Spirituality and recovery

Martin Nicolaus notices a not yet published study on the impact of spiritual guidance as part of treatment. There was no impact. In fact, the group with spiritual guidance by certified spiritual directors had worse outcomes on measures of depression and anxiety, though a group receiving spiritual guidance from their counselor did just as well as the other groups.

What's especially interesting about this study is that Bill Miller, the lead author, is very friendly to spirituality as an tool for facilitating change. He seems stumped but isn't questioning the study itself.

There is reason for confidence in the findings of this study. Outcome variables were carefully measured by independent interviewers, fidelity of interventions was good, and 82% of all possible follow-up interviews were completed. The studies were powered to detect a medium between-group effect size that would be sufficiently large to be of clinical interest ([Cohen, 1988] and Miller and Manuel (in press) Miller, W. R., and Manuel, J. K. (in press). How large must a treatment effect be before it matters to practitioners? An estimation method and demonstration. Drug and Alcohol Review.Miller and Manuel (in press)). Null findings were replicated across two study designs, and the direction of differences was, in many cases, opposite to prediction. We thus found no evidence for a beneficial effect of this spiritual counseling approach during the acute phase of addiction treatment. Different and more intensive spiritual counseling might increase daily spiritual practices, spiritual experience, and meaning and thereby influence substance use outcomes. Given the magnitude of changes that occur in early recovery, however, we believe that a more promising approach is to focus on spiritual development after a period of stabilization in which other basic needs have been addressed. Within a long-term care perspective, spiritual direction may fit better in later recovery, with a goal of maintaining and broadening the initial gains of sobriety.

It would be interesting to see more research on spirituality and recovery. I'm inclined to believe that spirituality can be a useful therapeutic tool. If nothing else, for people when enter treatment with spiritual beliefs, it might be used to increase engagement and participation in treatment. It might also be used as a long term source of support for change. (We do value a holistic approach, right?)

Along the lines of a stage dependent model, as Miller suggests, Project SAFE reported that many of the African American women in the study initiated their recovery in 12 step groups and sustained their recovery in churches.

The study said nothing of the participants' predisposition to spirituality. That seems important to me.

Other questions that might be interesting include:

• What forms of spirituality are helpful or unhelpful? Some clearly emphasize a stronger internal locus of control while others emphasize an external locus of control.
  
• Can helpful elements of the helpful forms of spirituality be unbundled?
• What are the non-spiritual paths to those helpful elements?
• There is a persistent assumption that all clients will benefit from spirituality. Is this true? Are these some who might benefit, others who are unaffected and some whose treatment outcomes are harmed?
• Along the lines of Miller's thinking, to what degree are these responses stage dependent?
  

DF employees - let me know if you want a copy of the study.

More on Methadone

My recent post on methadone prompted several comments, some making really great points. I decided to post all of them so that they would not be missed. The last 4 comments are great, you can guess what I think of the first 2.

armme said...

Your still working on the idea that addiction is some spiritual malady. Your way of thinking is in the DARK AGES, my friend. Your idea of recovery will soon be a thing of the past. It will be like performing an Exorcism on mental illness...once thought to be the ONLY form of treatment, but now considered completely irrational.

Your still trying to stop drug use...when you should be focusing how to get the addict to live a better life. Your treating an illness of endorphin dysfunction by taking away the only thing that corrects that dysfunction with stability.

You can continue to offer people your "exorcism approach" or you can learn the science behind opiate addiction and realize stopping people from using drugs doesn't stop the disease.

Do you want to treat the disorder so these people can have a better life--or do you just want them to stop using drugs no matter HOW miserable they have to be to do so?

Sometimes, MANY TIMES, you can't have both. Not with opiate addiction.

Anonymous said...

"counseling", while possibly helpful to some who may need referrals to things like job training, childcare, housing options, etc, is NOT the answer to most hardcore addiction problems. Science has shown clearly that addiction is a brain disease, a disruption of the brain chemistry. That is not something you can repair with a few hours of talk therapy. If talk therapy (or meetings or group therapy) worked even fairly well for addiction, there would have been no need to come up with something else to treat it--but it didn't and doesn't. We don't treat ANY other legitimate disease this way. People with schizophrenia, bipolar disorder, clinical depression, etc--all brain chemistry disorders--may receive some therapy sessions but it is almost always in conjunction with MEDICATION, which does the actual work of repairing and restabilizing the brain. Why should addiction be treated differently--especially when it has been clearly shown that abstinence based treatment has an extremely low effectiveness rate for addicts and particularly for opiate addicts?

Anonymous said...

As a recovering IV addict for more than 35 years, I continue to be appalled by these guys who push needles, methadone maintenance, etc. with their well-meaning efforts to "help us." Thankfully, none of you were around when I got clean - only people who assured me that I could in fact get clean and live a happy life.

