug policy.

Drug testing coming to Detroit high school

My gut reaction to this is very negative. Id be interested in visiting a school where this is already happening and hear about the impact, positive and negative.

Finney High School in Detroit received a federal grant Wednesday to start randomly testing some of its students for drug use as early as this fall.

Kanzoni Asabigi, the deputy director of substance abuse prevention at the Detroit Department of Health and Wellness Promotion, said the three-year pilot program could lead to random drug testing at all public high schools in Detroit.

It's also ironic that this pretty drastic action is being taken when, last I checked, underage drinking and drug use was a bigger problem in the suburbs.

A Genetic Clue to Quitting Smoking

An new direction for pharmacotherapy:

Reporting this week in the Archives of General Psychiatry, scientists describe for the first time a set of genes, about 100 in all, that seem to predict how well a smoker will respond to two different types of quitting programs — nicotine replacement or bupropion (Zyban). Nicotine-replacement methods, including the patch, pill and gum, work by weaning the smoker off nicotine gradually, usually over a period of weeks or months. Bupropion, on the other hand, is an antidepressant, which does not contain nicotine; instead, it works to curb nicotine cravings by interfering with the reward circuit in the brain, where addictions — to nicotine and other drugs, or behaviors — are reinforced. Nationally, about 70% to 80% of smokers say they want to quit, but any single attempt, regardless of the quitting method, is on average only 30% successful.

Society pays a high price for the bad choices of a few

This writer has an interesting take on the Insite controversy.

Some of his beliefs about addiction are deeply flawed:

I recognize, though, that the advantages of life are not universally shared. I recognize that some people have more choices than others. I recognize, too, that some people have stronger wills than others, and an instinct not to throw their lives down the drain.

I'm not aware that there are gangs, wielding syringes, roaming our streets and delivering the first fix that is said to begin addiction. I don't know what it is that forces thinking and aware people to become junkies if they don't have to.

I understand there may be some pre-existing medical condition that requires substances that are proscribed because there's nothing else available -- drugs that can make a partial life bearable.

But, he does make some interesting points:

I think it's commendable that our society tries to treat those who are addicted and get them off drugs, tries to prevent others from being hooked and tries to enforce laws that it deems appropriate to punish traffickers and those who commit other crimes to feed their self-destructive habit.

It's also commendable that society tries to reduce the collateral damage of addiction -- things like the spread of disease and the risk of harm, including death from overdose, to users.

This last bit is where Vancouver's Insite fits in. It's been an experiment with very modest results that are merely collateral to drug addiction and are measured in negatives. No one has died on the premises.

Based on the opinion of its supporters among medical practitioners and authorities and the less universal endorsement of police, there should be Insites in every city and town across Canada.

There aren't for two reasons: There are far greater medical priorities in the country, and our society is uncomfortable providing places for people to break the law and supplying professional backup to ensure they can do so safely.

...

Surely more is accomplished in treating addicts, trying to get them off the stuff and giving them a little hope than by idly standing by to "supervise" their self-destruction and then allowing them out to crawl in the filth again.

The idea that people have a constitutional entitlement to be rescued by the state while continuing to harm themselves, under the guise of the right to life, liberty and security of the person, surely is absurd. I hope a higher court declares it so.

This seems like someone who would be open to a both/and response if either side was offering one.

Fertilizer for your brain

This is a little creepy:

Drugs that encourage the growth of new neurons in the brain are now headed for clinical trials. The drugs, which have already shown success in alleviating symptoms of depression and boosting memory in animal models, are being developed by BrainCells, a San Diego-based start-up that screens drugs for their brain-growing power. The company hopes the compounds will provide an alternative to existing antidepressants and says they may also prove effective in treating cognitive disorders, such as Alzheimer's.

The Brain on (Lots of) Marijuana

An interesting finding:

Marijuana's effect on the brain is far from understood, but Australian research published Monday in the Archives of General Psychiatry suggests that very heavy long-term smoking might be associated with structural changes in two areas of the brain rich in receptors to the drug. The hippocampus, believed to regulate emotion and memory, and the amygdala, which plays a role in aggression and fear, were smaller—12 percent and 7 percent, respectively—in a group that smoked at least five joints daily for at least the past 10 years (and, on average, 20 years) when compared to a nonsmoking group.

Users also showed more signs of sub-threshold psychotic symptoms compared with those in the group that abstained. And on tests of memory and verbal ability, they performed more poorly. "Our findings suggest that everyone is vulnerable to potential changes in the brain, some memory problems, and psychiatric symptoms if they use heavily enough and for long enough," says lead author Murat Yucel of the ORYGEN Research Centre and Melbourne Neuropsychiatry Centre at the University of Melbourne.

With a caveat:

But it's way too early for parents to conclude that pot deteriorates the brain, cautions Scott Swartzwelder, professor of psychiatry and behavioral sciences at Duke University whose own research focuses on substance abuse and the adolescent brain. "Scientifically, it's a very limited set of data," he says. The study was tiny—it covered only 15 pot smokers and 16 abstainers—and looked at extreme behavior, so "I'm not sure how relevant it is to the general public," says Swartzwelder, who is coauthor of Just Say Know: Talking to Kids About Drugs and Alcohol and Buzzed: The Straight Facts About the Most Used and Abused Drugs From Alcohol to Ecstasy (an updated third edition is being released in August). [NOTE: A great book with dispassionate and reliable information.]

Aging doesn't stop drug use

From Scientific American:

Writing in the journal Neuropsychopharmacology, Gay­athri J. Dowling, Susan R. B. Weiss and Timothy P. Condon warn that many aging baby boomers, long accustomed to using illicit drugs for recreation and medicinals of all kinds for treating whatever ails them, will carry their love affair with drugs into old age. Medicine is only beginning to appreciate the consequences.

The baby boomers, the generation born between 1946 and 1964, make up 29 percent of the U.S. population today. By 2030 this “pig in the python” of the nation’s age-distribution profile will swell the number of people aged 65 and older to 71 million. The baby boomers, of course, became well known in the 1960s for their significantly higher use of illicit drugs than that of preceding generations. At one time, investigators were convinced that as people aged, they would “grow out of” the use of recreational drugs. There is little evidence that any such thing has taken place today.

Dowling and his colleagues cite hospital data that record the number of people aged 55 and older who sought emergency-room treatment and mentioned using various drugs. The number of cocaine mentions rose from 1,400 in 1995 to almost 5,000 in 2002, an increase of 240 percent. Similarly, mentions of heroin increased from 1,300 to 3,400 (160 percent), marijuana from 300 to 1,700 (467 percent) and amphetamine from 70 to 560 (700 percent).

