The Language We Use in Addiction Treatment

The language we use related to alcohol and drug use disorders is often stigmatizing and misguided. Alltyr’s mission is to transform addiction treatment in America. Changing language is a necessary step in that process.

Here’s is Alltyr’s guide to addiction language for the 21^st Century.

Instead of saying:	Say:
alcoholic	person with an alcohol use disorder (AUD)
addict	person with a substance use disorder (SUD)
alcohol /drug abuse	risky use, heavy drinking, risky drinking
sober	abstaining, in remission
betrayer, liar, cheat, thief, selfish	addicted person, sick, ill
enabler	loved one
enabling	unhelpful or unskillful behavior
tough love	self-care, setting reasonable limits and expectations
unmotivated, denial	ambivalent about change, non-adherent, not yet able to overcome barriers to change, demoralized
dry drunk	irritable, moody, troubled, erratic, struggling
slip, lapse, relapse	use episode, recurrence, set-back
recovery (abstinence + spiritual growth)	remission (absence of illness once present)
relapse	recurrence, set-back
relapse prevention	recovery skills training
treatment program	rehab
Treatment (meaning rehab)	treatment (includes all levels of care)
MAT (medication assisted treatment)	treatment, pharmacotherapy, anti-relapse meds
compliance	adherence
non-compliant	non-adherent
harm reduction	treatment, chronic care management, partial response

Want to learn more about The Alltyr Model of Care™? Visit our website: www.alltyr.com 

Informed Consent in Addiction Treatment: An Ethical Obligation

Informed Consent in Opioid Addiction Treatment: An Ethical Obligation

This article was originally published in The Carlat Addiction Treatment Report, Volume 2, #3, May 2014

Source: 

 CATR, May 2014, Vol 2, Issue 3, Opioid Addiction

Mark Willenbring, MD

Founder and CEO, Alltyr Clinic, St. Paul, MN, Former Director, Division of Treatment and Recovery Research, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD

Dr. Willenbring has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Informed consent—whether it be for psychotherapy, prescribing a medication, or performing a surgical procedure—is an ethical principle firmly established in law and medicine.

While there has been no formal research on this subject, my experience suggests that many addiction treatment programs fail to obtain valid informed consent. The starkest example occurs in the treatment of opioid addiction, where the practices and beliefs of clinicians often differ markedly from the evidence regarding effective treatments.

What is Informed Consent?

Informed consent refers to the collaborative process that a provider and patient go through to develop a treatment plan for the patient’s problems. This moral requirement is based on the principle of respecting a person’s autonomy, that is, their right “to hold views, to make choices, and to take actions based on their values and beliefs” (Beauchamp TL & Childress JF.Principles of Bio-medical Ethics, 7th ed. New York: Oxford University Press, 2013:122–123).

Valid consent fulfills three criteria (Grimm DA, N M Law Rev 2007;37(1):39–83). First, the patient needs to have decision-making capacity. Capacity, in a medical context, refers to patients’ ability to understand information, appreciate their situation, use reason to make a decision, and communicate their choices (Applebaum PS, N Engl J Med 2007;357(18):1834–1840). This is referred to as the “capacity” criterion.

Second, the provider needs to present the full range of available treatment options based on current scientific knowledge. During this discussion, he or she needs to outline the risks and benefits of these various options and what could be reasonably expected if the patient declines treatment altogether. This is called the “disclosure” criterion.

Finally, valid consent requires that patients are free from coercion—that is, they are in a position to voluntarily choose any treatment option that they feel is best for them. This is described as the “voluntariness” criterion.

A provider has failed to obtain valid informed consent if any of these elements are missing.

Legal Standards

Legal requirements for consent have evolved over centuries. Until relatively recently, courts used a physician-oriented point of view: the physician was required to provide information he or she felt was in the patient’s best interests. This resulted in practices such as informing a spouse, but not the patient, of a terminal disease. In other cases, providers deliberately omitted certain treatment options from their discussions with patients because of their personal beliefs or biases against them.

Through a series of court decisions, a new standard, the “reasonable person” or “prudent person” standard, emerged. Providers are now expected to present patients with information that a reasonable or prudent person would want to know in order to make healthcare decisions (Berg JW et al.Informed Consent: Legal Theory and Clinical Practice, 2d ed. New York: Oxford University Press, 2001:48).

In clinical practice, a provider is not allowed to withhold information from a patient based on his or her judgment that one treatment is better than another. The provider is thus required to present the scientific evidence supporting available treatment options, the expected outcomes of these various treatments, and the clinician’s recommendation for the patient and the rationale for it. This recommendation also needs to take into account any patient-specific features that factored into the provider’s decision-making.

This means that clinicians are legally obligated to provide information that they may prefer to withhold. The purpose of informed consent, however, is not to “conveniently promote a treatment plan; it requires informing patients with the recognition that they may disagree with a recommended treatment plan and retain the authority to do so” (Berg et al, op.cit).

There is also an important distinction between the actual process of obtaining autonomous authorization for a treatment or procedure and institutional requirements that patients sign informed consent documents. Patients frequently sign such documents in the absence of true informed consent (Beauchamp & Childress, op.cit).