The expectation that people like me are largely unable to find lasting clean time undermines our chances - and makes the way for the "experiments" by psychiatrists and others - naltrexone, methadone (now at new and much high doses!), acamprosate - hell, the Chinese drill out our limbic system with a Makita.

The lie is exposed - we CAN recover.

Anonymous said...

I too am a recovering IV user. I had the experience of being on maintenance several times and also of doing 21 day methadone detoxes in California a few times. My experience when I was using was that every time the methadone kicked in, the urge for CRACK became overwhelming. My problem is that I am a drug addict who has an allergy to drugs. When I get drugs in my system I want more and more and more. There is not enough methadone in the world to make me happy, or to fix whats wrong with me. I could drink a ton of methadone and be close to death but still be crawling across the floor trying to find more drugs. It doesn't work for me. Recovery after many years of using and living the lifestyle was not easy, but it did get better, and the alternative was way worse. I am SO glad that I was introduced to a program of abstinence based recovery and that the system did not give up on me by relegating me to a methadone clinic for the rest of my life. I am also quite sure that my family, the courts and everyone else on the road is glad as well. Recovery has changed my life!

Anonymous said...

You are SPOT ON in describing the "study" practices of those who want the world to believe that methadone is a miracle. Thanks for stating it this way.

The belief that methadone maintenance has a higher success rate than abstinance-based treatments is another huge lie these people use. They want to compare the people taking methadone to the people who have tried abstinance, without holding the same goals for each method. The maintenance population as about a quarter of the success rate at remaining abstinant as the other group after leaving mmt.

I personally think that nearly every sample used in these studies has a bias, and it is meant to be that way. The people conducting these "studies" have something to sell, and I think people should keep that in mind. It's little more that advertising in a free market economy, IMO...

Dr Dave said...

Nice critical appraisal of another tired study that does not help move things on at all. I couldn't agree more that low expectations of what opiate addicts might achieve is fundamental in ensuring that they don't achieve more.

I'm a doctor who is also a recovering opiate addict. At no point was methadone suggested as a treatment choice (apart from detoxification). The expectation was that I would recover with the right sort (and duration) of treatment. Now I adopt the same high expectation of my heroin addicted patients. They get better and stay better in the main. Our service is filled with reovered addicts who infectiously pass recovery on to their peers. Okay, so my recovery capital is arguably much higher, but we can increase the chances of success with some simple interventions (linking into recovery communities, providing housing and employment solutions, giving aftercare and long term management plans which focus on the client self-managing). We do it. It works. People get better.

More sentencing sense

I mentioned drug courts in a recent post. Well, the NY Times is reporting on drug courts.

Highlights:

Clearly, the courts do not help everyone. One of the most successful programs is in New York State, where about 1,600 offenders are in adult drug courts. Studies found that while 40 percent dropped out of the program along the way, those who started it, including both dropouts and graduates, had 29 percent fewer new convictions over a three-year period than a control group with similar criminal histories and no contact with drug courts, Mr. Berman said.

In other regions, half or more of those who start the program do not finish. And recidivism rates for participants are reduced by about 10 percent to 20 percent, depending upon the quality of the judges and treatment programs, said John Roman, a researcher at the Urban Institute, based on a recent study.

An earlier review of 57 “rigorous” drug court evaluations around the country, led by Steve Aos of the Washington State Institute for Public Policy, found that recidivism was reduced on average by only 8 percent, but with wide variation.

Yet even that modest reduction in crimes and prison yields cost benefits. The report this year by the Urban Institute found that, for 55,000 people in adult drug courts, the country spends about half a billion dollars a year in supervision and treatment but reaps more than $1 billion in reduced law enforcement, prison and victim costs. A large expansion would yield similar benefits, the report argued.

But some scholars, like Mark A. R. Kleiman, director of the Drug Policy Analysis Program at the University of California, Los Angeles, remain skeptical about the potential and the achievements. He suggests, for example, that success rates of some courts may be inflated because they take in offenders who are not addicted and entered this track only to avoid prison. Dr. Kleiman advocates a slimmed-down system that does not initially require costly treatment, as drug courts do, but simply demands that offenders stop using drugs, with the penalty of short stays in jail when they fail urine tests. Such an approach has shown promise with methamphetamine users in Hawaii, he said, and because it is far cheaper, it can be applied to far more offenders.

I'd like Kleiman's proposal if what he describes is a "pre-drug court" that would step addicts up into a full drug court.

There's something exciting and troubling about drug courts and health professional recovery programs in the context of the addiction treatment system. Exciting because there are important ways that they are succeeding in implementing some chronic disease management elements, namely long term monitoring and swift reintervention when relapse happens or appears imminent. Troubling because it seems that we are only implementing these strategies with involuntary involuntary clients and other systems are the ones implementing these programs for their own ends. (Not that there's anything wrong with this. In fact, it's great that these systems are approaching these problems in this way. But it should be cause for concern that these other systems are pulling us in this direction rather than us leading the way.) These programs get to be considerably more directive with these patients--they HAVE to go to treatment, they HAVE to get regular drug testing, they HAVE to attend recovery support groups, etc.