Data from the National Survey on Drug Use and Health corroborate those trends. In 2002 some 2.7 percent of adults between 50 and 59 admitted to illicit drug use at least once in the preceding year. By 2005 that number had increased significantly, to 4.4 percent. The investigators attribute the rise to the aging baby boomers, as well as to enhanced longevity coupled with people’s tendency to retain their long-held patterns of drug use as they grow older. Those numbers will put substantial new strains on the medical system: by one estimate, the number of adults aged 50 and older treated for drug abuse will rise from 1.7 million in 2000 and 2001 to 4.4 million in 2020.

The article goes on to discuss differences in metabolism and dangers as one ages and continues to use drugs.

Drug policy freak show

A scathing criticism of the Canadian federal government's opposition to Insite.

Complete with serious flaws when reporting history...

A major factor in the court's thinking was the widespread belief at the time that addiction could be cured easily thanks to a marvelous treatment invented by Charles B. Towns, a failed stockbroker. Unfortunately, it was realized not long after the ruling that Towns was a quack. But by then, it was too late. All maintenance programs had been shut down and the drug problems we are now so familiar with -- black markets, violence, disease -- sprouted in American cities.

...and idealized reporting of drug policy and other countries...

I've seen it at work in the Netherlands. Imagine healthy heroin addicts. With jobs. And apartments. And families. Addicts who are not a blight on the community. It's all thanks to an array of harm reduction programs which this country is too timid to even try.
...
In the United Kingdom, by contrast, maintenance remained the central policy for another 45 years. In all that time, the underworld drug scene scarcely existed.

...and insults for those the writer disagrees with...

The government's handling of drug policy is so ignorant and foolish it is a challenge to explain why in a newspaper column. To expound on stupidity of this magnitude requires a very long book.

I thought for some time about whether to post anything about this column. It's so hostile to those who disagree and it is dripping with what Anne Lamott once called "excessive certitude". I didn't want to give it any attention, but it exemplifies two things that I'd like to draw attention to. First, as I've written before, there is no problem-free drug policy. Any drug policy will have problems, probably serious problems. The important questions are:

• Which problems are we most unwilling to live with?
  
• Which problems are we most willing to tolerate?
• What strategies will help us achieve these goals while maintaining concern for all problems?

Of course, of equal importance is our willingness to regularly re-assess policy to improve our response and address unanticipated problems.

The second point I wanted to make is that drug policy dicussion has devolved in a way that is similar to American political discourse. In his book, The Way to Win, Mark Halperin describes the phenomena of the political "freak show" where media is shining the spotlight on the extreme poles of political thought. These voices get more attention and often eventually intensify their rhetoric to keep the spotlight on them. These voices get framed as "the debate" when most people are somewhere in the middle or adopt positions that are not represented at all. Discourse gets uglier and uglier, and the voices on the poles intensify their rhetoric (often getting increasingly intellectually lazy and/or dishonest) while everyone else withdraws.

I see something similar happening in drug policy debates. There is a lot that reasonable people can disagree about. Where we have disagreements, we should disagree and disagree vigorously. But, we should try to keep in mind that all of us come into these discussions with our own priorities and values. We should be willing to identify our own priorities and values and be willing to listen to those of other people. There's a strong public health case for Insite and other HR programs--and that abstinence-oriented providers were not responsive enough to the needs of pre-contemplative addicts and public health concerns. There's a strong libertarian case for treating drug use as a matter of personal liberty--and that we should all be troubled by incarceration rates and that we should be thoughtful and cautious in the use of coercion to get people into treatment. There is also strong case that drug policy is too often focused on the needs of people other than the addict and is too often based on beliefs that addicts don't want help, can't get well, and are of questionable character. All of these positions offer important perspectives, but none of them capture the whole picture.

The range of what we think and do is limited by what we fail to notice. And because we fail to notice that we fail to notice, there is little we can do to change, until we notice how failing to notice shapes our thoughts and deeds.

Ronald Laing

Alcoholics Anonymous and Narcotics Anonymous benefit adolescents who attend

Recently, some questions have been raised about the appropriateness of 12 step facilitation with adolescents. It's been suggested that it's an ineffective strategy and, worse, that it's harmful to adolescents.

First, let me address the use of 12 step facilitation with adolescents at Dawn Farm. First, we only employ 12 step facilitation with clients who meet diagnostic criteria for dependence and can be characterized as having chronic, high severity problems with alcohol and other drugs. There is some history of treatment providers indiscriminately employing 12 step facilitation with every client who walks through their doors. Second, Washtenaw county is fortunate to have a large, vibrant, and welcoming community of young people in 12 step recovery. It may be harmful to refer a 16 year old to 12 step groups in communities where they will be the youngest person in the room by 10 to 20 years. Thirdly, are treatment strategies are not limited to 12 step facilitation. We work with clients to identify other strategies and communities to support their recovery.

It just so happens that an upcoming issue of the journal Alcoholism: Clinical and Experimental Research has a study on the subject. Here's an excerpt from a press release:

“AA and NA are explicitly focused on abstinence and addiction recovery, they are widely available across most communities, they provide entry to a social network of recovery-specific support and sober events that can be accessed ‘on demand’ – particularly at times of high-relapse risk such as evenings and weekends, the services are free, and AA/NA can be attended as intensively, and for as long, as individuals desire,” he said.

However, he added, despite growing evidence that adults benefit from AA and NA, little is known about how these abstinence-focused organizations help youth, and what is known lacks scientific rigor.

“This knowledge gap is particularly noteworthy given that adolescents and young adults face more barriers to AA and NA than older adults and yet appear to be referred there just as frequently by treatment providers,” said Kelly. “Youth tend to have less severe addiction problems, on average, and consequently do not feel a strong need to stop using alcohol and/or drugs. ‘Why should they bother to go to abstinence-oriented organizations like AA and NA, and would they benefit even if they did go?’” These are the questions Kelly and his colleagues wanted to address.

The researchers recruited 160 adolescent inpatients (96 males, 64 females), with an average age of 16 years, who were enrolled at two treatment centers in California having a focus on abstinence and based on a 12-step model. The study participants’ length of stay ranged from four to six weeks, after which they were re-assessed on a number of clinical variables at six months, and one, two, four, six, and eight years.

