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.”

Buprenorphine: 4 Counseling: 0

It hasn’t been a good couple years for counseling in the buprenorphine treatment literature. Yet another study, authored by a team led by the venerable Walter Ling, and currently available in Addiction Journal’s “early view” section online, has shown that counseling adds nothing to buprenorphine maintenance, in terms of measured outcomes. By our count, this makes four consecutive studies to show basically the same thing: counseling, while by no means harmful, has not been shown to add anything to buprenorphine maintenance in opioid-dependent patients without significant co-occurring psychiatric disorders.

Ling, et al.’s study is arguably the most convincing study yet. The team performed a randomized control trial in which patients were randomized to one of four behavioral treatment conditions, as adjuncts to buprenorphine maintenance: cognitive behavioral therapy (CBT), contingency management (CM), both CBT and CM, and no behavioral treatment. Counselors were master’s-level trained counselors who met with patients weekly for the initial phase of the study.

The results showed no differences in opioid use after the behavioral treatment phase, during the second (medication-only) phase, or at follow-ups at weeks 40 or 52. In addition, there were no statistically-significant differences in any of the secondary measures (retention, other drug use, withdrawal and craving, addiction severity index ratings, and adverse events).

Interestingly, there were differences in reported treatment satisfaction ratings. While the majority of participants reported being “very satisfied” with treatment, and 85% reported Suboxone was “very effective”, just 60% reported that their behavioral treatment was “very effective”. On the other hand, 21% of the no-treatment group reported that their behavioral treatment was “not effective”, compared to 3% of the CBT group and 0% of the CBT + CM group.

As a student of behavioral health counseling, this science is particularly hard to swallow. However, it does seem to affirm the fact that, for patients with opioid-use disorders, ensuring easy and affordable access to maintenance medications is currently our best and most important tool for their treatment.

What do you think?

Is Maintenance the Best Therapy for Opioid Addiction?

Ian McLoone	6:30 PM (4 hours ago)
to me

Mark

I have been having some heated discussions lately about maintenance and the science around it. A lot of people say, "well reduced drug use is great, but what about quality of life?" For example, the studies comparing buprenorphine with and without counseling - there's no difference in outcomes, but those outcomes don't measure QoL. I did some research, and most of the studies I saw found improvements, but in the case of methadone, the improvements all occurred in the first 30days of Tx. Just wondering what you say about this perceived lack of QoL in the literature. 

Thanks

Mark Willenbring	10:57 PM (3 minutes ago)
to Ian

QOL measurement is a conundrum, very difficult to measure, since it's a perception, an interpretation, and doesn't correlate well with more objective measures of function or discomfort. 

I think their argument is simply a defensive one. The counterargument is that many more people who are treated with abstinence-based therapies relapse and die. Dozens of studies, internationally. What kind of QOL do dead people have?

The fact is, the ball is in their court: if they can prove that overall QOL is better (as well as survival) with abstinence-based treatment, terrific. If not, shut the heck up. If you reject a scientific finding on ideological grounds, say so. It's fine to assert: "Yes, more people use fewer drugs and fewer die if they take medication, but they aren't "really sober", they haven't "spiritually grown. Therefore, the goods of less drug use, more remission and fewer deaths are outweighed by a moral argument that their recovery is false. It is better to die than to take medication, because maintenance is not morally acceptable." That's a potentially valid position if you agree with their assumptions, which I obviously do not.

But don't argue that the findings aren't what they are because you don't like them. More people recover using medications, fewer people have legal, job, medical or social problems, and fewer people die with medication. These are established facts that cannot realistically be challenged, other than by rejecting current scientific methods and a broad international consensus of researchers and senior clinicians, not to mention the World Health Organization, the National Institute on Drug Abuse, the VA and DOD, and the CDC. I think the burden on the other side is formidable.

As Bernard Russell said, "When the facts change, I change my mind. What do you do, sir?"

Mark

Substance Matters Has Moved to Alltyr!

Substance Matters has migrated to the Alltyr website.

Oxytocin Shown to Block Alcohol Withdrawal

In a small, randomized, double-blind clinical trial, intranasal oxytocin blocked the effects of alcohol withdrawal on a population presenting to a hospital-based detoxification unit. Results from the study were published in the March edition of Alcoholism: Clinical and Experimental Research and are the first to confirm results obtained in other studies using non-human subjects.