There will be a whole new set of challenges with voluntary clients. I suppose we'll face the same challenges that cardiac care and diabetes programs face every day.

How methadone research works

Start with the premise that opiate addicts don't get well. (Unless they're doctors.)

Perform a study offering only two variations of your preferred treatment. (Cheap and crime reducing.) One is high dose or long duration and the other low dose or short duration. Do not offer a recovery oriented option at all, or offer a recovery oriented option of inadequate duration and intensity.

Find that, when offering 2 lousy options, the lousy option with the longer duration or higher intensity reduces symptoms better at follow-up.

Run a headline of, "Methadone Detoxification Remains No Match for Methadone Maintenance, Even with Minimal Counseling." In the comments, declare, "Methadone maintenance is the preferred treatment approach for heroin dependence."

Bonus: "No difference between groups was found for cocaine use or depressive symptoms."

Bonus bonus: "Results for MM with standard counseling (2 hours a month) did not differ from those for MM with minimal counseling (15 minutes a month)."

Question: Do you think this will be used to justify offering even less counseling to methadone recipients?

UPDATE: I got some grief on this post. Here's my response:

Five points:

• First, a question. If methadone is a superior treatment option, why don't they use it for opiate addicted health professionals? Health professionals have high rates of opiate addiction and typically receive long term treatment with monitoring that lasts several years. Treatment is stepped up or down as needed. Guess what? They have great treatment outcomes. You might be inclined to chalk it up to a population with lots of recovery capital. To be sure, that plays a role, but surely a real chronic disease management approach plays a role too. 
  
• Second, is it coincidence that this study was done on poor black men? Why aren't studies like this done on young adults from affluent communities?
  
• Third, methadone used to be one component of some comprehensive bio-psycho-social treatment programs. I understand that there are still some programs that fit this description, but every program in my area is a dosing clinic and little more.
  
• Fourth, regarding misery, notice that there was no difference in depressive symptoms. 
  
• Fifth, heroin addicts in our long term programs do just as well as everyone else. It's all about hope and expectations. Beware of the subtle bigotry of low expectations.
  

All I want is a day when addicts are offered recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose.

Seizure Drug May Treat Alcoholism

Topiramate has been used to treat alcoholism for a little while now and was featured in the HBO Addiction series. This story has been very widely reported over the last few days. It may become a useful tool for a small number of alcoholics, but I find the results reported in this article pretty underwhelming:

Compared with placebo treatment, treatment with Topamax was associated with an 8 percent greater reduction in the percentage of heavy drinking days during the trial, the researchers reported.

Researcher Bankole Johnson, MD, tells WebMD that alcoholics in the trial who took Topamax went from the equivalent of drinking a bottle and a half of wine a day to about 3 1/2 glasses of wine.

"I think that is a big difference," he says. "Most people can manage that amount of alcohol without getting into too much trouble."

The researchers reported that Topamax users had a greater rate of achieving 28 or more days of continuous nonheavy drinking during the study and 28 days of continuous abstinence.

The manufacturer has also been accused of promoting off-label use:

But in a letter to the FDA, the consumer interest group Public Citizen accused the company of illegally promoting use of the drug for this purpose.

While doctors can legally prescribe FDA-approved drugs for nonapproved conditions, it is illegal for the companies that market the drugs to promote these so-called "off label" uses.

The Public Citizen complaint involved a question-and-answer sheet distributed to the media before publication of the study, which specifically discussed the drug's potential "off label" use for alcohol dependence.

Kara Russell of Ortho-McNeill tells WebMD that the company knew nothing about the question-and-answer sheet until the Public Citizen letter became public."

Ortho-McNeil Neurologics does not support any reference to off label use of its products and only promotes the use of Topamax in the approved indication of migraine and epilepsy treatment," Russell says.

I'm not surprised. I've wondered what arrangement led to the prominent placement of topiramate in the HBO series. It was practically an infomercial and led the lay people I know to grossly overestimate the effectiveness of the drug.




Technorati Tags: topiramate, addiction, alcoholism, treatment, research, medication

Powered by ScribeFire.

More on the new Canadian drug plan

65% for prevention and treatment (including culturally specific treatment) doesn't exactly sound Draconian:

The Conservative government's new $63.8-million, two-year drug strategy could be worse, but it could be better.Fully half the money will go toward beefing up treatment for addicts. Since health and social services are mainly a provincial responsibility, however, that money will go mainly to development of national benchmarking - so that evaluations can be consistent across the country - and extra programs for aboriginals. The main burden of helping addicts remains with the provinces.Another $10 million will go to prevention - ad campaigns and brochures to remind people, especially young people, how damaging addiction is. "Drugs are dangerous and destructive," Prime Minister Stephen Harper said, unveiling the plan. "If drugs do get hold of you, there will be help to get you off them."