“We found that most of the youth attended at least some AA/NA meetings post-treatment,” said Kelly. “Those patients with severe addiction problems and those who believed they could not use alcohol/drugs in moderation attended the most. The NA and AA focus on abstinence/recovery probably resonates better with these more severely dependent individuals who also typically need ongoing support.”

Even though many of the youth discontinued AA/NA after time, they nonetheless appeared to benefit from attendance.

“We found that patients who attended more AA and/or NA meetings in the first six months post-treatment had better longer term outcomes, but this early participation effect did not last forever – it weakened over time,” said Kelly. “The best outcomes achieved into young adulthood were for those patients who continued to go to AA and/or NA. In terms of a real-world recovery metric, we found that for each AA/NA meeting that a youth attended they gained a subsequent two days of abstinence, independent of all other factors that were also associated with a better outcome.”

A little can go a long way, he added. “During the first six months post-treatment,” said Kelly, “even small amounts of AA/NA participation – such as once per week – was associated with improved outcome, and three meetings per week was associated with complete abstinence. This suggests youth may not need to attend as frequently as every day, sometimes recommended clinically, to achieve very good outcomes.”

Kelly believes that part of the reason for the success of AA/NA among adolescents who attend meetings is related to their developmental needs.

“Given the need for social affiliation and peer-group acceptance outside of the family at this stage of life, peers can exert strong influence on the behavior of young people,” he noted. “When you couple this fact with the reality that most adolescents and young adults are experimenting with, or heavily using, alcohol and other drugs, it may be hard to find suitable peer contexts that can facilitate recovery. In fact, we know that most youth relapses are connected with social contexts where alcohol/drugs are present; unlike adults, youth rarely relapse alone. So, organizations such as AA/NA may provide support, and encourage and provide alternatively rewarding sober social activities.”

The article will be published in the August issue.

When hope is lost

Uncritical reporting of a Canadian heroin maintenance trial:

Though the formal results are not yet available, the program's anecdotal results suggest that the prescribed opiate treatment has helped some addicts improve their lives. "I think that what we can see from the experience over the past few years is that the treatment appears to be very safe," Schechter said. "And we can see that one of the things we consider, which is the retention rate or how well people stay in treatment is very high -- it's been 85 percent at one year."

The research team has heard stories about women who no longer turned to prostitution for drug money, Schneiderman said. Some participants said they had stopped committing crimes in order to buy heroin, and others had found employment. "I know that Dr. Schechter has told stories of people who have thanked him and said.

"This is the first time that I've gotten up in the morning and the first thing that I didn't think about was where I was going to get my next fix,"' she said. The study provided a reminder that for addicts, that next fix is the focus of their entire day, she said; when that need is removed, they have time to focus on other ones, like employment, housing or relationships.

Prescribing heroin to addicts is not a new idea. Several prescribed morphine and heroin clinics ran in the United States from 1919 until 1923, when the government shut them down. The UK has been prescribing injectable heroin and methadone to opiate addicts for decades now, though evaluation of the programs is limited. And in 1972, an inquiry commission in Canada recommended a heroin prescription trial for addicts who hadn't been helped by conventional treatments.

A decade-old Swiss study of 1,000 long-term opiate addicts had a 69% retention rate, with no deaths and more than half of those who dropped out entering other treatment programs. The participants showed improvements in physical health and social indicators, their rate of arrests and illegal income generation went down substantially, and their rate of employment doubled over the 18-month period of the study. Another trial that began in the Netherlands in 1998 targeted people in methadone maintenance therapy -- widely available in that country -- who were still using illicit drugs, and the researchers saw improvements in the participants' physical and mental health, drug use and social indicators.

Jim B. often refers to an old N.A. poster that said "The lie is exposed. We can recover." This is what happens when the lie goes unchallenged, we start providing palliative care for a treatable condition.

Effectiveness of antidepressants

More troubling analysis of antidepressant studies:

Antidepressants, in particular newer agents, are among the most widely prescribed medications worldwide with annual sales of billions of dollars. The introduction of these agents in the market has passed through seemingly strict regulatory control. Over a thousand randomized trials have been conducted with antidepressants. Statistically significant benefits have been repeatedly demonstrated and the medical literature is flooded with several hundreds of "positive" trials (both pre-approval and post-approval). However, two recent meta-analyses question this picture. The first meta-analysis used data that were submitted to FDA for the approval of 12 antidepressant drugs. While only half of these trials had formally significant effectiveness, published reports almost ubiquitously claimed significant results. "Negative" trials were either left unpublished or were distorted to present "positive" results. The average benefit of these drugs based on the FDA data was of small magnitude, while the published literature suggested larger benefits. A second meta-analysis using also FDA-submitted data examined the relationship between treatment effect and baseline severity of depression. Drug-placebo differences increased with increasing baseline severity and the difference became large enough to be clinically important only in the very small minority of patient populations with
severe major depression. In severe major depression, antidepressants did not become more effective, simply placebo lost effectiveness. These data suggest that antidepressants may be less effective than their wide marketing suggests. Short-term benefits are small and long-term balance of benefits and harms is understudied. I discuss how the use of many small randomized trials with clinically non-relevant outcomes, improper interpretation of statistical significance, manipulated study design, biased selection of study populations, short follow-up, and selective and distorted reporting of results has built and nourished a seemingly evidence-based myth on antidepressant effectiveness and how higher evidence standards, with very large long-term trials and careful prospective meta-analyses of individual-level data may reach closer to the truth and clinically useful evidence.

Harm Reduction, Treatment, and Recovery in Scotland

Scotland may be on the verge of a very bold and exciting overhaul of their treatment system.

They have depended almost exclusively upon methadone maintenance. The majority of their clients have been expressed a preference for abstinence oriented treatment and they are poised to move toward a recovery oriented treatment system.

I had been thinking of this as an example of the failure of harm reduction as treatment. Not to say that there is not a place for harm reduction, rather to say that it is a poor substitute for treatment.

I had also been thinking about it as an example of the limitations of responding to addiction as a public health problem. A lot of treatment advocates argue that addiction should be treated as a public health problem instead of as a criminal problem, but I often feel I alone shudder at the idea. I tend to think of public health as advocating community (or, public) welfare even if it means that some individuals will suffer. I fear that addicts will too often end up on the losing side of this accounting exercise.

Interestingly, I was listening this morning to a lecture by Neil McKeganey. His observations suggest that some of the failures could be laid at the feet of harm reduction and public health, but his emphasis was on this as a failure of treatment-oriented treatment. He argues that the focus of services in Scotland has been to get people in treatment and keep people in treatment to the exclusion of helping people get well. The treatment system's belief was that the system was succeeding as long as people were continuing to take their methadone. The result was that people entered the system and never exited. The patient never achieved their goals, but the system gave itself a pat on the back for achieving its goals.