Evidence-Based Treatment

Providers are obligated to summarize the scientific data concerning the effectiveness of various treatment options. The only treatment with consistent, strong evidence of effectiveness for opioid addiction is indefinite opioid maintenance therapy with either buprenorphine or methadone (Mattick RP et al, Cochrane Database Syst Rev 2014;2:CD002207).

Currently, the World Health Organization, US Centers for Disease Control and Prevention, US Department of Health and Human Services, and many other agencies and organizations recommend methadone and buprenorphine maintenance as first-line treatments.

In contrast, there is no evidence commending drug-free (or so-called abstinence-based) treatments (Mayet S et al, Cochrane Database Syst Rev2005;1:CD004330). Moreover, there is good evidence that psychosocial or intensive behavioral approaches fail to improve outcomes compared to minimal drug counseling in patients receiving opioid maintenance therapy (Amato L et al, Cochrane Database Syst Rev 2011;10:CD004147; Fiellin DA et al, Am J Med 2013;126(1):74.e11–17).

Naltrexone is the only other medication that has been approved by the FDA for opioid addiction. Oral naltrexone (ReVia) is ineffective (Minozzi S et al,Cochrane Database Syst Rev 2011;4: CD001333) and the efficacy of extended-release, injectable naltrexone (Vivitrol) was established in just a single, industry-sponsored study conducted in Russia, where buprenorphine and methadone are not legally available (Krupitsky E et al, Lancet2011;377(9776):1506–1513).

Presently, evidence for Vivitrol’s effectiveness is limited and generalization of clinical trial data to other countries is questionable. (For more, see“Vivitrol: Another Option for Opioid Addiction?”)

Meeting the Capacity Criterion

In addiction treatment, patients who are experiencing severe withdrawal symptoms may not have capacity due to pain and emotional distress. Other confounders include co-occurring mental disorders and cognitive impairment associated with prescribed medications and substances of abuse. Although beyond the scope of this article, simple bedside instruments allow providers to evaluate and easily document a patient’s decision-making capacity (Tunzi M, Am Fam Physician 2001;64(2):299–306).

Meeting the Disclosure Criterion

Providers need to have a clear understanding of available treatment options and the scientific evidence supporting each one, so they can meet their obligation concerning disclosure.

This article’s brief summary may serve as a starting point. Standard textbooks are also a ready source of such information (eg, Strain EC & Stitzer ML eds. The Treatment of Opioid Dependence. Baltimore, MD: Johns Hopkins University Press, 2006). In addition, a number of plain language resources geared toward patients are available (eg,http://1.usa.gov/1ibCKou).

Providers need to present patients with more than their program’s philosophy or even the community standard of care. Remember, the standard for disclosure is what a reasonable or prudent patient would want to know, not a narrow presentation concerning usual care or the provider’s personal preferences. In the case of opioid addiction, this means summarizing the scientific data on the effectiveness of treatment options. This is a fiduciary duty that trumps the clinician’s personal preferences and their program’s philosophy of care.

Meeting the Voluntariness Criterion

Providers need to be very sensitive to overt, and more subtle covert, coercion when discussing treatment options with patients. Many people presenting for substance use treatment are subject to significant coercion from the legal system, employers, and families. Thus, we need to ensure that consent is truly voluntary and that we are not using coercion to impose our own views concerning treatment upon patients.

This ethical obligation may require advocating for a treatment option different than what a judge, probation officer, employer, or family prefers or recommends.

CATR’s Take: Addiction treatment has historically been very prescriptive and patients often had little choice about the care that they received. This article is a good reminder that providers have an affirmative duty to obtain informed consent and engage patients in shared decision-making.

Alltyr Clinic Featured on NPR's Weekend Edition!

Alltyr Clinic is featured on NPR's Weekend Edition Sunday today, June 8, 2014. We are positioned as an alternative to traditional rehab, in this case Hazelden. One of our patients, Shane Linehan, was brave enough to share his experience with both Hazelden (where he went first) and Alltyr Clinic (where he is being treated now.) I want to thank him and applaud his courage for speaking out. (For the record, Alltyr Clinic gave him no incentive; we simply offered the opportunity to many of our patients.) We are honored to be compared to arguably the best known traditional rehab in the country (if not the world.)

Unfortunately, in the summary on the program's landing page, our approach is described as being almost totally oriented around prescribing anti-relapse medications. Although we use every proven anti-relapse medication, we also use every evidence-based behavioral/psychosocial approach. This includes individual and group therapy using motivational, cognitive-behavioral, coping skills, 12-Step Facilitation, EMDR, CRAFT, DBT, psychodynamic, community reinforcement, couples and family approaches. Which we use depends on the needs of the patient. Our team includes addiction psychiatrists, addiction medicine specialists, psychologists, social workers, counselors and recovery coaches.

Furthermore, we fully integrate treatment for any co-existing mental health disorder, such as anxiety, depression, PTSD, personality disorders, bipolar disorder, cognitive disorders, as well as medical problems such as insomnia and chronic pain. We really aim to be a "one-stop shop." If sober housing is needed we work with community partners to help our patients secure it. 

The bottom line is this: coming to Alltyr Clinic is like coming to a mental health clinic or any other health care service using a multi-disciplinary approach. Each patient receives a comprehensive individual evaluation upon which the treatment recommendations are based. Selecting from a large menu of services, a truly individualized treatment plan is arrived at by the patient, the treatment team, and if appropriate, the family. After treatment is started, the plan is modified as needed. The length and intensity of treatment is also completely individual and flexible. We do whatever we can and we stay with you as long as it takes. We aren't a program, we're a clinic.

