tag:blogger.com,1999:blog-6154923121857389373.comments2023-07-07T05:11:26.707-05:00Substance MattersMark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.comBlogger161125tag:blogger.com,1999:blog-6154923121857389373.post-88914770265088151162013-11-20T23:49:58.313-06:002013-11-20T23:49:58.313-06:00As silly as I've often thought these "arc...As silly as I've often thought these "archaic and puritanical" laws are, they often played a role in helping me stay or get back on track when I was struggling with alcohol. Anne Fletcher, MS, RD, Author, Inside Rehab and Sober for Goodhttp://www.annemfletcher.comnoreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-84415792133159740752013-11-10T23:32:11.365-06:002013-11-10T23:32:11.365-06:00That is good advice but it assumes that there is a...That is good advice but it assumes that there is a marketplace in healthcare where one can act like a customer. That seems to rarely be the case when the quality of mental health and addiction services is at such a low level of quality after decades of rationing. You can actually be part of a health plan and not get adequate detox services and have no access to the timely treatment of medical or psychiatric comorbidity.<br /><br />That is not because there is a shortage of expertise but because the services have been rationed for the past 30 years and cost shifted out of health plans. I am not hopeful that the recently published parity rule will do much to change that.<br /><br />There are numerous ways that complaints from consumers in healthcare are cancelled out. I would recommend establishing 2 agencies in each state to oversee the health plans and to assist clinicians who are whistleblowers to protect them from blow back created when they disagree with a health plans rationing procedures. George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-32423845665825361482013-11-02T07:03:00.397-05:002013-11-02T07:03:00.397-05:00Methylphenidate and dexamphetamine have both been ...Methylphenidate and dexamphetamine have both been proposed as possible substitution therapies, and have certainly, in the case of dexamphetamine, shown to improve retention rates. The problem with topiramate, which is of interest because of the pharmacological actions that lead to the inhibition of glutametergic activity, is that it has significant cognitive side effects.<br /><br />The group approach to medications is really interesting... will read that paper!Shaun Shellyhttps://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-45750339864729378452013-11-02T06:51:55.421-05:002013-11-02T06:51:55.421-05:00The evidence certainly is mounting, and I have cer...The evidence certainly is mounting, and I have certainly had to change my views from "mildly optimistic" to "strongly in favor" when it comes to MT. One thing that strikes me about the study is that they actually used a very direct form of contingency management to ensure retention levels - they paid a gift-card incentive for each visit to the total of $410. The other issue is that there were twice weekly urine tests, and some counseling or certainly contact occurred during these interactions. There was also careful monitoring of dosage during the study. For these reasons I think we need to look more closely at the WAY buprenorphine maintenance is managed. I would suggest that optimal dosage and retention in treatment are the vital components, and perhaps points of contact which help keep the individual focused.Shaun Shellyhttps://www.blogger.com/profile/00320880733187014324noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-25115425430714012882013-10-31T21:30:08.504-05:002013-10-31T21:30:08.504-05:00What a lovely and thoughtful response to a good qu...What a lovely and thoughtful response to a good question! We have a practice of well-trained clinicians...who use MI, CBT, CM and DBT (that's alot of initials!). And at the end of the day, we know that the ability to establish an alliance, to work with a client where they are at when they are sitting across from you...with no emotional investment in how they change...is what matters. And this takes alot of clincial skill, and training, and re-training....and supervision to maintain that balance. The outside culture with all it's opinions about addiction, denial, co-dependency and enabling...invades the work constantly. Thanks for pointing out that changing behavioral patterns (like substance use) is a process, that takes time and prolonged effort. And that is a windy, up and down road. I agree...I have never sat with a person dependent on substance who was happy to be in the position they were in. The heart-ache is more often immense. Carrie Wilkensnoreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-81548154166683631922013-10-29T11:23:14.787-05:002013-10-29T11:23:14.787-05:00Thank your for your words of wisdom and I have hea...Thank your for your words of wisdom and I have heard this time and time again, that empathic listening, instilling home, and unconditional positive regard is essential in counseling the suffering addict. Anonymoushttps://www.blogger.com/profile/04040342679454862583noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-3495057286492745102013-10-19T18:21:28.090-05:002013-10-19T18:21:28.090-05:00very thoughtfully written- as a dual diagnosis the...very thoughtfully written- as a dual diagnosis therapist doing numerous groups per w eek in patient, I use all of the above mentioned therapies, but most importantly, the community knows our hospital has an unconditional place to come too if needed- the relationship throughout the years as they fight their addictions that gives hope is huge..sandy daignault, lcswnoreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-21345267244670372772013-10-17T08:18:43.941-05:002013-10-17T08:18:43.941-05:00Well stated indeed. I have had the honor to observ...Well stated indeed. I have had the honor to observe your work and your style is a great reflection of your teaching.