This raises one of the biggest dangers of framing addiction as a chronic disease. I suspect that this tension between recovery and addiction as a chronic illness is something that can't be resolved. The result is that we'll have to find a way to live on the slippery slope and be vigilant that we don't allow ourselves to slide in one direction or the other.

UPDATE: About my cringing at calls for a "public health" approach. I just fear approaches that put community welfare ahead of individual welfare. Here's a description of public health:

Most definitions share the premise that the subject of public health is the health of populations—rather than the health of individuals—and that this goal is reached by a generally high level of health throughout society, rather than the best possible health for a few. The field of public health is concerned with health promotion and disease prevention throughout society. Consequently, public health is less interested in clinical interactions between health care professionals and patients, and more interested in devising broad strategies to prevent, or ameliorate, injury, and disease.

I'm not sure what term I'd rather see people use instead. I'm reluctant to say we should call it a "medical problem" because I support addiction treatment as a specialty or categorically separate field. I'm not crazy about "behavioral health", but maybe that's the least bad option.

We should stop treating addiction as a criminal problem and start treating it as a behavioral health problem!

I'm not feeling it.

Explosive Increase in (Dutch) Cannabis Addiction

I won't speculate on what this means, but it will be an interesting subject to watch.

Court rules in favor of injection site

A Canadian court ruled that the Canadian goverment's prohibition of injection centers is unconstitutional.

There has been a great deal of passion and energy spent on both sides; the Feds trying to shut down the injection site, and the local goverment and researchers defending it. It would be nice to see everyone involved put a little of that energy into trying to help these addicts recover.

Hangover Time

From The New Yorker:

Hangovers also have an emotional component. Kingsley Amis, who was, in his own words, one of the foremost drunks of his time, and who wrote three books on drinking, described this phenomenon as "the metaphysical hangover": "When that ineffable compound of depression, sadness (these two are not the same), anxiety, self-hatred, sense of failure and fear for the future begins to steal over you, start telling yourself that what you have is a hangover. . . . You have not suffered a minor brain lesion, you are not all that bad at your job, your family and friends are not leagued in a conspiracy of barely maintained silence about what a shit you are, you have not come at last to see life as it really is." Some people are unable to convince themselves of this. Amis described the opening of Kafka's "Metamorphosis," with the hero discovering that he has been changed into a bug, as the best literary representation of a hangover.

[via Jim]

Different Roads

A commentary advocating for abstinence oriented treatment in England. It also bristles that the characterization of addition as a chronic illness appears set up arguments for drug maintenance and endless treatment.

I suppose context is important. We've (the U.S.) been operating in an environment where treatment has been getting increasingly less intense and shorter. While in the U.K., MMT has been the dominant response to opiate addiction.

Strong words:

There is an old saying about addiction treatment – ‘if you want drugs, go to treatment services; if you want to stop drugs, go nowhere near drug services’.

...

If you have workers in a system that is predicated on a belief of crime reduction and chronic disease management, the self-fulfilling pessimism permeates the client and the worker and generates limited goals.

The Spirituality of Recovery

NPR's Speaking of Faith has dedicated an episode to the spirituality of recovery. Susan Cheever talks about the spirituality of AA, her recovery, and her father's recovery.

The episode also devotes significant time to Buddhism and the 12 steps. They link to the Buddhist Recovery Network. Interestingly, Alan Marlatt is on their board.

Nothing scientific here, good for anyone who thinks AA is a Christian program.

It's worth a listen.

Methadone

The same reader on the days when methadone was one element of some comprehensive bio-psycho-social treatment programs:

The hospital where I trained had one of the original methadone pilot programs. They rounded up a bunch of addicts, provided counseling, educational assistance, housing assistance, employment assistance, health care, peer suppport and peer counselors, and oh yeah, methadone. Guess what, some of the "incurable sociopaths" got better, got jobs, rejoined their families, etc., so the methadone program seemed to be working. So they took away the counseling, educational assistance, housing assistance, employment assistance, health care, peer suppport and peer counselors, and left the clients with - methadone. Funny thing, it didn't seem to work as well any more.

This, of course, beg the queston of what is the effective ingredient. I'm guessing that this was also not a maintenance program. Of course the next part of the story is that, when these clients started doing poorly, rather than re-implement all the other services, they decided that all of them needed to be on methadone longer--maybe forever. Then, when they still did poorly, they decided that they needed to be on higher doses, and then ultra high doses. (The slide above is from this presentation.)

More on "the most dangerous place"

A reader response to my previous post:

That study was done in 2000. There are certainly major problems remaining with the ability of health care providers to recognize and provide appropriate referrals and/or treatment for addiction and addiction-related problems - but this is way improved since 2000. Assessment tools designed for medical offices, ER's and clincs are attaining wider use and "brief interventions" have been documented as effective in reducing AOD-related problems and are being taught to front-line health care providers. When I went to nursing school 35 years ago I was taught that cocaine was not addictive, that AA was a nice bandaid for alcoholics but only psychotherapy could "cure" alcoholism and alcoholics rarely wanted to be "cured;" and heroin addicts were untreatable sociopaths. When I floated to the "private" wards of the hospital I worked at and encountered patients experiencing impending DT's, I was often screamed at by their personal physicians for suggesting that their Very Important Patient might be an alcoholic (and then the physician would prescribe detox-level doses of ATC librium, magnesium sulfate and thiamine injections to "calm his nerves.") The nurses and doctors I encounter these days are way better educated and equipped. There is much progress in this area, and while more progress is needed I would hope that people would not be discouraged from seeking help and support from health care providers, in cooperation with whatever other help and support they need to recover, and that if their health care provider is not competent to provide appropriate support that they find one who is.

the "most dangerous place" for an alcoholic to seek help

The CEO of Betty Ford says it's your doctor's office:

An expert on alcoholism and addiction, Dr. Garrett O'Connor struggled for years with an alcohol problem of his own. He saw several doctors during that period but "the only person who ever said I might have a problem," he notes, "was my dentist." During some routine dental work "all my teeth fell out. I was going to sue [the dentist], until he pointed out my liver was deficient, not his skills." O'Connor claims his experience is far from unusual; many family doctors are still unequipped, he claims, to help patients with addiction.