At Alltyr Clinic, "We Don't Just Call Addiction a Disease, We Treat It Like One."TM

Baclofen Shows Promise for Treating Relapse in Cocaine Use Disorders

Via ScienceDaily:

Relapse is the most painful and expensive feature of drug addiction -- even after addicted individuals have been drug-free for months or years, the likelihood of sliding back into the habit remains high. The National Institute on Drug Abuse estimates that 40 to 60 percent of addicted individuals will relapse, and in some studies the rates are as high as 80 percent at six months after treatment. Though some relapse triggers can be consciously avoided, such as people, places and things related to drug use, other subconscious triggers related to the brain's reward system may be impossible to avoid -- they can gain entry to the unconscious brain, setting the stage for relapse.

Researchers at Penn Medicine's Center for Studies of Addiction have now found that the drug baclofen, commonly used to prevent spasms in patients with spinal cord injuries and neurological disorders, can help block the impact of the brain's response to "unconscious" drug triggers well before conscious craving occurs. They suggest that this mechanism has the potential to prevent cocaine relapse. The new findings are reported in the Journal of Neuroscience.

"The study was inspired by patients who had experienced moments of 'volcanic craving', being suddenly overcome by the extreme desire for cocaine, but without a trigger that they could put their finger on," says senior author Anna Rose Childress, PhD,research professor of Psychiatry, director of the Brain-Behavioral Vulnerabilities Division in the Perelman School of Medicine at the University of Pennsylvania. Dr. Childress and colleagues previously found that subliminal drug "reminder cues" (the sights, sounds, smells, and memories of the drug) could activate the brain's reward circuit. "Now, we wanted to understand whether a medication could inhibit these early brain responses," said Childress.

Kimberly Young, PhD, an NIH/NIDA Post-doctoral Fellow at Penn, and first author of the study explained that, "Drug reward and motivation is largely mediated by dopamine transmission in the brain's reward circuit -- even drug "reminder cues" can cause dopamine release. Since baclofen and similar medications reduce these effects in laboratory animals, we wanted to examine whether it could prevent drug-cue induced activation in the human brain."

The study tested baclofen, which was approved by the U.S. Food and Drug Administration in 1977 for spasm, on 23 cocaine-dependent men, ages 18 to 55. Each reported using cocaine on at least eight of 30 days before screening. Inclusion in the study required that they stay for up to 10 days in a supervised inpatient drug treatment facility, be drug-free for the duration, not be on any medication affecting dopamine or neurotransmitter response, and have no history of psychosis, seizures, or brain syndromes unrelated to cocaine use.

Upon admission, patients were randomized to receive baclofen or placebo. Over the first six days, patients in the baclofen group received the medication in increasing dosage to 60 mg. While on the full 60 mg dose of baclofen, patients were placed in an fMRI and shown a series of images, to measure their neural responses to "ultra-brief" pictures of cocaine or other comparison pictures. Each of the ultra-brief 33 msec "target" pictures was immediately followed by longer picture of non-drug objects or scenes. Under these conditions, the participants are aware of the longer pictures, but the ultra-brief target pictures remain completely outside conscious awareness -- they are "backward-masked."

"We wanted to present the key stimulus: images of drug use and preparation, sexual images, and other aversive images in a way such that the brain could not consciously process them, but so that we could measure their earliest, subconscious effect on the brain," said Childress.

What the team found was that the patients who were treated with baclofen showed a significantly lower response in the reward and motivational circuits to subliminal cocaine cues versus neutral cues, as compared to the placebo-treated control group. In addition, no difference was seen in the active versus the control group in their response to sexual and aversive cues, indicating that the effects of baclofen on cue-induced brain activation were specific to drug cues.

"These findings suggest that the brain response to drug cues presented outside of awareness can be pharmacologically inhibited, providing a mechanism for baclofen's potential therapeutic benefit in addiction," says Young. "Further studies will show whether the prevention of these early brain responses is associated with reduced rates of craving and relapse in cocaine-dependent patients," added Childress. 

Source: http://www.sciencedaily.com/releases/2014/04/140401172914.htm

This could be exciting news for one of the most difficult substance use disorders to treat. Does anyone have experience using baclofen with patients with cocaine use disorders?

Is Addiction Always Permanent?

Recently, a colleague challenged what he perceived to be my "insistence that addiction is permanent." Here is my reply:

Dear John (not his real name):

As you know, I'm well aware of the studies regarding the life course of people who at some point in their lives meet dxic criteria for a SUD. And also, as you are aware, I've been talking about that, and therefore the need to have a wider continuum of care and to individualize approaches to SUDs for at least 10 years. In my presentation, Alcoholism Isn't What It Used to Be, which you frequently reference, I point out that 20 years after onset of DSM IV Alcohol Dependence, the most common outcome is low-risk drinking (40%), followed by abstinence (roughly 1/3), partial remission (about 20%) and then finally currently dependent (8%). So I'm not sure what the basis is for concluding that I have made blanket statements about ALL addicts in ALL circumstances.