<br /><br />I strive to do the same, and find your direction both encouraging and affirming. <br /><br />Thanks for your leadership.Anonymoushttps://www.blogger.com/profile/07043502428595306902noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-7605460752447615342013-10-16T04:48:57.653-05:002013-10-16T04:48:57.653-05:00Brilliant. I have always found your approach to be...Brilliant. I have always found your approach to be compassionate towards the patient yet unemotional towards the treatment modality. In other words, you hold none of the sacred cows dear as much of the treatment field does, but rather you go where the evidence takes you. <br /><br />Your approach has helped inform the program I run and we certainly show the results which support the recommendations you make above. <br /><br />Keep up the great work, and keep sharing your knowledge.Shaun Shellyhttp://www.addictioncapetown.blogspot.com/noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-81465987195210050522013-10-15T08:41:55.741-05:002013-10-15T08:41:55.741-05:00Dr. Willenbring,
What a thoughtful and generous r...Dr. Willenbring,<br /><br />What a thoughtful and generous response. As the addictive treatment community becomes the "poster child" for what ails our entire sick care industrial complex, I love what you're offering in the way of an integrated, multidisciplinary approach.<br /><br />Returning to balance and wholeness cannot be a cookie cutter algorithm because we don't have a CLUE how to measure the whole. Recovering awareness about the wisdom of our self-regulating, self-healing mind-bodies IS a clue. Deep empathy and patient-centered care–another.<br /><br />Thanks for the great work you're doing in the world as the addiction treatment community becomes the entire community and we start practicing Health Care as the hopeful, alive and open hearted whole people we are.<br /><br />Dr. Herby Bellherbybellhttps://www.blogger.com/profile/02223243645728981454noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-24551267496413023092013-09-23T00:14:45.582-05:002013-09-23T00:14:45.582-05:00I didn't know about the opioid overdose earlie...I didn't know about the opioid overdose earlier. Thanks for sharing the article. I think most of the crimes in Asia are happening because of drugs. If it is strictly wiped out of the world then about 50% of the crimes will be put to halt.<br /><br />Regards,<br />Arnold Brame<br />Health And Safety Consultant Peterboroughhttp://www.conservosafety.com/noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-6966425288407082102013-09-12T09:42:50.548-05:002013-09-12T09:42:50.548-05:00I concur completely with the last paragraph of thi...I concur completely with the last paragraph of this particular subject; with sincere gratitude for the last statement!!! I Love it! "Get over it. The brain is flesh and blood. It gets dysregulated just like any other organ and sometimes it is incapable of healing or fixing itself. Sometimes it needs help with medication, as well as social support, psychotherapy, spirituality, exercise, and other non-medication supports and treatments" I struggled with alcoholism for 23 years and went through 6 inpatient treatments, 5 being unsuccessful (without medication) and the 6th being long term, (13 months) with the utilization of medication to counteract the withdrawls, insomnia, and mood instability. As a result of this, I am successfully and contently sober and sincerely support medication assisted therapy. Additionally, I enhance other areas of my recovery with AA meetings, exercise and weekly spiritual encounters. As a result of this, I am approaching 3 years of continued sobriety. Anonymoushttps://www.blogger.com/profile/04040342679454862583noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-60246563784837715762013-09-11T15:59:50.576-05:002013-09-11T15:59:50.576-05:00As usual, very well stated. Thanks, Mark!As usual, very well stated. Thanks, Mark!Matthew Wolmutt, MSW, LICSWhttps://www.blogger.com/profile/05548406996931210622noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-77537694068389856672013-09-10T22:07:09.881-05:002013-09-10T22:07:09.881-05:00Dr. Willenbring,
Would you agree that a person in...Dr. Willenbring,<br /><br />Would you agree that a person in recovery should have a solid relapse prevention plan in place regardless of the recovery path they choose. For example a person could choose abstinence-based recovery (AA/NA, CBT, counseling, etc.), Medication Management, or a combination of those, in whatever multitude of variations. Isn't it still imperative that they stay away from their former lifestyle as much as possible?<br /><br />-Stay away from the places you obtained your drug of choice?<br />-Stay away from the places you used your drug of choice?<br />-Stay away from the people that provided your drug of choice?<br />-Stay away from the people you used with?<br /><br />What are your thoughts regarding these and other common relapse prevention measures with regard any treatment/recovery option available?