There was a study done at Columbia University where they surveyed primary care physicians and found that 94 per cent were unable to diagnose addiction. They were diagnosing high blood pressure or depression. They were seeing only the symptoms of addiction, and not the disease itself. Sometimes, the most dangerous place for an addict or alcoholic to be looking for treatment is in a doctor’s office. It’s a terrible tragedy.

...alcohol is the great imitator of all diseases, because it goes to every cell in the body and can be present as a neurological disorder, a gastrointestinal one, a cardiac disorder, high blood pressure, a skin disorder, an eating disorder and as the whole raft of psychiatric disorders, including depression and bipolar disorder.

Hazy screens: Is Hollywood pushing marijuana?

Hazy screens: Is Hollywood pushing marijuana?:

There seem to be movies that are produced by a younger generation than the baby boomers, [by people] who seem to have had a lot of experience with marijuana,' says Jacob Sullum, senior editor at Reason magazine and author of 'Saying Yes: In Defense of Drug Use.'

Tom Hedrick, spokesperson for Partnership for a Drug Free America, says he worries that the uptick in such depictions makes the behavior appear too normal, creating bad role models.
...
"I think movies have a weird line to walk," says Wesley Morris, a film critic at The Boston Globe. "They derive a lot of entertainment from drug use and yet, at the same time, they go only so far in endorsing it. 'Harold and Kumar' … doesn't have anything to say negatively about drug use, but, at the same time, there is a stigma attached." In "Knocked Up," a lead character has to stop smoking marijuana because it gets in the way of him becoming a good father.
...
Legalization advocates argue that signs of societal tolerance, including decriminalization of possession of small amounts of marijuana, hint that casual pot use is widespread – something filmmakers are increasingly less afraid to portray.
...
But antidrug campaigners say it's time for Hollywood to tighten up.

"Is this the beginning of a major new reflection and glamorization in popular culture?" asks Hedrick. "I think it's too early to tell, but it worries us because it tends to portend, potentially, a return to attitudes that lead to more kids trying, and more kids using."

About 39% Of IDUs Living In Spain Are HIV-Positive, IHRA Report Says

Wow. Harm reduction isn't enough. Many of these people can become citizens who are great parents, business owners, neighbors, and contribute to every aspect of community life in meaningful ways.

Help keep them from contracting diseases, but that's no substitute for getting them well.

Obama on Medical Marijuana

Jacob Sullum compiles Obama's statements on medical marijuana,

More from Pat Deegan

When Help is Not Helpful

Help, and in particular toxic help, is not a topic that is discussed often in professional rehabilitation cultures. The nature of help is one of those topics about which we are often silent because we are too busy being helpful to stop to talk about it. But we must break that taboo. We must dare to talk about help because power, including the power to oppress, often disguises itself as help. Power-disguised-as-help is used to silence disabled people. Paolo Freire (1989) says that oppressive power submerges the consciousness of the oppressed into a culture of silence. Toxic help oppresses and silences people with disabilities.

Help isn't help if it's not helpful. Help that is not helpful can actually do harm. Being helpful requires that professionals ask us what we need. But asking is never enough. Professionals must also listen to what we say. In this way help becomes something that is co-created between the disabled person and the professional. When help is co-created as an explicit agreement between the professional and the individual, then silencing is avoided.

In my opinion, one of the best methods for amplifying the voice and values of those of us who are disabled is the shared decision making process. In this process, the clinician and service user come to agreement on *what the service need is, what the course of rehabilitation will be, what the desired outcomes of services are and what the respective responsibilities of each party will be in achieving those outcomes. It seems to me that the shared decision process is more than a method. It is an ethical obligation that makes explicit the power of the professional and brings it into alignment with the voice and directives of the disabled person.

Micro-Aggressions

[note: "Mentalism refers to the oppression of people who have been diagnosed with psychiatric disorders."]

Peer practitioners may encounter mentalism in all its forms when on the job. In its most obvious form, mentalism is a macro-aggression. A macro-aggression is obvious and easily identified by all who witness it as unfair, biased and/or discriminatory. An example of a mentalist macro-aggression is an emergency room automatically placing people with psychiatric diagnoses in restraints while waiting to be seen by a physician or having only clients (not staff) go through a metal detector at a local mental health center.

Another form that mentalism can take is called micro-aggression. Micro-aggressions are more subtle, not as obvious and therefore are harder to point out or confront. Mentalist micro-aggressions occur frequently and have a tendency to wear us down over time. Micro-aggressions tend to be “invisible” and we often experience the cumulative effect of them as tension between ourselves....

Most peer practitioners will encounter micro-aggressions on the job. How should staff handle these types of experiences and still remain within the role of the peer practitioner? The answer is that first peer practitioners must be able to identify micro-aggression when it happens. This requires consciousness raising and a supportive group of peer practitioners who can help us name mentalism when it is happening. Secondly, peer practitioners must support and validate for each other, the reality of mentalist micro-aggression when it is reported by a co-worker. Third, peer practitioners must learn to strategically respond to those people or policies that are oppressive, whether it was intentional or not.

Healing Relationships

Relationships are the cornerstone of the recovery process for most people. Relationships that are marked by kindness and compassion can heal. ... In a culture steeped in the belief that there is a “pill for every ill”, it can be important to remind ourselves of the healing power of human relationships.

The people I have interviewed mention certain important characteristics of people who were experienced as helpful in their recovery. Many said the helpful person showed fortitude, patience and love. For instance, John said:

“Relationships helped me. Patience. Sticking by you regardless. Like my wife. Sticking by you through thick and thin. Constant support. Constant encouragement from the outside. That's what I think a person needs the most. And love.”

Fidelity, patience and fortitude are evident when the helpful person is present during the most difficult of times and does not simply come around when recovery seems promising. People who are experienced as helpful are able to hold the relationship during times when the other does not reciprocate affection and care. This holding of love and relationship, even during the most barren and anguished winter of recovery, requires compassion. The word compassion comes from the Latin passio, to suffer and com, to be with. To be compassionate is to suffer with the person in distress. To be compassionate is a way of being with the other without an agenda to change them, to relieve their suffering or to suffer for them. Through compassion we can reach out to the other even when they refuse to reach back. With compassion we see the person, not the diagnosis or disorder....