 

What I do believe, and here I think the science and epidemiology are equally persuasive, is that in the case of severe addiction, there are brain neuroadaptations that are irreversible. For example, the likelihood of achieving non-abstinent recovery is inversely related to the severity of alcohol dependence. Conversely, abstinent outcomes become more likely as severity increases. This is as true in rodents as in humans. Since rehab and AA are populated almost exclusively by people at the very severe end of the spectrum, the likelihood of sustained non-abstinent recovery for current treatment seekers or AA members is relatively low. Thus, the AA stance is accurate for most AA members. Severity of dependence is the strongest predictor of AA affiliation, especially long-term affiliation, as opposed to a few weeks or months after a spell in rehab. Established heroin or other opioid addiction is another example; thus buprenorphine and methadone maintenance and the virtually complete failure of abstinence (or moderation) for treatment seekers. Those who could stop on the their own do so and therefore do not present for tx. That, of course, is a function of the awfulness, expense, stigmatization and disruption most current treatment includes.

 

At Alltyr Clinic, for example, I have seen many pts who come with a mild AUD who achieve non-abstinent recovery.

 

Just as abstinence is not a requirement for everyone who develops a SUD, neither is moderation possible for a sizeable proportion of them. The size varies by drug: Probably close to 100% of dependent smokers will require lifelong abstinence, whereas, most cannabis users will not, etc. Heroin, meth and cocaine addiction also probably have high to relatively high proportions where abstinence (which includes people taking opioid agonist therapy) is the only positive outcome option. In alcohol, I think it's probably somewhere in the middle, a large minority achieve non-abstinent recovery.

 

So the newer data simply seem to affirm the NESARC data, that conclusions have been based on clinical samples, and that if you look at community samples, the picture is very different. That's true for almost all common complex diseases, such as asthma or arthritis or even hypertension, the difference being that with SUDs there is a very high full remission rate, something that happens in very few other common complex diseases. Depression is very likely to be a pretty good analogue as well.

 

Finally, noting that many people have milder, self-limiting forms of SUDs doesn't mean they aren't brain disesases. How can you have a behavioral illness that doesn't include failures in brain regulation of behavior? It's just that in too many instances, people misinterpret "brain disease" to mean "permanent". Also, it hasn't helped that NIDA and SAMHSA keep stressing the chronicity of addiction, something I constantly fought against when i was at NIH. It's often not chronic. Neither is asthma, but I suspect you wouldn't have trouble thinking of mild, self-limited childhood asthma as a lung disease, or immune disease.

SAMHSA Releases State and National Behavioral Health Barometer

The federal Substance Abuse and Mental Health Services Administration recently released its yearly report on the general state of behavioral health needs and services in the US. Based on population and treatment-facility data sets from state to state, the Behavioral Health Barometer is a sweeping, in-depth look into adolescent and adult drug use, treatment and mental health service utilization.

Among the highlights:
- Nationally, youth and young adult use of nonmedical pain relievers is declining in general.
- Past-month cigarette use among teens nationally and locally is declining, although Minnesota saw a small increase in 2011-2012
-Over 50% of Minnesota adolescents, and over 60% of adolescents nationally, did not receive treatment for their past-year depressive episode.
-In Minnesota, only 6.6% of people with past-year alcohol dependence received treatment. For illicit drugs, the number is 14.6%
-In Minnesota, while the number of people receiving methadone treatment has increased by nearly 1000 people since 2008, the number of people receiving buprenorphine has actually decreased in that time (owing to a sharp drop from 2008-2009.

The national report is here:
http://www.samhsa.gov/data/StatesInBrief/2K14/National_BHBarometer.pdf

Read the MN report here:
http://store.samhsa.gov/shin/content/SMA13-4796/SMA13-4796MN.pdf

And find your state here:
http://store.samhsa.gov/product/Behavioral-Health-Barometer-2013/SMA13-4796

Study: Hallucinogen Use Predicts Reduced Criminal Justice Recidivism

In a potentially fascinating article, published in this month's Journal of Psychopharmacology, researchers identified a correlation between naturalistic hallucinogen use and reduced recidivism among substance-involved offenders under community corrections supervision. The sample is very large (n=25,622) and it appears the relationship remains after controlling for "an array of potential confounding factors." Given the report last year that lifetime psychedelic use was not associated with current mental health problems in an adult population, this study's implications could be especially interesting.

Unfortunately, my institution doesn't allow me access to this journal - if there are any readers who can access the full article, please let me know.

(Comment after the fact: Keep in mind that this shows a correlation and that correlation does not establish directionality. That it, it's at least equally plausible that people with a diagnosis of psychedelic use disorder (a tiny fraction of the population) are different in ways that statistical controls cannot compensate for, and are therefore less like to reoffend. This makes sense in that psychedelic drug use is minimally addictive, if at all, and craving and urges are not typical in this group. It seems highly implausible to me that hallucinogen use had a beneficial effect. The authors should never have been allowed to make that claim, a fault of the editor. In addition, use of LSD or psilocybin has never been associate with increased incidence of mental disorders, in contrast to MDMA or synthetic cannabinoids.)