Based on American experience, mandatory minimum sentences don't seem like a wise move, but why not start lobbying and negotiating instead of calling them idiots.


Technorati Tags: canada, addiction, treatment, prevention, policy

Powered by ScribeFire.

Methylphenidate for Amphetamine Dependence

The American Journal Psychiatry ran a recent study on the effectiveness of methylphenidate for speed addiction. Could this be a future evidence-based practice? Let's hope not.

Electric shock therapy for addicts

Scotland starts a new trial of ECT (source):

A radical new treatment for heroin addiction is to undergo its first clinical trial in Scotland, it was announced yesterday.

Neuro-electric therapy - NET - has been billed as a safer, more effective alternative to methadone, the heroin substitute which is both addictive and damaging to health.

The creators of NET believe their detoxification therapy not only reduces withdrawal symptoms but also removes cravings.

Psychiatric disorders and substance misuse

Last night I posted an article about gender and substance misuse. I didn't realize that the Psychiatric Times had a special report section on psychiatric disorders and substance misuse. I haven't had time to read the whole thing yet. What I did read seemed okay other than a sky high prevalence estimate for borderline personality disorder in people with substance use disorders:

Nearly one third of those with a lifetime SUD diagnosis also have BPD (median, 27%; range, 5.2% to 74.0%).^16,20 BPD appears to be less prevalent in persons with alcohol use disorders (median, 16%; range, 3.2% to 27.4%) than in those with drug use disorders, especially cocaine and opioid abuse.^17,20 For example, Ross and colleagues¹⁷ found that almost half (47%) of individuals using heroin who entered treatment for SUD also had BPD.

Here's a list of all the articles:

• The Link Between Psychotic Disorders and Substance Use By Emma Barkus, PhD
• Safe Treatment of Pain in the Patient With a Substance Use Disorder By Penelope P. Ziegler, MD
• Schizophrenia and Substance Abuse: Is There a Role for Atypical Antipsychotics? By Giovanni Caracci, MD
• Implications for Treatment and Prognosis of Borderline and Substance Use DisordersBy Ulrike Feske, PhD, Paul H. Soloff, MD, and Ralph E. Tarter, PhD
• Substance Abuse in Women: Does Gender Matter?By Sudie E. Back, PhD, Regana Contini, MD, and Kathleen T. Brady, MD, PhD

Methadone in the news

Two recent stories on methadone. First, researchers may have identified a genetic marker that indicates the person's drug metabolism. They believe that these finding could be important in determining dosing for methadone. Second, a story about prison-based methadone programs.

Substance abuse in women: Does gender matter?

The Psychiatric Times runs a helpful review of gender differences in substance misuse. It covers several areas including epidemiology, comorbidity, diagnosis, course and neurobiology. From the section on treatment:

A number of studies indicate that women are less likely than men to enter treatment.¹ Reasons for lower rates of treatment entry may include sociocultural factors (eg, stigma, lack of partner/family support to enter treatment), socioeconomic factors (eg, child care), pregnancy, fears concerning child custody issues, and complexities associated with increased rates of co-occurring psychiatric disorders and the availability of appropriate dual-diagnosis treatments.^1,30,46 Furthermore, as previously stated, many women seek treatment at settings or clinics other than substance abuse clinics (eg, primary care, mental health).¹⁸

Those women who do enter substance abuse treatment receive similar benefits to those received by men. There are few, if any, consistent gender differences in treatment outcome, retention rates, or relapse rates across various types of substances, treatment settings, and types of treatment.^1,47,48 In studies that have found gender differences, women typically have better outcomes than men. For example, women have been found to have higher rates of abstinence at 6-month follow-up (79.3% of women vs 54% of men) and at 5 years (odds ratio, 1.9).^24,49,50 Women also demonstrate greater improvement in other domains (eg, medical problems⁵¹), have shorter relapse episodes,⁵² and are more likely to seek help following a relapse.^52,53

Do drug courts tame the meth monkey?

Utah's Governor starts a drug court push for meth addicted mothers and proposes significant investment in treatment:

Despite efforts to combat it, Utah's meth problem continues to grow - especially for women.
For five years, meth has been the top illegal drug of choice for Utahns entering public treatment. For women it surpasses even alcohol, the traditional front-runner, making it the only drug in history to have its female users outnumber males. Nearly half the women in treatment statewide have children.

Gov. Jon Huntsman Jr. has proposed investing $2 million in Utah's drug courts and $2.5 million to build two residential clinics in northern and southern Utah to treat 600 women, giving priority to those involved with the child welfare system. But Huntsman will have to convince lawmakers it's a wise investment, no easy task considering the stigma attached to addiction and a dearth of data on treatment, including how patients and drug court graduates fare over the longer term.