Another characteristic of people who are helpful to the recovery process is that they believe in the person in distress, even when that person does not believe in themselves. Believing in the other is not expressed in optimistic rhetoric such as, “I just know that in time you will do better.” Shallow optimism ignores the challenges and difficulties that the person in distress faces. Optimism may help us feel better, but it leaves the other alone and distanced. Believing in someone, on the other hand, takes the form of a fundamental affirmation of that person's goodness. It is a hopeful stance that admits the the future is uncertain and ambiguous while simultaneously expressing a willingness to walk together into that unknown future....

People who are helpful to the recovery process are able to convey feelings and are experienced as being very human. No one reported that professional distance and demeanor were helpful. Instead, our own humanity is the bridge that connects us to people in distress. Sometimes humor can form a connection of warmth, joy and affection....

Relationship includes the idea of mutuality and reciprocity. This can be very healing for people who have been in the patient or client role for a long time. That is, being socialized into the role of a “good” mental patient often means learning to become preoccupied with matters pertaining to “me”. Socialization into self-preoccupation starts in the hospital where each day begins with a nurse asking you if your bowels are moving, if you slept that night, etc. Socialization into me-ness proceeds on through the years as each and every casemanager, therapist, residential worker or vocational rehabilitation counselor asks, “How are you doing?” Unlike normal social discourse in which 'how are you doing' acts as a perfunctory greeting, mental health discourse requires the client to take the question seriously and to answer by revealing more about “me”. In addition, in most mental health settings, clients are not encouraged to help each other or anyone else. In this sense, the currently popular term “consumer” seems apt. It conjures the image of a large mouth consuming and consuming without a hint that it would be possible to contribute something back.

Socialization into me-ness, self-preoccupation and being a consumer means that many people are denied the opportunity to discover they have something to offer to other people. This iatrogenic wounding is another reason relationships can be so healing. It is healing to learn that one needs and is needed, cares and is cared for, and can receive as well as give.

Recovery and the Conspiracy of Hope

I think Pat Deegan does a great job describing the cycle of despair in settings that don't facilitate or witness recovery. I think this translates very well to addiction treatment providers. What it misses is those who step in after hope is abandoned and ennoblize the suffering of patients--"accepting them as they are", but never accepting them for what they can become.

From Recovery and the Conspiracy of Hope:

From the outside it appears that the person just isn’t trying anymore. Very frequently people who show up at clubhouses and other rehabilitation programs are partially or totally immersed in this despair and anguish. On good days we may show up at program sites but that’s about all. We sit on the couch and smoke and drink coffee. A lot of times we don’t bother showing up at programs at all. From the outside we may appear to be among the living dead. We appear to be apathetic, listless, lifeless. As professionals, friends and relatives we may think that these people are “full of excuses”, they don’t seem to try anymore, they appear to be consistently inconsistent, and it appears that the only thing they are motivated toward is apathy. At times these people seem to fly into wishful fantasies about magically turning their lives around. But these seem to us to be only fantasies, a momentary refuge from chronic boredom. When the fantasy collapses like a worn balloon, nothing has changed because no real action has been taken. Apathy returns and the cycle of anguish continues.

Staff, family and friends have very strong reactions to the person lost in the winter of anguish and apathy. From the outside it can be difficult to truly believe that there really is a person over there. Faced with a person who truly seems not to care we may be prompted to ask the question that Oliver Sacks (1970, p. 113) raises: “Do you think William (he) has a soul? Or has he been pithed, scooped-out, de-souled, by disease?” I put this question to each of us here today. Can the person inside become a disease? Can schizophrenia pith or scoop-out the person so that nothing is left but the disease? Each of us must meet the challenge of answering this question for ourselves. In answering this question, the stakes are very high. Our own personhood, our own humanity is on the line in answering this question.

...

However, when faced with a person lost in anguish and apathy, there are a number of more common responses than finding a way to establish an I-Thou relationship. A frequent response is what I call the “frenzied savior response”. We have all felt like this at one time or another in our work. The frenzied savior response goes like this : The more listless and apathetic the person gets, the more frenetically active we become. The more they withdraw, the more we intrude. The more willless they become, the more willful we become. The more they give up, the harder we try. The more despairing they become, the more we indulge in shallow optimism. The more treatment plans they abort, the more plans we make for them. Needless to say we soon find ourselves burnt out and exhausted. Then our anger sets in

...

Our anger sets in when our best and finest expectations have been thoroughly thwarted by the person lost in anguish and apathy. We feel used and thoroughly unhelpful. We are angry. Our identities as helping people are truly put to the test by people lost in the winter of anguish and indifference. At this time it is not uncommon for most of us to begin to blame the person with the psychiatric disability at this point. We say things like : “They are lazy. They are hopeless. They are not sick, they are just manipulating. They are chronic. They need to suffer the natural consequences of their actions. They like living this way. They are not mad, they are bad. The problem is not with the help we are offering, the problem is that they can’t be helped. They don’t want help. They should be thrown out of this program so they can 'hit bottom'. Then they will finally wake up and accept the good help we have been offering.”

During this period of anger and blaming a most interesting thing happens. We begin to behave just like the person we have been trying so hard to save. Frequently at this point staff simply give up. We enter into our own despair and anguish. Our own personhood begins to atrophy. We too give up. We stop trying. It hurts too much to keep trying to help the person who seems to not want help. It hurts too much to keep trying to help and failing. It hurts too much to keep caring about them when they can’t even seem to care about themselves. At this point we collapse into our own winter of anguish and a coldness settles into our hearts.

We are no better at living in despair than are people with psychiatric disabilities. We cannot tolerate it so we give up too. Some of us give up by simply quitting our jobs. We reason that high tech computers do as they are told and, besides, the pay is better. Others of us decide not to quit, but rather we grow callous and hard of heart. We approach our jobs like the man in the Dunkin Donuts commercial: “It’s time to make the donuts, it’s time to make the donuts”. Still others of us become chronically cynical. We float along at work like pieces of dead wood floating on the sea, watching administrators come and go like the weather; taking secret delight in watching one more mental health initiative go down the tubes; and doing nothing to help change the system in a constructive way. These are all ways of giving up. In all these ways we live out our own despair.

Additionally entire programs, service delivery systems and treatment models can get caught up in this despair and anguish as well. These systems begin to behave just like the person with a psychiatric disability who has given up hope. A system that has given up hope spends more time screening out program participants than inviting them in. Entry criteria become rigid and inflexible. If you read between the lines of the entry criteria to such programs they basically state: If you are having problems come back when they are fixed and we will be glad to help you. Service systems that have given up hope attempt to cope with despair and hopelessness by distancing and isolating the very people they are supposed to be serving. Just listen to the language we use: In such mental health systems we have “gatekeepers” whose job it is to "screen" and “divert” service users. In fact, we actually use the language of war in our work. For instance we talk about sending “front-line staff” into the “field” to develop treatment “strategies” for “target populations”.