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-59854088489191262502013-08-28T08:11:12.649-05:002013-08-28T08:11:12.649-05:00But that's an important distinction - "am...But that's an important distinction - "among informed people". Unfortunately, many policymakers, public health advocates, and even chemical dependency and mental health professionals are not well-informed of the science of opioid addiction. I can tell you anecdotally that I regularly hear folks in the treatment field say that they discourage the use of maintenance medications because they don't want their clients trading one high for another. Studies like these are important because they help increase the knowledge of the general public - granted, I agree with you that this survey has limitations. However, I think the main point I was trying to make is that if buprenorphine were more easily accessible, street sources wouldn't be needed - or, certainly, quite as common.Anonymoushttps://www.blogger.com/profile/02083530358646742701noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-1394916625314530062013-08-28T08:10:11.288-05:002013-08-28T08:10:11.288-05:00This comment has been removed by the author.Anonymoushttps://www.blogger.com/profile/02083530358646742701noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-75221116162046341842013-08-22T07:24:30.951-05:002013-08-22T07:24:30.951-05:00Drug abuse makes the abuser hopeless and it become...Drug abuse makes the abuser hopeless and it becomes challenging for them to seek support by themselves.<br /><a href="http://www.addictioninterventionnow.com/" rel="nofollow">Family Intervention</a> Intervention serviceshttps://www.blogger.com/profile/07813366149867340859noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-15816951356683540782013-08-02T11:16:56.283-05:002013-08-02T11:16:56.283-05:00Paula, your viewpoint is always relevant and your ...Paula, your viewpoint is always relevant and your post comes at an appropriate time because I recently have been facing similar issues.<br /><br />Last week I did an assessment on a 20 year old male meth user who had multiple mental health diagnoses. The reason he came in for the assessment was to fulfill probation obligations because he had a positive UA for meth and marijuana and consequently went to jail for a week. <br /> <br />During the assessment he said that he hadn't used for about a month. He wasn't on any medications for his mental health issues except for Adderall for ADHD and never has been compliant with his medications. I asked him if probation had some expectations from him and he said individual counseling. After talking to him my initial feelings were that he had a lot of mental health issues that needed to be addressed. Therefore, my recommendation was that he attend individual counseling 1-2 times a week, have a psych eval and medication compliance. <br /><br />After the assessment I talked to both his probation officer and his mother for collateral information. I got a lot of information from his mom and she thought that he was still using and that he needed inpatient treatment. She told me she took him to get checked out because she thought something was off with him and he was acting strange. The hospital she took him to was in the Fairview system (where I work) so I am able to access the notes in his chart. He had a UA which was positive for methamphetamine.<br /><br />After all of this I was really struggling with whether or not I should change my inital recommendation. I sat on this assessment for days and all I had to do was fill in the recommendations. Finally, I came to the conclusion that I was letting the outside parties' information/opinions influence my decision. The UA that he had done was 2 weeks prior to the assessment so even if he wasn't truthful about when he last used as far as I know it was still over 2 weeks ago. My job is to give a recommendation based on the information that the client gives me. My job isn't to catch them in a lie and I don't feel comfortable changing dimension ratings or recommend residential treatment based on what a family member thinks is going on.<br /><br />Additionally, I think that counselors sometimes use probation as a means to not have to deal with clients that may be challenging. If the client continues to struggle in treatment it's easier for the counselor to play the probation card than it is to actually do the work and figure out what the client needs.Anonymoushttps://www.blogger.com/profile/12556658140379537024noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-1904022134312436462013-07-30T22:01:26.004-05:002013-07-30T22:01:26.004-05:00Yes, Anne, it is true - in this study, participant...Yes, Anne, it is true - in this study, participants had to have "good physical and psychiatric health", which would rule out significant COD. While opioid-use disorders and psychiatric disorders often co-occur, it's not as prevalent as is commonly believed - the 50% number that is often referenced is too high. But that is certainly a limitation, and likely where counseling would have a much different effect on outcomes.