Helping Utah's women poses another challenge: transforming a system that wasn't built for them.

"Substance abuse treatment has been historically geared for white, middle-aged male alcoholics," said Salt Lake County substance abuse Director Patrick Fleming. "We're a hell of a lot better at treating women than 10 years ago, but there's room for improvement."

I'd challenge the "dearth of data" statement. We have a lot of data on the effectiveness of treatment and drug courts.

Lush Life: How Stars Make a Mockery Out of Rehab

More news coverage on treatment as havens for the rich.

Kennedy, Ramstad hit the road to tout mental health measure

Substance abuse and mental health parity bills have been introduced several times in the last decade. Supporters reportedly have all the votes they need to pass it and President Bush has indicated that he would sign it, but Republican house leadership consistently blocked it from going to the floor for a vote. Hopefully this will be an opportunity to enact it.

Reps. Patrick Kennedy (D-R.I.) and Jim Ramstad (R-Minn.) will embark on a six-city tour today to tout legislation that would require insurance companies to treat mental illness and addiction just as they would any physical illness. The tour will kick off in Providence, R.I., then head to Ramstad’s district in Minnetonka, Minn., and continue on to Rockville, Md., Los Angeles and Vancouver, Wash.

Benefit-Cost in the California Treatment Outcome Project: Does Substance Abuse "Pay for Itself?"

I think I posted a news article summarizing these findings, but this link includes a PDF of the journal article:

Results from a cost-benefit analysis of substance abuse treatment programs are presented. Sections of this article include: abstract; methods; results according to per diem substance abuse treatment costs, average cost and benefits associated with substance abuse treatment, pre-post changes in the individual sources of monetary benefit, sensitivity analyses; "inflating" the arrest data, multiple regression models, cohort, and varying treatment intensity across providers; and discussion. A ratio of 7:1 benefits to costs exists; a benefit of $11,487 to a cost of $1,583.

Facts on the new smoking cessation medication

A new fact sheet on Varenicline (the generic name for Chantix), the newly approved smoking cessation drug. It's the first drug to target nicotine receptors.

Assertive Continuing Care effectiveness

More evidence for the effectiveness of assertive continuing care (ACC) in adolescents. It's an important emerging recovery management approach:

ACC led to significantly greater continuing care linkage and retention and longer-term abstinence from marijuana. ACC resulted in significantly better adherence to continuing care criteria which, in turn, predicted superior early abstinence. Superior early abstinence outcomes for both conditions predicted longer-term abstinence.

Advocates Renew Push for Mental Health 'Parity' Bill

This NPR story suggests that there is a good opportunity right now for passing parity legislation. The story never mentions addiction treatment. In the past, every time they get close to passing comprehensive parity (mental health and addiction), they drop addiction. We'll see what happens with this go-round.

Encouraging Posttreatment Self-Help Group Involvement to Reduce Demand for Continuing Care Services

A new study on 12 step involvement as continuing care:

Background: Accumulating evidence indicates that addiction and psychiatric treatment programs that actively promote self-help group involvement can reduce their patients' health care costs in the first year after treatment, but such initially impressive effects may wane over time. This paper examines whether the positive clinical outcomes and reduced health care costs evident 1 year after treatment among substance-dependent patients who were strongly encouraged to attend 12-step self-help groups were sustained at 2-year follow-up.

Methods: A 2-year quasi-experimental analysis of matched samples of male substance-dependent patients who were treated in either 12-step–based (n=887 patients) or cognitive-behavioral (CB, n=887 patients) treatment programs. The 12-step–based programs placed substantially more emphasis on 12-step concepts, had more staff members "in recovery," had a more spiritually oriented treatment environment, and promoted self-help group involvement much more extensively than did the CB programs. The 2-year follow-up assessed patients' substance use, psychiatric functioning, self-help group affiliation, and mental health care utilization and costs.

Results: As had been the case in the 1-year follow-up of this sample, the only difference in clinical outcomes was a substantially higher abstinence rate among patients treated in 12-step (49.5%) versus CB (37.0%) programs. Twelve-step treatment patients had 50 to 100% higher scores on indices of 12-step self-help group involvement than did patients from CB programs. In contrast, patients from CB programs relied significantly more on outpatient and inpatient mental health services, leading to 30% lower costs in the 12-step treatment programs. This was smaller than the difference in cost identified at 1 year, but still significant ($2,440 per patient, p=0.01).

Conclusions: Promoting self-help group involvement appears to improve posttreatment outcomes while reducing the costs of continuing care. Even cost offsets that somewhat diminish over the long term can yield substantial savings. Actively promoting self-help group involvement may therefore be a useful clinical practice for helping addicted patients recover in a time of constrained fiscal resources.