Is there another alternative? Must we respond to the anguish and apathy of people with psychiatric disability with our own anguish and apathy? I think there is an alternative. The alternative to despair is hope. The alternative to apathy is care. Creating hope filled, care filled environments that nurture and invite growth and recovery is the alternative.

Remember the sea rose? During the cold of winter when all the world was frozen and there was no sign of spring, that seed just waited in the darkness. It just waited. It waited for the soil to thaw. It waited for the rains to come. When the earth was splintered with ice, that sea rose could not begin to grow. The environment around the sea rose had to change before that new life could emerge and come into being.

People with psychiatric disabilities are waiting just like that sea rose waited. We are waiting for our environments to change so that the person within us can emerge and grow.

Those of us who have given up are not to be abandoned as “hopeless cases”. The truth is that at some point every single person who has been diagnosed with a mental illness passes through this time of anguish and apathy, even if only for a short while. Remember that giving up is a solution. Giving up is a way of surviving in environments which are desolate, oppressive places and which fail to nurture and support us. The task that faces us is to move from just surviving, to recovering. But in order to do this, the environments in which we are spending our time must change. I use the word environment to include, not just the physical environment, but also the human interactive environment that we call relationship.

From this perspective, rather than seeing us as unmotivated, apathetic, or hopeless cases, we can be understood as people who are waiting. We never know for sure but perhaps, just perhaps, there is a new life within a person just waiting to take root if a secure and nurturing soil is provided. This is the alternative to despair. This is the hopeful stance. Marie Balter expressed this hope when asked, “Do you think that everybody can get better?” she responded: “It’s not up to us to decide if they can or can’t. Just give everybody the chance to get better and then let them go at their own pace. And we have to be positive - supporting their desire to live better and not always insisting on their productivity as a measure of their success”. (Balter 1987, p.153).

So it is not our job to pass judgment on who will and will not recover from mental illness and the spirit breaking effects of poverty, stigma, dehumanization, degradation and learned helplessness. Rather, our job is to participate in a conspiracy of hope. It is our job to form a community of hope which surrounds people with psychiatric disabilities. It is our job to create rehabilitation environments that are charged with opportunities for self-improvement. It is our job to nurture our staff in their special vocations of hope. It is our job to ask people with psychiatric disabilities what it is they want and need in order to grow and then to provide them with good soil in which a new life can secure its roots and grow. And then, finally, it is our job to wait patiently, to sit with, to watch with wonder, and to witness with reverence the unfolding of another person’s life.

Mad Pride: Mental illness and recovery

The NY Times has an article on anti-stigma efforts by mentally ill people.

This caught my attention in relation to all of the attention that harm reduction has been getting recently. There has also been a mental illness consumer advocacy movement demanding a recovery orientation in mental health services. This movement emerged in response to psychiatry's harmfully low expectations for people with serious mental illness.

I see a parallel.

The business of treatment

Apparently there has been some turmoil at Hazelden over a new CEO's modernization of their business practices. It doesn't offer much detail, but here's a little history:

It started in 1949 in a farmhouse where men followed a recovery program based on the Twelve Steps of Alcoholics Anonymous. Teams of psychologists, chaplains and clinicians developed an approach that was copied worldwide.

But by the time Jerry Spicer became chief executive in 1992, managed-care companies had decided they didn't like what had become known as the Minnesota Model, with its costly, long-term inpatient approach. They preferred cheaper short stays and outpatient care. Hazelden felt the cost pressure. Hundreds of other centers closed or downsized.

An outsider moves in

A decade later, Spicer's successor, health care executive Nick Hilger, lasted one year. In 2002, Breyer was plucked from Hazelden's board and made president and chief executive.

She had been vice president for marketing at Ryan Companies, a commercial real estate developer. Breyer brought an outsider's corporate sensibilities to the insular treatment field. Hazelden inked a contract with Blue Cross and Blue Shield of Minnesota, which now brings in about 30 percent of Hazelden's patient revenue.

That Blue Cross contract opened the floodgates to insured patients but squeezed out those at the high and low end. Therapists and alums used to referring patients wouldn't always get their self-paying patients in the door. At the opposite end, charity care fell.

Still, it was hard to argue with the numbers: In 2007, Hazelden had operating revenues of $109.3 million and a record 10,754 patients. Donors gave a record $12 million.

Despite Hazelden's traditional devotion to abstinence-based treatment, Breyer approved use of new pharmaceuticals to treat addiction.

She won some fans. "People generally thought highly of Ellen," said Jill Wiedemann-West, Hazelden's senior vice president and chief operating officer of clinical and recovery services. "She brought a vision."

...

In 2006, Breyer brought in the Hay Group, New York consultants who grouped Hazelden's activities into three "strategic" businesses: treatment, publishing and the graduate school. Fundraising was a fourth important area.

"Trying to get your hands around that organization was like trying to sort stuff out of cotton candy," Hunsicker said. "Ellen, for good, better or worse, rolled up her sleeves and said I'm going to build some accountability."

That year, the National Association of Addiction Treatment Providers named Breyer Administrator of the Year.

By the next year, Hazelden executives began leaving.

General counsel Ivy Bernhardson became a Hennepin County judge. Carol Falkowski, director of research communications, is now director of chemical health at the Minnesota Department of Human Services. Both declined to be interviewed.

Chief Medical Officer Dr. Marvin Seppala left to head an in-home treatment program. Vying to return as Hazelden's chief executive, he declined to talk.

Mike Ranum, chief financial officer and chief administrative officer, joined an architectural firm in St. Paul. He did not return calls for comment. Nor did Tom Galligan, former market development chief.

All left, Breyer said, because of other opportunities. The departures "had very little, if anything, to do with me," she said.

Moyers, working on public policy, had become Hazelden's most recognizable public face. He also tried to leave last year but stayed after Hazelden funded a Center for Public Advocacy and put him in charge.

But to others, she represented a break from the Hazelden of old, where being in recovery was a credential as good as any fancy academic degree.

"The addiction field has been known for its warmth, its compassion, its affirmation," said Hunsicker. "Ellen brought with her a bit of an aloofness."