<br />Interestingly, in a recent study published in the journal Drug and Alcohol Dependence, one of the patient characteristics positively correlated with successful opioid use outcomes (in suboxone patients receiving Tx for addiction to prescription opioids) was "past-year or lifetime diagnosis of major depressive disorder". So, we should in no way assume that folks with a history of mental illness cannot also benefit from buprenorphine maintenance.Anonymoushttps://www.blogger.com/profile/02083530358646742701noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-84227932784416654912013-07-30T17:03:10.700-05:002013-07-30T17:03:10.700-05:00This IS hard to swallow but science is science. Wh...This IS hard to swallow but science is science. What I'm wondering is just how many people with opioid dependence DON'T have co-occurring disorders. Isn't it true that, in studies like this, such people are screened out and, as such, don't reflect the "real world" of patients? Anne Fletcher, MS, RDhttp://www.annemfletcher.comnoreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-77183708021940062882013-07-29T13:46:05.560-05:002013-07-29T13:46:05.560-05:00Ian, I like your comment regarding the research. ...Ian, I like your comment regarding the research. As professionals within an empirically driven field aimed at creating maximum outcomes for the individuals we serve we need to understand how our biases can reduce our effectiveness. Ultimately, the evidence base is there to direct our work regardless of our personal biases. If one is not able to practice in this way I wonder if one should be practicing...Matthew Wolmutt, MSW, LICSWhttps://www.blogger.com/profile/05548406996931210622noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-48222261410136332092013-07-27T14:44:27.920-05:002013-07-27T14:44:27.920-05:00The reply to this comment makes an excellent point...The reply to this comment makes an excellent point - those who tend to define maintenance as an equal-to-or-worse-than alternative to heroin or other opioids are probably not good candidates for maintenance medication - and the medications aren't necessarily for everybody. However, buprenorphine with its low effect ceiling and partial-agonist properties, and methadone with its relatively low euphoric effect are generally not abused by folks with a tolerance for opioids because they just don't feel good compared to oxycodone or heroin. Not to mention, at a therapeutic dose, virtually no sedation or noticeable effect can be felt.<br />Ultimately, for the majority of patients, these meds provide a "freedom" from an old destructive way of life; a freedom from the obsession of use. The very nature of maintenance medications is that the addiction goes away. Sure, a physiological dependence is created - just as with antidepressants, insulin, and a host of other medications. The important difference is that the compulsive behavior, excessive time spent obtaining and using, the social and occupational problems, and the significant impairment or distress are all absent - the true hallmarks of addiction.<br />I agree with you that the voice and opinion of the patients themselves is paramount. If a person decides they don't want to use a maintenance med then they should not, and they should receive the best care possible. However, they should also know that their likelihood of relapse if substantially greater, and the risks relapse carries with it includes death. I disagree, however, that these medications are being pushed and propagated without the consent of the patients - the simple fact is that countless people have regained their lives thanks to the help of meds like these. Otherwise, organizations like NAMA would not exist: http://methadone.org/Anonymoushttps://www.blogger.com/profile/02083530358646742701noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-26031565337275925282013-07-23T21:44:09.136-05:002013-07-23T21:44:09.136-05:00My son is recovering from opiod addiction and is o...My son is recovering from opiod addiction and is on suboxen treatmentand doing quite well. His psychiatrist seems excellent and thankfully is a believer in suboxen treatment. It is likely that my son will be on suboxen for a lengthy period. Standard support groups such as NA however do not support the use of suboxen and have attempted to push him away from the use of suboxen. As such my son feels outcast and has stopped attending NA meetings. However, he would like to attend support groups and needs a path to finding supportive, sober friends. Are there any other support groups nationally which are not anti suboxen?? FYI, my son is in another state and is stuck there due to a probation issue from his prior use.<br /><br />AKAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-66374300812008689902013-07-23T02:23:23.088-05:002013-07-23T02:23:23.088-05:00Without knowing anything of the basis for your con...Without knowing anything of the basis for your contact with the heroin addicts you mention, I'm guessing the context of your encounters with the folks you mention is through a 12-step program like NA or AA, or as a treatment provider of chemical dependency services. Either way, you are only interacting with those for whom methadone or buprenorpine did not work. People who have achieved stabilization and success on methadone or BPN don't show up to seek chemical dependency services or attend AA or NA (although this will hopefully change). Remember, we are talking about a class of drugs where every post-treatment relapse is potentially fatal, and all too many are. Unknownhttps://www.blogger.com/profile/04557001239168962084noreply@blogger.comtag:blogger.com,1999:blog-6154923121857389373.post-47651087534240892772013-07-23T02:08:38.270-05:002013-07-23T02:08:38.270-05:00One has to wonder how this newly minted psychiatri...One has to wonder how this newly minted psychiatrist acquired such a grotesquely punitive attitude towards persons trying to recover from alcoholism. If he is in recovery, this kind of rigid dogmatic 'fundamentalism' does show up among AA members, but seems much less likely to be harbored by anyone who's completed a psychiatric residency. Perhaps he simply needs therapy to address his alcoholic mommy or daddy issues. <br /><br />Mark Edmund Rose, MA<br />Licensed Psychologist Unknownhttps://www.blogger.com/profile/04557001239168962084noreply@blogger.com