Here's the abstract via SagePub:

Abstract

Hallucinogen-based interventions may benefit substance use populations, but contemporary data informing the impact of hallucinogens on addictive behavior are scarce. Given that many individuals in the criminal justice system engage in problematic patterns of substance use, hallucinogen treatments also may benefit criminal justice populations. However, the relationship between hallucinogen use and criminal recidivism is unknown. In this longitudinal study, we examined the relationship between naturalistic hallucinogen use and recidivism among individuals under community corrections supervision with a history of substance involvement (n=25,622). We found that hallucinogen use predicted a reduced likelihood of supervision failure (e.g. noncompliance with legal requirements including alcohol and other drug use) while controlling for an array of potential confounding factors (odds ratio (OR)=0.60 (0.46, 0.79)). Our results suggest that hallucinogens may promote alcohol and other drug abstinence and prosocial behavior in a population with high rates of recidivism.

Sources:
http://jop.sagepub.com/content/28/1/62.abstract
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0063972

Update:
Thanks to Paul and Jason for sending the full piece. 
Treatment Accountability for Safer Communities (TASC)provided the authors access to de-identified records on 25,622 felony-charged individuals on community corrections supervision from  between 2002-2007. "Any hallucinogen use" was not a descriptor in the data, so they were confined to hallucinogen-use disorder, abuse or dependence, assuming that case workers would likely interpret any use as disordered. Interestingly, 73.6% of folks with a hallucinogen-use disorder in the sample were white/Caucasian. And, according to the researchers, hallucinogen-use disorder was the third strongest predictor of recidivism rates, behind cocaine- and cannabis-use disorder, respectively, which most strongly (but positively) predicted recidivism.The authors call for RCTs to explore hallucinogen-based therapies in the criminal justice population.

Wacky Progressives and Scientific Illiteracy

In a disturbing article in the New York Times, Amy Harmon chronicles the tale of a brave county councilman on the island of Kona, Hawaii, who refused to be steamrolled by those who categorically believe that genetically modified organisms (GMOs) are dangerous and should be banned across the board. He actually took the time to look into the scientific research, to consult with scientists who know about this, and he attempted to draw a reasonable conclusion. He is faced, however, with a group of true believers, who keep repeating obscure claims based on long-discredited "research." They shout down their opponents and make outlandish claims that have no scientific basis or rationale. They demonize their opponents, and constantly shift the arguments when faced with scientific facts. Most disturbing of all was the refusal of his fellow council members to even allow scientists to testify, instead giving the floor repeatedly to unqualified zealots who continued to make broad, unsupportable statements. 

It turns out, then, that it's not only climate-change deniers and birthers who maintain passionately held beliefs that have no scientific basis. Worse, it shows how repeating false claims becomes a sort of echo chamber for those with similar beliefs. Finally it shows that such behavior is not limited to Tea Party fanatics or religious zealots, but applies equally to so-called progressives on the left side of the political spectrum. I write about this because it applies as well to too much in the fields of psychotherapy, behavior change and addiction treatment.

We tolerate too much of this type of thinking in our field. How many treatment centers offer "holistic" therapies such as yoga, energy field work, Reiki, or massage, or worse, "nutritional treatment" that is not only unsupported, but may well be harmful? Why are state agencies still allowing such centers to obtain licensure? Why are people paying for brain scans or quantitative EEGs or neurofeedback? And, of course, why do so many people cling to the fiction that 90x90 is effective for most people, or that 12-step approaches are 100% effective if you follow directions? (What treatments for human maladies, short of penicillin for strep throat, can claim 100% effectiveness?)

I'm not arguing that an absence of evidence of effectiveness is evidence of ineffectiveness. There is lots we all do that hasn't been studied well, simply because it is impossible to conduct a large randomized controlled trial on every possible therapy. However, in addiction treatment we have a very large and very strong evidence base from which to draw. It's actually far better than in many other areas of health care. In order to include an approach in a licensed program, at the least, we should require 1) a scientifically plausible rationale for a treatment, 2) that unsupported treatments should not be likely to cause significant harm or cost a significant amount of money, 3) that there is not significant evidence that the approach is not effective, and 4) that there is not a well-supported approach already available.

I'm also not suggesting that yoga, meditation, Reiki, energy field work, reflexology, acupuncture, massage, etc., may not be experienced as beneficial to some people. I recently underwent Rolfing, for example, which I found to be very helpful (if painful). But I didn't expect my health insurance to pay for it, and I reject any large claims concerning what it and similar approaches might accomplish. Such approaches might be made available to clients (at their own expense), but not as presented as a scientifically based health practice.

I have been surprised at how trendy the psychotherapy community is in general, not just in addiction treatment. One current example is the spread of dialectical behavior therapy (DBT) beyond its proven focus on borderline personality disorder. It seems that it's being applied to anyone and for every condition short of psychosis. Another trend is "trauma informed therapy" using eye-movement desensitization and reprocessing therapy (EMDR), DBT, prolonged exposure, or mindfulness. All of a sudden, everyone has "trauma" for which these are appropriate treatments, even though many do not meet criteria for post-traumatic stress disorder (PTSD.) What was psychoanalysis if not focused on trauma? For that matter, "mindfulness" is another trendy approach, with practitioners charging for something the Buddha gave away 2600 years ago and which can be had for free at your local Buddhist meditation center.