These are strange times in the field of addiction treatment. In the wake of the collapse of much of the addiction treatment system, many are seeing financial opportunity. Prometa, tv shows like Intervention and Celebrity Rehab, boutique treatment programs for the rich and famous, recovery coaches for hire, etc. There's a trade publication with cover stories like, "The King of Methadone" and "The Big Money Cometh". The magazine celebrates the business of addiction treatment, "high end" providers, and focuses one the scores of acquisitions that are creating some enormous companies with enormous profits.

It seems to be an era of entrepreneurship in addiction treatment and I find that pretty frightening.

The article didn't say much about what exactly is changing within Hazelden's culture. Smart business practices don't have to mean abandoning their mission, hopefully Hazelden will avoid some of the pitfalls that many other providers seem to be stepping in. Although, it's worth noting than many people think that Hazelden was one of the first providers to turn treatment and recovery into big business.

Science and Harm Reduction

I'm stepping into it here, but the rush of these articles (here and here are two examples) proclaiming Insite's empirical goodness (my word, not theirs) is getting on my nerves. The implication is that any critic is motivated by moral panic or some evangelistic impulse. (Many critics fit these characterizations. I'm bothered by them too.)

The first clue that something isn't quite kosher is this line, "A scientific review at the XVI International AIDS Conference in Toronto on August 15 became the scene of an emotional outpouring of support for Insite, Vancouver's supervised-injection site."

Let me be clear. I think that there can be a place for a program like Insite, especially in a city with HIV rates like Vancouver, but context matters.

"Success" depends on how one defines "success", doesn't it? Science supports the use of opioids to reduce pain in cancer patients. Is that an adequate response to cancer? We can create situaltions where the surgery is a success but the patient dies.

Many harm reduction advocates accuse critics of having a value-laden perspective on drug problems. I agree. I'm suggesting that values drive harm reduction activities as well. Public health has its values too. For example, it tends to focus on disease transmission, it tends to focus on communities rather than individuals, and can, at times, reduce decisions to an accounting exercise. One extreme example is medicalization of female circumcision.

I'd encourage all providers working with addicts to identify the values that drive their practices. We've done it, here.

So, Insite is fine with me, as long as it is used as a place to engage addicts and move them incrementally toward recovery. To do so, you have to have a lot of other pieces in place. I may be wrong, I'm 3000 miles away, but I get the sense that there is a lot more enthusiasm for harm reduction than for recovery.

These agruments might get put to rest if they tried a both/and approach.

Racial Inequity and Drug Arrests

A NY Times editorial on the insanity of the drug war and its disproportionate impact on communities of color.

Now, two new reports, by The Sentencing Project and Human Rights Watch, have turned a critical spotlight on law enforcement’s overwhelming focus on drug use in low-income urban areas. These reports show large disparities in the rate at which blacks and whites are arrested and imprisoned for drug offenses, despite roughly equal rates of illegal drug use.

Black men are nearly 12 times as likely to be imprisoned for drug convictions as adult white men, according to one haunting statistic cited by Human Rights Watch. Those who are not imprisoned are often arrested for possession of small quantities of drugs and later released — in some cases with a permanent stain on their records that can make it difficult to get a job or start a young person on a path to future arrests.

...

Between 1980 and 2003, drug arrests for African-Americans in the nation’s largest cities rose at three times the rate for whites, a disparity “not explained by corresponding changes in rates of drug use,” The Sentencing Project finds. In sum, a dubious anti-drug strategy spawned amid the deadly crack-related urban violence of the 1980s lives on, despite changed circumstances, the existence of cost-saving alternatives to prison for low-risk offenders or the distrust of the justice system sowed in minority communities.

Nationally, drug-related arrests continue to climb. In 2006, those arrests totaled 1.89 million, according to federal data, up from 1.85 million in 2005, and 581,000 in 1980. More than four-fifths of the arrests were for possession of banned drugs, rather than for their sale or manufacture. Underscoring law enforcement’s misguided priorities, fully 4 in 10 of all drug arrests were for marijuana possession.

One quibble. I do wish that these advocacy pieces would be consistent in distinguishing between arrests and incarceration. An arrest that results in a drug court, or a sentence to treatment and probation is very different that an arrest that results in a jail or prison sentence.

[hat tip: Matt Statman]

The American treatment system

A presentation from the Recovery Symposium I linked to the other day included this nugget.

Is Food Addictive?

From Slate:

As neuroscientists focus their attention on obesity, you can expect to see morestudies comparing food cravings to drug addiction. As these studies accumulate, you can expect to hear them cited in campaigns to regulate junk food.

Great Stuff

Here's a library of resources from the recent recovery conference in Philadelphia.

Of special note is this article: The Role of Clinical Supervision in Recovery-oriented Systems of Behavioral Health Care. It includes several references to Dawn Farm.

Powder cocaine comeback

This is certainly consistent with what I've been seeing in my intake interviews. I went years with very few mentions of recent powder cocaine use, but lately it's coming up every day.

Speedy Decline

A FEW years ago Pierce county, in Washington state, was in the grip of a methamphetamine epidemic. Toothless addicts roamed quiet rural roads, stealing everything that was not nailed down, ... “It was behind every bush,” she [the Sheriff] says.

The life cycle of the "meth epidemic" is an interesting story and I don't have my head wrapped around it yet, but the media's use of sensation and stigmatizing language has certainly colored attitudes and perceptions. The intro to this article makes it sounds like the film 28 Days Later.

I think that it's safe to conclude that there have been some successes in shortening the life cycle, but it's important to remember that drug use patterns are cyclical.

[via DailyDose.net]

Friend or foe? Drunk, the brain can’t tell

A new study exploring why people do risky things when they're drunk.

Housing First

There was an Op-Ed in today's USA Today advocating the housing first approach with "chronic public inebriates" (CPIs).

I have no objection to housing first is they continue to try to facilitate recovery. I'm uncomfortable with programs that place NO contingencies on the housing. I think there ought to be some expectation of at least minimal particiation in treatment or recovery support services. If a program opts not to place those contingencies on housing, they ought to at least continuously encourage use of those services/resources--looking for windows of opportunity. Housing is not enough.

The reason many programs seem to wince at this suggestion seems to be philosophical. They believe that addiction doesn't cause homelessness. Gentrification, racism, sexism, domestic violence, and other societal problems cause homelessness. That homelessness is not caused by individual factors, but community conditions. Therefore, to focus on their addiction is to blame the victim.

I also worry two other things. Financial considerations are important, but we shouldn't reduce these decisions to accounting exercises. We also need to be careful that these programs don't send messages to clients and the community that CPIs are hopeless and fan the flames of stigma.

Other posts on housing first here.