September 5th, 2012
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:
- 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].
- Many addiction treatment facilities in California are providing medical care in clear violation of their licenses and often by under-trained staff.
- 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.
- 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:
- Allow for medical service provision at addiction treatment facilities but legislate strict oversight and accountability paid for by agency fees.
- Medical detox facilities should be required to have medical directors.
- Establishing requirements and procedures for death investigations at addiction facilities.
- Strict oversight of programs found to admit clients it is not fit to treat including immediate license suspension.
- 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.
July 29th, 2012
A recent open label study found some support for the effectiveness of a Risperidone injection, given once every 2 weeks, in reducing crystal meth (speed) use.
The 22 patients who participated reduced their weekly crystal meth use from an average of 4 times per week to only 1 time per week. The difference between those who were able to stay completely clean and the others seemed to have to do with the levels of Risperidone in the blood.
The nice thing about using an injection as addiction treatment is that it removes the possibility of patients choosing not to take their medication on any given day. Such non-adherence to treatment is very often found to be the reason for relapse.
This study will need to be followed up by placebo-controlled double-blind studies, but given Risperidone’s action as a Dopamine antagonist, I suspect that those trials will also show a strong treatment effect. The promise of medicines as addiction treatment cures always seems great, but I believe that at best, they can be an additional tool to be used in conjunction with other therapies.
The question will be whether the side-effects common with antipsychotic medication will be well-tolerated by enough people to make the drug useful for addiction treatment.
|Posted in: Medications, Treatment
Tags: about addiction, addiction, addiction cure, addiction help, addiction research, crystal, crystal meth, drug abuse, Drug addiction, ice, injection, medication, meth, methamphetamine, my addiction, risperidone, Speed, treatment, Treatment
May 5th, 2012
I get asked which addiction treatment option is the best all the time. The short answer? Whichever one ends up working for the client.
I don’t like being stuck in the corner, having to pick a “best of” option just because I’m asked. For some clients Moderation Management will work, others need intense day-treatment or an in-hospital residential treatment program before moving into a more traditional residential place for a year or more. Some clients feel suffocated by such a structured environment and can’t manage it – outpatient treatment options can be a better fit there.
Sometimes we ask ourselves questions in a way that forces us to make bad choices: Which is better, chocolate or vanilla ice-cream? I reject the premise.
It’s about time we all faced the fact that only rare occasions allow for two-word answers that are absolutely true. The world is full of nuance and if we don’t start allowing some gray into our conceptualization of questions and answers we are going to keep repeating the past mistakes of polarized opposition to a small number of camps that are all equally wrong.
Brain research supports the notion that they way in which questions are posed can affect the sort of answers we look for – our brain pays attention to the stimuli it expects to find. So if you think that all you have to pick from are two or three options, your brain will calculate costs and benefits and spit out an answer – 42. It’s what happens when you ask the wrong question – you get a nonsensical answer.
So I don’t answer question like “which treatment is best?” or “which is more important, biology, the environment, or personality?” The way I see it the pieces are all so interconnected that the separation is false. The question is moot. And that’s true whether you’re picking addiction treatment or a your favorite cone.
|Posted in: Education
Tags: AA, addiction, best, CBT, cognitive behavioral therapy, dbt, moderation management, outpatient treatment, rehab, residential treatment, SMART, treatment, Treatment
April 12th, 2012
A client come in today for an addiction treatment evaluation. She had so much shame about her drug use that even the relative who brought her in didn’t know what drug she’d been using every day for the last year or so. I told her the same thing I tell all those who ask me for help – it is absolutely up to you to figure out who you feel comfortable telling about your alcohol, drug, gambling, or sex addiction problems. Just keep in mind that being shameful and secretive about your problems can cause addicts in recovery to be secretive when they experience cravings, triggers, and thoughts about using or acting out.
As hard as it is, disclosing these issues can provide an amazing amount of support while also allowing those close to you to be a real part of your recovery. Importantly, you don’t have to disclose to your significant other, your daughter, or your aunt. You can find an outside support system, either through peer-support groups like the 12-steps or SMART recovery or another group where you feel truly comfortable sharing. Shame will keep you isolated, sharing will help set you free.
Honesty, trust, and humility, along with the ability to admit that you are not necessarily managing recovery perfectly can actually be seen as strengths, not weaknesses. Try it out.
April 8th, 2012
In all but 13 States in the U.S., drug possession for personal use is still considered a felony punishable by years in prison and hefty fines. This despite the fact that a significant portion of those arrested meet criteria for dependence (addiction) on the drugs they are caught with, and the fact that our own federal drug abuse agencies (The National Institute on Drug Abuse – NIDA) considers addiction to be a medical condition that involves reduced control over the drug use itself. I guess that’s why the federal government also considers possession for personal use as a misdemeanor.