At the same time, I seldom encounter high quality cognitive-behavior therapy (CBT) being applied to co-existing anxiety or depressive disorders, in spite of a mountain of evidence supporting their effectiveness. And too many in our field still believe that "I don't believe in it" is an adequate reason to not support anti-relapse medications that also have a strong evidence base. When we have such well-supported therapies, why aren't we using them? Why are we instead embracing half-baked ideas and approaches? Why do we tolerate so much scientific ignorance? Why do we tolerate lack of informed consent, where clients are not given information about what the evidence supports and what it does not, but instead receive biased and incorrect information that deprives them of the opportunity to make an informed decision?

Are Financial Incentives the Answer to SBIRT Implementation?

Researchers from Imperial College London may have found a way to increase alcohol screening and brief intervention in a primary care setting: financial incentives. The results, published online Dec. 26 in the Journal of Public Health, show that offering a points-based incentive for successful screening, brief intervention and referral to specialists significantly increased the number of patients who were screened. As a result, the authors say, more patients with risky alcohol intake were identified and offered care, reducing hazardous and harmful drinking in some.

While the evidence for SBIRT is abundant and well-known, there have been considerable problems in promoting widespread implementation - especially in primary care. Financial incentives could be one effective means of changing this. (Granted, a large-scale effort by the federal government or the insurance companies would likely be required to provide funding. In this study, data was collected from 2008-2011, until the UK's Quality and Outcomes Framework funding was withdrawn.)

Abstract

Introduction Alcohol screening and brief intervention (ASBI) is effective but underprovided in primary care. Financial incentives may help address this. This study assesses the impact of a local pay-for-performance programme on delivery of ASBI in UK primary care.

Methods Longitudinal study using data from 30 general practices in north-west London from 2008 to 2011 with logistic regression to examine disparities in ASBI delivery.

Results Of 211 834 registered patients, 45 040 were targeted by the incentive (cardiovascular conditions or high risk; mental health conditions), of whom 65.7% were screened (up from a baseline of 4.8%, P< 0.001), compared with 14.7% of non-targeted patients (P < 0.001). Screening rates were lower after adjustment in younger patients, White patients, less deprived areas and in patients with mental health conditions (P < 0.05). Of those screened, 11.5% were positive and 88.6% received BI. Men and White patients were significantly more likely to screen positive. Women and younger patients were less likely to receive BI. 30.1% of patients re-screened were now negative. However, patients with mental health conditions were less likely to re-screen negative than those with cardiovascular conditions.

Conclusion Financial incentives appear to be effective in increasing delivery of ASBI in primary care and may reduce hazardous and harmful drinking in some patients. The findings support universal rather than targeted screening.

Source: http://intljpubhealth.oxfordjournals.org/content/early/2013/12/26/pubmed.fdt121.abstract

Advice for Consumers of Addiction Services

In the November issue of the prestigious journal Health Affairs, Anne Fletcher's book Inside Rehab got a very favorable review. Yours truly was highlighted with this paragraph from the review:

"Certainly the most useful part of the book is the advice provided by Mark Willenbring, former director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism. He recommends that those seeking treatment should see themselves as customers and seek the best treatment that will work for them. They should get a comprehensive evaluation from someone not financially invested in a specific treatment program, demand nothing less than master’s degree–prepared therapists, and make sure the program treats any co-occurring issues. They should also not go through the same treatment protocols over and over again when it is obvious that they aren't working."

Thanks to Anne of course, and also to the reviewer, Rick Mathis (Richard_Mathis@bcbst.com), a a health
researcher at the BlueCross BlueShield of Tennessee Health Institute.

MW

Overcoming Addictions, a web-based application, & SMART Recovery: Outcomes of a randomized clinical trial

This week's entry comes from Dr Reid K Hester, PhD. He is Director of the Research Division at Behavior Therapy Associates, LLC, where they have been conducting some exciting new research using a web-based application, Overcoming Addictions. Thank you, Dr Hester, for the guest post:

Overcoming Addictions, a web-based application, & SMART Recovery: Outcomes of a 

randomized clinical trial

My research staff and I recently published the early outcomes of a new web app, Overcoming Addictions in the Journal of Medical Internet Research (http://www.jmir.org/2013/7/e134). Overcoming Addictions (OA, www.overcomingaddictions.net) is an abstinence-oriented, cognitive behavioral program based on the protocol of SMART Recovery. SMART Recovery (www.smartrecovery.org) is an organization that has adapted empirically supported treatment strategies for use in a mutual help framework with in-person meetings, online meetings, a forum and other resources.

A firm believer of “In God we trust, everyone else has to show their data,” we evaluated the effectiveness of OA and SMART Recovery (SR) with problem drinkers in a randomized clinical trial. We recruited 189 heavy problem drinkers primarily through SMART Recovery’s web site and their online and in-person meetings. We randomly assigned them to: (1) OA alone, (2) OA+ attend SMART Recovery meetings (OA +SR), or to (3) attend SMART Recovery meetings (SR) only. Outcome measures included self-reported percent days abstinent, mean drinks per day when they did drink , and alcohol/drug related consequences. We also interviewed significant others to corroborate the participant’s self-report.

We predicted that: (1) All groups would reduce their drinking and alcohol/drug related consequences at follow-up compared to their baseline levels; (2) the OA groups would reduce their drinking and alcohol/drug related consequences more than the control group (SR).