In the study, participants (n=11) were given either lorazepam and oxytocin (n=7), or lorazepam and placebo (n=4), over three days of inpatient detox. They were then administered several standardized alcohol withdrawal measurements (CIWA, AWSC, ACVAS, POMS) and compared the two groups. Across the board, patients who were administered intranasal oxytocin scored significantly lower on withdrawal measures, while reporting significantly less craving and significantly better mood.
While the limitations of the study (small size) are clear, these findings are impressive and will lead to further research. In recent years, oxytocin has shown promise in the treatment of multiple disorders. Certainly, this research will add another voice to the chorus of oxytocin advocates.

Ants, Corporations, Complexity, Emergence

Heard on NPR Morning Edition:

Ants, bees, and other colonizing insects have complex organizations similar in many respects to modern corporations. Each ant has a specialized function that varies by age. The young ones tend the queen, middle-aged ants do clean up duty, and the older more experienced ants go out foraging for food. "The queen is really the only one with a dead-end job: laying eggs." Ants can jump over the clean up straight to foraging, similar to overachieving corporate managers. I don't know if the ants have to suck up to whoever is the ant CEO (this actually didn't come up) or not. Actually, it doesn't appear there is a CEO, the colonies are self-organizing. The scientist discussing this was asked about whether ants retire and her answer was that "ant retirement is not pretty." There is a specialized function for some ants, namely corpse disposal.

So in many ways, ant colonies are similar to corporations, but in addition to the presumed lack of a CEO or Board, there are other differences as well. Ant communication is much more efficient than in corporations. The ants communicate through chemical and other means than spread throughout the colony. "There is no email in an ant colony." (Lucky them, and presumably no Facebook or Twitter or texting either.) Another difference is that that there are no ants who get 400-500% more of the goodies than the median ant, while average CEO:median worker pay ratio is something like that. (According to Payscale.com, the Wal-Mart CEO is paid greater than 1000% more than the median worker there.) And presumably, ants don't get memberships in country clubs as part of their executive pay package.

The scientific principles here are complexity and emergence, an extremely important property of self-organizing systems, such as humans and the human "colony."  If you want to learn more, there is a fun site where you can set up your own ant colony. Just don't try to be the CEO.

MW

Restricted Access to SUD Meds and the Lack of Informed Consent

by Ian McLoone

A recent study by Abraham, et al., published in the March Journal of Studies on Alcohol and Drugs, finds that patients receiving treatment at publicly-funded programs have significantly less access to potentially life-saving substance use disorder (SUD) medications like buprenorphine, disfulfiram, acamprosate, and naltrexone. Buried in the report, however, is the shocking statistic that a full 56.4% of the programs (publicly- or privately-funded) prescribed no medications whatsoever. Clearly, there are a whole lot of consumers not being informed of their full array of choices when it comes to managing their treatment.

The study analyzed nearly 600 treatment programs throughout the country - data originally part of the National Treatment Center Study – and looked for differences in physician access and SUD medication access. The authors found that 10.9% offered access to one medication, while 32.7% offered more than one medication. Fewer than 5% of programs offered access to all of the above medications.

The authors note that nearly 2/3 of all specialty SUD treatment programs in the US are publicly funded, relying on government block grants and state contracts for the money needed to provide treatment, while private funding tends to come from private insurance and self-paying patients.

When divided into publicly-funded and privately-funded categories, private programs were almost 15% more likely to have a physician on-staff and nearly 10% more likely to employ master’s-level counselors. And while publicly-funded treatment programs were almost 14% less likely to prescribe buprenorphine, only 32.5% of all programs offered the medication. Only 20.6% of programs offered disulfiram, 27% offered tablet naltrexone, 27% offered acamprosate, and a slim 13.1% of programs offered injectable naltrexone.

Among other findings, programs with a more professional workforce were positively correlated with the number of SUD medications offered, and programs with a physician on staff were more likely to offer higher numbers of SUD medications than programs with no access to physicians.

These findings beg the question: why are evidence-based practices so rare and why is this tolerated in addiction treatment but not in other professional treatments? (What if over half of American cardiologists prescribed no medications to their patients?) Sure, public programs offer fewer scientifically-supported therapies – but even people who are spending a fortune of their own money are often getting poor care. When patients are not informed of the full array of treatment options, the lack of informed consent becomes an ethical – and likely legal – issue.