This article focuses on cost savings, so the abstract is limited to this narrow area. Here's an additional finding from the study:

Both 12-step and CB program patients experienced substantial and comparable improvements in substance-related problems and psychiatric outcomes and required less ongoing professional treatment between 1 and 2 years than they had in the year after discharge. However, patients treated in 12-step treatment programs achieved substantially better abstinence rates (49.5 vs 37.5% in CB). This difference is actually slightly larger than that identified at 1-year follow-up (45.7% in 12-step vs 36.2% in CB

It's worth noting that, while the authors are supporters of 12 step groups, they suggest that this outcome may have more to do with mutual aid group involvement than with the specific mutual aid group.

Recovery: The bridge to integration?

Bill White and Larry Davidson suggest that shifts toward recovery orientation models in mental health and addiction services could serve as a bridge toward integration:

“Recovery-oriented system transformation” is becoming an umbrella concept for integrating behavioral healthcare and creating systems of care that are culturally competent, trauma-informed, evidence-based, inclusive of families, based on strengths, and connected to communities (as indigenous sources of recovery support). Leading the call for such system transformation are new recovery advocacy movements in both the addictions and mental health fields. These movements, led by people in recovery, their families, and visionary professionals, are demanding that care be focused on the processes of long-term recovery and anchored within natural supports and local communities.

Theoretically, I don't disagree at all. My fear is that this process will not be a merger between equals, my experience (admittedly limited to southeastern Michigan) is of watching mental health systems devour addiction treatment systems. This fear is compounded by the fact that, at least in our region, mental health agencies are well-organized and well-connected governmental behemoths while addiction treatment programs are small, unstable and diffused.

Consider these historical reflections from some of Bill's other works:

The Segregation/Integration Pendulum
American history is replete with failed efforts to integrate the care of alcoholics and addicts into other helping systems. These failed experiments are followed by efforts to move such care into a categorically segregated system that, once achieved, is followed with renewed proposals for service integration. After fighting 40 years to be born as an autonomous field of service, addiction treatment is once again in the throes of service-integration mania. This cynical evolution in the organization of addiction treatment services seems to be part of two broader pendulum swings in the broader culture, between specialization and generalization and between centralization and decentralization. Once we have destroyed most of the categorically segregated addiction treatment institutions in America, a grassroots movement will likely arise again to recreate them. When the 21^st century once again gives birth to specialized addiction treatment, perhaps this “new” institution will be given a colorful name fitted to its form and function – perhaps something like inebriate asylum.

Diffusion and Diversion
Diffusion and diversion constitute two of the most pervasive threats in the history of addiction treatment institutions and mutual-aid societies. Diffusion is the dissipation of an organization’s core values and identity, most often as a result of rapid expansion and diversification. Diffusion creates a porous organization (or field) that is vulnerable to corruption and consumption by people and institutions in its operating environment. Diversion occurs when an organization follows what appears to be an opportunity, only to discover in retrospect that this venture propelled the organization away from its primary mission.

The current absorption of addiction treatment into the broader identity of behavioral health is an example of a diffusion process that might replicate two earlier periods – the absorption of inebriate asylums into insane asylums and the integration of alcoholism and drug-abuse counseling into community mental health centers in the 1960s. This diffusion-by-integration has generally led to two undesirable consequences: 1) the erosion of core addiction treatment technologies; and 2) the diversion of financial and human resources earmarked to support addiction treatment into other problem arenas.

A Panicked Field In Search of Its Soul and Its Future
In the face of such threats (managed care, facility closures, merger mania & integration into behavioral health systems), the field is experiencing a strange phenomenon. As the core of the addiction treatment field shrinks, the field is growing at the periphery. Where the total amount allocated to residential and inpatient treatment services is shrinking, the numbers of outpatient services is actually increasing, as is a growing number of new specialty programs that extend addiction treatment services into allied fields. The growth zone of the addiction treatment industry is not at the traditional core but in the delivery of addiction treatment services into the criminal justice system, the public health system (particularly AIDS related projects), the child welfare system, the mental health system, and the public-welfare system. If one looks at these trends as a whole, what is emerging in the 1990s is a treatment system less focused on the goal of long-term personal recovery than on social control of the addict. The goal of this evolving system is moving from a focus on the personal outcome of treatment to an assurance that the alcoholic and addict will not bother us and will cost us as little as possible.

The fate of the field will be determined by its ability to redefine its niche in an increasingly turbulent health-care and social-service ecosystem. That fate will also be dictated by more fundamental issues – the ability of the field to: 1) reconnect with the passion for service out of which it was born; 2) re-center itself clinically and ethically; 3) forge new service technologies in response to new knowledge and the changing characteristics of clients, families, and communities; and 4) the ability of the field to address the problem of leadership development and succession.