There were several striking features of our participants. First, 60% of them were female. While this is consistent with the clinical trials of our other web applications like the Drinker’s Check-up (www.drinkerscheckup.com) and Moderate Drinking (www.moderatedrinking.com), it is significantly more than what one would predict given the prevalence of problem drinking in women versus men (35 vs. 65% respectively) in the epidemiological data. Second, this was a highly educated group with an average of 16 years of education. Third, while these folks were not seeking formal treatment, they had a level of alcohol problems comparable to the outpatient arm of Project MATCH.

At the 3 month follow-up both the intent-to-treat analyses and the actual use analyses showed highly significant improvement from baseline to follow-ups.  Mean within-subject effect sizes were large (d > .8) overall. There were, however, no significant differences between groups. Participants in all groups significantly increased their percent days abstinent from 44% to 72% (P<.001), decreased their mean drinks per drinking day from 8.0 to 4.6 (P<.001), and decreased their alcohol/drug-related problems (P<.001) by about 50%. These are clinically meaningful improvements in outcomes.

These outcomes indicate that both our Overcoming Addictions web app and attending SMART Recovery meetings and using their resources online (www.smartrecovery.org) were effective in helping people recover from their problem drinking.

These graphs reflect outcomes of the actual use analyses.

Advice for Mental Health Clinicians

A clinician recently sent me this email:

Dr. Willenbring,

I read an article in the New York Times from early this year discussing Effective Addiction Treatment that in part highlighted your comments and Alltyr's mission to be a 21st century model for addictions treatment.

As a therapist in an outpatient practice not specializing in addictions treatment--but who nevertheless encounters co-morbidity with substance abuse on a pretty regular basis--it can be confusing to know how to approach the psychosocial aspects of treatment. I believe in a multimodal approach for chronic forms of addiction but there are tons of options out there for my part in that process:  motivational enhancement therapy, cognitive-behavioral, contingency management interventions/motivational incentives, the matrix model, 12-step, DBT, family behavior therapy, interpersonal neurobiology, etc. There is so much out there it's dizzying, and I feel overwhelmed. There are some that seem more indicated for alcohol, others that seem better for stimulants, another for opioids. I've worked for agencies that are sold on one particular treatment for every type of substance abuser, and others that turn their therapists loose to use whatever they think best.

I want to use the best, empirically validated approaches and everyone seems to have an opinion on what that is. Where would you recommend I start, particularly for treatment options?

Here's my reply:

Hi Jxxxx,

It is indeed a confusing landscape out there, both for non-specialist clinicians and for patients and families. 

A good place to start is with the ASAM textbook on treatment of addictive disorders. It's coming out with a new edition (or it has just come out). Also, the American Psychiatric Association textbook is pretty good as an overall summary of evidence-based practice.

On an individual clinician level though it can be confusing. Here are some thoughts:

First, there is no ONE RIGHT WAY to overcome addictions. There are many different pathways. Our job is to help each person find his or her own best way.

Second, a skilled clinician is usually effective no matter the specific technique, as long as the clinician is focused on the patient, not the technique or path. Focus on general skills, such as empathy, reflective listening, unconditional positive regard, and instilling hope. There is no evidence that a specific technique is more effective than another, except in specific circumstances. The relationship is more important.

Third, be patient oriented. Take them where they are. Find out what they want, help them clarify their goals and how to reach them. Help them learn skills to achieve their goals, while also gently helping them realize that the ideal goal (use without consequences) is out of reach.

Finally, be patient and let them teach you about their disorder and its nature. Recovery is a two-steps-forward, one-step backward process. Trying and failing is a necessary step for most people, and the important thing is to accept that, learn from each step back, and then look forward. Persistence is the key. 

A couple of other things.

Never use the words denial, codependency, or enabling. Don't threaten, cajole or berate. Don't share your own experience unless it is (very) clearly in the best interests of the patient (it usually isn't). 

Never question their motivation to get better. I've never met an addict who liked being addicted. They all want to feel better, but sometimes it takes awhile to figure what the way forward is. 

Accept that you can't help everyone. Why should we be able to universally help everyone with a complex human affliction? Be humble, but hopeful and available. Never blame the patient/client for the failure of our treatments, which are modestly effective at best. People die of this disease, and too often we can't stop it or know how to help them. People die from all sorts of illnesses. It's no different to die of a dysregulation in our brain than in our heart, immune system or pancreas. We need to get over ourselves a little bit. We don't need to blame the person with the disease in order to protect ourselves from our inability to stop it. 

And keep working, and trying, and stay hopeful and alive and open hearted. That does the most of all.

Thanks for writing,

MW

Relapse Prevention Strategies and Anti-Relapse Medications

A recent commenter asked these questions:

Anonymous has left a new comment on your post "Is Maintenance the Best Therapy for Opioid Addicti...": 

Dr. Willenbring,

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?

-Stay away from the places you obtained your drug of choice?
-Stay away from the places you used your drug of choice?
-Stay away from the people that provided your drug of choice?
-Stay away from the people you used with?

What are your thoughts regarding these and other common relapse prevention measures with regard any treatment/recovery option available? 

