Death in rehab- What is wrong with California’s addiction treatment?

We at A3 have long been saying that there is something seriously wrong with the way addiction treatment is being regulated and with the addiction treatment system that has sprouted up as a result. Now, a government report created for the California Senate Rules Committee called “Rogue Rehabs: State failed to police drug and alcohol homes, with deadly results” (see here) supports our notion and extends them in alarming ways. Among the major findings:

  1. Over the past decade, the California department in charge of regulating residential drug and alcohol programs consistently failed to catch life threatening problems [with addiction treatment facilities].
  2. Many addiction treatment facilities in California are providing medical care in clear violation of their licenses and often by under-trained staff.
  3. Addiction treatment providers are accepting patients that are far too impaired (as in sick) for them to handle because they would rather take the money than turn away a patient.
  4. These problems have led to several deaths within the California addiction treatment system in the last decade.

Obviously these findings are extremely disturbing and cases like the one studies in the report of Brandon Jacques, a patient who died while under the care of MorningSide Recovery’s care,  could have been prevented with more attention and transparency in our system. The idea that addiction treatment facilities that are not equipped to handle severe cases are taking them just for the money is sickening and antithetical to the reason for their existence. As far as I’m concerned, such unethical flouting of patient care should lead to an immediate revocation of their license and a ban for the management from the field.

The most distrubing factor to my mind is the fact that many of these providers know that what they are doing is wrong. But they also know that more than 50% of people who are looking for addiction treatment are doing so for the first time and have no idea what to ask, what addiction services they need, or how to assess whether a facility is appropriate. That means they can take advantage of them with fancy websites and the use of terms like “holistic treatment” that mean little and promise much. It’s disgusting and flies in the face of everything our field is supposed to stand for. It’s also the main reason I worked so hard to develop our Rehab-Finder, which while far from perfect and in need of serious work that I can’t afford to put into it, tries to fix these problems by recommending treatment that is appropriate given the specific issues a client is dealing with. We are currently conducting a study with UCLA on the effectiveness of tools like this and I am committed to figuring out a safer way to help those in need find the right addiction treatment for them.

Importantly, the report also makes a number of recommendations:

  1. Allow for medical service provision at addiction treatment facilities but legislate strict oversight and accountability paid for by agency fees.
  2. Medical detox facilities should be required to have medical directors.
  3. Establishing requirements and procedures for death investigations at addiction facilities.
  4. Strict oversight of programs found to admit clients it is not fit to treat including immediate license suspension.
  5. Information sharing between addiction treatment licensing boards and medical boards.

We think it’s time that addiction treatment providers be held to the same standard that other medical facilities are held to. It might help finally close the gap in terms of recovery outcomes. Running as a relatively unregulated industry does not help patients, it does not help move the field forward, and although they can’t see it it does not even help the treatment providers who are behaving unethically since many of them are eventually forced to close and face lawsuits. It’s time to move forward on this.

THC for HIV: Is smoking weed the only way?

The medical marijuana debate is still raging and I have little doubt that it will be around for at least a decade to come. In the mean time, there is little doubt that marijuana, and more specifically its most active ingredient THC, are useful for individuals suffering from a number of medical conditions (see medical uses of marijuana). One of those conditions is HIV, where THC is particularly useful for helping patients fight the anorexia that often goes along with the infection and treatment. While a number of states (15 and the District of Columbia at last count) allow for medical marijuana prescriptions, most others require that patients get their THC in a synthetic form known as dronabinol.

Synthetic THC in a capsule

I’m not getting into the discussion of whether putting THC in a synthetic form is the American government’s way of directing money towards the pharmaceutical industry. The bottom line is that smoking marijuana, like smoking cigarettes, causes pulmonary (as in lung) problems including an increased risk of cancer as well as a host of other diseases like emphysema and such. New(ish) devices like vaporizers may help reduce that risk, but until more data comes in, I doubt those are going to cause any movement in terms of legislation. And since smoking marijuana is still illegal in most states, patients are pretty much left with the dronabinol pill.

The only problem is that something like 30% of HIV patients report smoking marijuana any way for relief of disease-associated symptoms and no one ever assessed the effectiveness of dronabinol on these patients until now. In this recent study, researchers assessed the efficacy of a very high dose of dronabinol (10mg – twice the recommended daily dose and half of the allowed daily maximum dose) on HIV/AIDS patients who smoke marijuana recreationally. Not surprisingly these patients showed a reduced response to the drug and even this high dose was only effective for the first half (eight days – during which they consumed 350 more calories a day and slept better) of the experimental period, after which it was no more effective than placebo at improving caloric intake and sleep.

The researchers’ conclusion in this article is that is seems higher doses are necessary for these patients, although I wonder about the rates of lying about regular marijuana use by patients given its legal status in most states. The patients in this study all smoked marijuana but while some smoked sporadically (2 days a week), others were daily or near daily smokers. I would assume that those two groups reacted differently to the dronabinol, but this paper didn’t address any such differences.

So… Do you have to smoke weed to get the medical benefit of THC?

Overall this study, like a few others before it, shows that synthetic THC is effective in treating a number of the effects of HIV/AIDS infection and treatment. Nevertheless, there is little doubt that HIV patients who use marijuana require different dosing than patients who don’t smoke weed, an effect that was probably predictable. Given the high prevalence of marijuana smoking among HIV/AIDS patients, it seems that more research should be carried out in order to fully develop a recommended dose range for such patients.

For HIV/AIDS patients who live in states where medical marijuana use is legal, it is likely easier and more cost effective to get their THC from marijuana leaves, though given their increased risk of infection and the lung effects of inhaling smoke, they should likely play it safe and use a vaporizer rather using more traditional methods (as in joint, bowl, or bong). The last thing HIV patients need to do is to put their body at any increased risk of any sort of medical complication. However, since dosing can be an issue this way, and since not everyone objects to the notion of taking pills instead of smoking weed, dronabinol might be a good options for those who are simply looking to counteract their infection complications and not to light up.

Citations:

Gillinder Bedi, Richard W. Foltin, Erik W. Gunderson, Judith Rabkin, Carl L. Hart, Sandra D. Comer, Suzanne K. Vosburg & Margaret Haney (2010). Efficacy and tolerability of high-dose dronabinol maintenance in HIV-positive marijuana smokers: a controlled laboratory study. Psychopharmacology, 212, 675-686.

Arno Hazekamp, Renee Ruhaak1, Lineke Zuurman, Joop van Gerven, Rob Verpoorte (2006). Evaluation of a vaporizing device (Volcano®) for the pulmonary administration of tetrahydrocannabinol. Journal of Pharmaceutical Sciences, 95, 1308-1317.