Alcoholics forced into hospital treatment

Australia is piloting a program that commits their most severe addicts and alcoholics for 28 days. Interesting in light of Australia's embrace of harm reduction:

HEAVILY-addicted drug users and alcoholics will be forced to have treatment in hospital under a two-year pilot proposed by the New South Wales Government.

The trial, with up to 28 days of involuntary care at Nepean Hospital, would be a "circuit breaker" for the most severely addicted, state Health Minister John Hatzistergos said today.

"The four-bed service at Nepean Hospital will aim to break the addiction cycle for alcoholics and long-term entrenched drug users, before they are referred to longer-term treatment and rehabilitation with community support and follow-up," he said.

"We expect up to 50 patients a year from western Sydney will be treated in the four-bed secure unit."

The Government is drafting changes to the Inebriates Act 1912 to enable the trial to take place.

The changes would allow medical practitioners to seek a court order referring a severely drug- or alcohol-dependent person to compulsory treatment.

Fight the stupor: Teen Care takes sobriety to school

A horrible headline but it's interesting that Hawaii has treatment in every high school:

All public high schools and some middle schools in Hawaii have alcohol and drug treatment programs, and the 2005 Legislature provided $1.8 million to expand services to 21 middle schools on Oahu, four on the Big Island and three in Maui County.

...

Keith Yamamoto, chief of the state Health Department's Alcohol and Drug Abuse Division, said funding for adolescent alcohol and drug treatment programs in schools this fiscal year totals $6.5 million, including the new appropriation. Schools receive $10,000 to $90,000 for the program, depending on their size, he said.

Changing tactics: Recovery programs crucial to winning drug war

A Kentucky paper discusses an alternative to the war on drugs:

No one thinks drug abuse is OK. The question is how best to fight it.

There are signs that the answer is shifting toward fighting drug abuse one person at a time, helping users recover, preventing others from getting hooked.

It's slow, it's personal, it's expensive. But without it, history and economics say, we are doomed to failure.

Dynamic Drug Policy

An editorial in the new issue of Addiction questions the static drug policy models that dominate current policy debates:

Drug researchers have long understood that there can be long-term waves of greater and lesser drug use and that upswings can involve epidemic-like spread. These and other dynamics discussed below imply that policy ought to vary over the course of a drug use cycle, but drug policy debates have not yet internalized this perspective.

...

Because drug problems vary in these complex ways, it seems plausible that drug policy should vary over time as well; yet it is rare to hear someone couch their drug policy recommendations in these terms. This is striking and more than a little troubling. It suggests that the mental models guiding policy discussions implicitly superimpose a static framework on an intrinsically dynamic phenomenon, akin to popular nostrums for get-rich-quick investing that never vary even as economic conditions change over the business cycle.

It is not clear why policy is not discussed more often in dynamic terms. Perhaps disciplinary boundaries and stove-piped bureaucracies create single-issue advocacy. Perhaps both the health and criminal justice perspectives favour individual-level analyses. Whatever the reasons for their absence to date, dynamic perspectives on drug policy are, in fact, possible.

What are the policy implications? The author discusses the stage-specific limitations and strengths of several approaches:

Preventing an initiation in the early stages of an epidemic is tremendously valuable, because it short-circuits a chain reaction that would have involved many people. (In technical terms, the reproductive rate at that point would have been large.) However, primary prevention cannot be timed to react to a burgeoning epidemic because of intrinsic lags. For example, the median age of cocaine initiation in the US is 21 years, but students in school-based prevention programmes are younger, often only 13 years old. Therefore, if school-based prevention interventions were to have any hope of affecting cocaine initiation dramatically, the ideal time to have run them would have been in the early 1970s, 8 years before the peak in initiation. However, no one knew in 1970 that there was a cocaine epidemic brewing. Conversely, the vast majority of cocaine consumed from 1985 to 2005 was consumed by people who were already older than 13 years in 1985. For instance, over 85% of people the Treatment Episode Data Set (TEDS) records as receiving treatment for cocaine between 1992 and 2003 were born before 1973. Consequently, prevention programmes initiated around the time the cocaine epidemic became salient could not possibly have had a dramatic effect on use over the next generation, regardless of how effective they were.

Treatment also has limited ability to stave off a burgeoning epidemic, because early in the epidemic most users do not have a treatable medical condition. Precise estimates are not available because population-level estimates of treatment need exist only for recent years, but need for treatment is correlated with average duration of use. In 2003, 39% of respondents reporting past-year cocaine use to the US Household Survey had been using for 10 or more years. In 1979, the peak year for cocaine initiation, that proportion was just 3%. For drugs that are not injected, the role of harm reduction strategies is similarly limited when most users are not experiencing significant harms with their use.