The simplest answer is that yes, a relapse prevention plan is essential to recovery from any SUD. The examples this reader gives are common-sense strategies designed to reduce exposure to cues that might trigger urges, craving, preoccupation and, most importantly, opportunity. An old saying in AA is, "If you hang around a barber shop long enough, sooner or later you're going to get a haircut." I like the CBT approach of "Recognize, Avoid, Cope." First, do what you can to Recognize higher-risk situations, such as a social event that involves drinking (for someone with alcohol use disorder,) or where you are likely to be stressed or sleep-deprived (you have to work long hours for some reason, or a close family member is seriously ill.) For many people, a trip out of town to a work meeting, or, often worse, their spouse is going to be out of town (when the cat's away...) are high risk. Recognizing allows you to plan your strategy to reduce your risk of a recurrence. 

Second, Avoid the high-risk situation if you can. If a social event is going to involve a lot of drinking or drug use, and it's an optional event, skip it. Why put yourself in that situation? Why stress about it? Besides, one of the first things most people realize is that being sober while the other people are intoxicated isn't any fun. Although they (and you, in the past) may think that they're witty, charming and sexy, the reality is anything but. Typically, intoxicated people are dull and sometimes obnoxious. Unfortunately, avoiding intoxicated people too often means that you have to develop new friends, and you may have to endure some lonely times as that develops. Community support groups such as AA can help by providing you with a built-in social system to bridge that gap, but there are many other opportunities: book clubs, hiking clubs, bicycling organizations, volunteering, spiritual or religious activities, among many others. Be creative!

Finally, if you can't avoid the higher risk situation, develop strategies to Cope with it before you get there. Take a supportive friend, or identify another non-user within the group. Plan an early exit if possible. Practice drink/drug refusal skills. Take an anti-relapse medication (ARM). Remember, no one has any right to know your personal business, including whether you decide to use intoxicants or not. Have one or two stock phrases that 1) don't give a lot of information but don't lie, and 2) don't invite further questions. For example: "Hey, what's up? What's with you not drinking any more? Too stuck up for your bros? Let my buy you a drink, come on!" "No thanks. I just don't like the way I feel when I drink," or "You know, these days it pays to stay sharp, and I get too fuzzy headed if I drink." I'm sure you can come up with others. If the other person persists, you might retort, "Does my not drinking make you uncomfortable? What's the problem?"

One more thing, though, is that I think it's time to give up the false "abstinence-based recovery" vs. "medication-assisted treatment" dichotomy. It's a remnant of 1955. Is someone taking insulin for diabetes on "medication-assisted therapy" versus someone who tries to manage it by lifestyle changes alone? Is someone taking an antipsychotic or mood stabilizer "not abstinent?" My patients struggle at least as much with having to take medications for arthritis, MS, or depression as they do with taking anti-relapse medications. How about ARMs like naltrexone, or disulfiram (Antabuse), or topiramate (Topamax)? If you take those, are you "abstinent?" What if, by trying to "be abstinent," you are a miserable wretch with a high relapse risk, while if you take a medication such as buprenorphine (Suboxone), you are a happy, productive person with a low relapse risk? Why is "being abstinent" automatically thought to be superior, better, and to reflect more positively on you? Is it because we "should" be able to "do it ourselves?" Is it because "God should be enough?" Is it because it shows we are stronger, morally superior, more capable? Why "should" we be "able to recover without medications"? Who says? On what basis? This one idea kills more people with SUDs than almost any other, and I mean that quite literally. 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. So what? 

We Still Have a Ways to Go

Very excited to feature a post written by Paula DeSanto, Founder and President of Minnesota Alternatives and a leader in the movement to bring paradigm change to chemical dependency and mental health treatment in Minnesota. Thank you, Paula

We Still Have a Ways to Go

Four years ago I was inspired to open a clinic to help people with substance use issues because of the many, many stories I was hearing about ineffective and often times, harmful treatment.

While we are making progress with embracing more person-centered, stage matched interventions; I continue to have experiences that affirm how far we still have to go.  For example:

I was training a large group of clinicians and practitioners about person-centered care, and we were having a very spirited discussion about why drug and alcohol counselors seem compelled to report their clients use to probation officers.  I have worked as a mental health professional for over 2 decades and mental health clinicians don’t share this compulsion.   In fact, I can’t recall any MH worker ever thinking that this was their professional responsibility.

As this discussion progressed, a man raised his hand and offered a useful perspective.  He commented, “I worked as a probation officer for over 8 years, and throughout that time, we always thought of addiction providers as extensions of us.  There was a strong sense of “we – they” and the counselors job entailed trying to catch the clients using.”

Why do drug and alcohol clinicians think their job includes the role of a correctional officer?

No wonder clients “go underground” in treatment and say whatever they think others want to hear.

Another example:

I was interviewing a young woman who smoked a large quantity of cannabis daily and her parents were very concerned about her well-being.  She had been in treatment previously including some very prominent programs.   I asked this young woman why she smoked pot but before she had a chance to answer her mother jumped and stating, “She smokes because she has a brain disease, and her disease is controlling of her life”.

I again asked the young woman why she smokes, and she proceeded to explain that she smokes to relax especially at night before bed. What unfolded was a discussion about other motives for use and exploration as to whether this young woman even thought she had a problem.

A few days later her mother called me and shared this comment:

“My daughter has been in some of the best programs in the state and I have never heard anyone ever ask her why she uses.  She has always been told that she has a brain disease and they have the fix for it.”

“Kudos to you for asking.”