Enforcement's effectiveness at suppressing drug use declines markedly as the size of a drug market grows. However, enforcement has unique ability to focus its effects in both space and time. If a crack house opened next door, neither funding school-based prevention nor additional treatment slots would bring rapid relief. Parking a patrol car in front of the crack house would at least displace the activity. Similarly, assume treatment was five times more cost effective than incarceration at reducing drug use. Incarceration could still be twice as cost effective at reducing drug use this year—because incarceration's effects on drug use are concentrated in the present whereas treatment's effects may be spread over a decade or more. Hence, these models suggest that supply control programmes may have a unique capacity to disrupt the contagious spread of a new drug, but limited ability to eradicate established markets. (Enforcement may also be able to displace established markets into less destructive forms, such as forcing visible street dealing to convert to discreet meetings arranged by cell phone.)

Harm reduction offers particular advantages later in the epidemic cycle, when use has stabilized at high endemic levels. For injectable drugs in countries with low violence and few street markets, harm reduction may focus on syringe exchange programmes, supervised injection rooms and training ambulance crews to treat overdose. For drugs that are not injected and which are supplied through violent street markets, harm reduction may focus instead on using enforcement to target the minority of dealers who cause the greatest social harm. In either case the premise is that, with or without the harm reduction, the flow of new people into problem drug use will be modest, so reducing harmfulness of drug use has few drawbacks. That may not be a safe premise early in an epidemic, when there are feedbacks that can amplify small shocks to the system into dramatic effects on its trajectory.

I'm not sure I agree with the author's assumptions about the strengths and limitations of he various approaches, but he makes a compelling argument:

• that the static models currently being debated and advanced all have their place in policy;
• they are all inadequate by themselves;
• and, that there isn't even a correct formula because the needs, opportunities, crises, etc. are constantly changing.

New Smoking Cessation Resource for Treatment Providers

IRETA just released a new publication called Smoking Cessation Treatment and Substance Use Disorders. It's makes the case for addressing nicotine addiction in treatment and talks about the challenges and offers some strategies for integrating smoking cessation and going tobacco-free.

Treatment response by primary drug of abuse: Does methamphetamine make a difference?

Another study challenges the conventional wisdom that meth addiction is harder to treat than addictions to other drugs.

Sobering Vacation

Expensive, luxury treatment programs are quickly becoming the highest profile treatment programs. This, combined with the Foley/Gibson/Kennedy coverage, is troubling when one considered the historical cycles of public backlash against treatment programs perceived as havens for the rich.

Each sumptuous bed here at a retreat called Promises has been fitted with Frette linens and a cashmere throw. The elongated pool beckons as does the billiard room beyond, tucked into the Santa Monica mountains overlooking the Pacific Ocean.

But not just anyone can come to this exclusive getaway -- and really, not many would want to. Promises is an addiction-treatment center that caters to a mix of celebrities, corporate chiefs, their families and people who want to live like them.

Promises is part of a growing niche in the burgeoning business of addiction treatment: centers that are truly, deeply luxurious. With more than a dozen recovery centers in this seaside village, Malibu has become the center of the high end of the industry -- perhaps logically, given its resort-like location, enclaves of celebrity homes and proximity to Los Angeles, a city whose primary industry is rife with partying and free-flowing cash. California law has helped by allowing rehab centers to be located in residential neighborhoods if they have no more than six beds.

At Renaissance, where a staff of 50 caters to a dozen patients, one bedroom suite for a single resident measures 2,000 square feet -- as big as many three-bedroom homes. Another center, Harmony Place, will supply personal concierges and pedicures if patients ask. A few miles north of Promises on the Pacific Coast Highway, Passages offers surfing instructors. Clients stroll around in swim trunks chatting on cellphones in a sprawling sea-view mansion that is hard to distinguish from a luxury resort.

Sometimes, the Why Really Isn’t Crucial

Something that I can heartily agree with Sally Satel about. Disease model critic Sally Satel explains that insight is overrated as a path to recovery:

Reconstructing the story of one’s life is a complicated business... What scientists call hindsight bias kicks in when we try to figure out the causal chain of events leading to the current situation. We may well come up with a tidy story but, inevitably, it will contain large swaths of revisionist history. It’s not that we bias ourselves deliberately; it happens because the mind tends to make events in the past appear comprehensible and orderly. We forget the uncertainties that might have beset us as we struggled in real time.

Narratives are shaped also by a natural tendency to focus on information that confirms theories we already hold....

If our own accounts of our actions are often so slanted and embellished, is composing them simply a misbegotten quest? Surely not. To a therapist, the attempt signals that patients are aware that they have a problem worthy of attention. And the narratives themselves can help them make sense out of confusion. This, in turn, can diminish anxiety and exaggerated guilt. Such relief might be sufficient in and of itself for some, or, depending on the goals of therapy, it could embolden a patient to make further healthy adjustments.

But the grail-like search for insight can also backfire when it becomes a way for patients to avoid the hard work of change.

Hat tip: New Recovery