In essence these state laws are putting drug users, and especially drug addicts, at risk of being locked up for years, placed on parole, and subject to the endless other barriers to employment and housing, which make it more difficult for these convicted felons to reintegrate into the community. As if fighting drug addiction wasn’t hard enough.
The question is, would reducing the penalty for drug possession for personal use to a misdemeanor in more states result in increased drug use and crime or would it actually help free up resources being used for incarceration towards more effective strategies for combating the problem?
California State senator Mark Leno is bringing up a bill for consideration in the state senate (SB1506) that is seeking to do just that – reducing the penalty for possession for personal use of any drug to a misdemeanor. Mind you, this law is not to affect any other drug-related offenses such as drug possession for sale, drug manufacturing, or transportation. What it would do is cap the maximum incarceration length of possession at one year in jail (not more years in prison) as well as cap the maximum community supervision length at 5 years (3 years are commonly assigned for such offenses).
I know what some of you are saying – drug users know they’re breaking the law and they should be punished for it. Indeed, punishing them for it will make them less likely to use, which will leave them facing no jail time instead of continuously facing single years in jail for reduced drug possession offenses. Besides, if we cut the penalties for drug possession aren’t we being soft on crime? Aren’t we saying that using drugs is okay?
The problem with that argument is that it assumes that states that have higher penalties for drug possession for personal use have lower rates of crime, drug use, or drug possession arrests. The don’t. Indeed, the 13 states (and D.C.) that already consider drug possession for personal use a misdemeanor have incarceration rates that are no higher, illicit drug use rates that are slightly lower, and addiction treatment admission rates that are on par and even a bit higher than the rates of felony states. Again, that means the states that reduced the penalty for drug possession see less arrests, more people in addiction treatment, and a smaller percentage of their population using such drugs. Interestingly, those results are somewhat similar to the effect complete decriminalization had on drug use, crime, and addiction treatment in Portugal.
In previous articles we’ve spoken about the stigma of addiction and the barriers people report to entering addiction treatment in the U.S. Aside from cost and lack of information, people usually report that they either don’t want help, think they can handle the problem on their own or are too ashamed to ask for help. We’ve also reported on the ridiculous prison overcrowding problem in California due to the high incarceration rates of drug users. The question of decriminalization has come up many times (see here, here, and here) and the evidence I’ve seen keeps pointing towards the conclusion that reduced penalties get more people into addiction treatment while reducing incarceration rates with no real collateral increased in illicit drug use or crime. When you think about it, since the Harrison Narcotics act of 1914 essentially created the black drug market in the U.S. when it restricted, for the first time, the sale of narcotics, it makes sense that loosening up those restriction would reduce the size of that same black market and with it drug-associated crime.
I have spent the last 10 years researching the best ways to fight addiction problems and almost everything I’ve seen suggests that treatment and prevention efforts, not long jail or prison sentences, are the best ways to combat the problem. I have seen evidence that very shirt-term incarceration can help certain resistant offenders, but those efforts can easily be applied for misdemeanor and require nothing close to multiple-year sentences. For that reason, I support not only Senator Leno’s SB1506 bill in California, but other efforts around the country to reduce the criminal penalties associated with simple drug possession to get more of the people who need help into addiction treatment and away from jails. It saves us money, it is more humane, and it just makes sense.
If you want to help Senator Leno pass this bill, contact his office through this link: http://sd03.senate.ca.gov/
U.S. Census Bureau, 2012 Statistical Abstract, Table 308. Crime Rates by State, 2008 and 2009, and by Type, 2009 (2012).
Collins et al., (2010). The Cost of Substance Abuse: The Use of Administrative Data to Investigate Treatment Benefits in a Rural Mountain State. Western Criminology Review 11(3), 13-28.
Gardiner, Urada, and Anglin (2011). Band-Aids and Bullhorns: Why California’s Drug Policy Is Failing and What We Can Do to Fix It. Criminal Justice Policy Review, 23, 108-135.
|Posted in: Education, Links, Opinions, Treatment
Tags: addiction, drug, drug possession, drug possession personal, drug use, drug use crime, Leno, Mark Leno, personal use, personal use misdemeanor, possession, possession personal use, SB1506, treatment, use
March 19th, 2012
By Dr. Adi Jaffe and Tariq Shaheed
How annoying is it to be running late for work unable to find your keys, wallet, or coveted smart phone? You check under the bed, between the sofa cushions, and in your useful phone valet, before giving up and calling in late to work (if it’s not your phone you’re missing). You ask your wife, who says she hasn’t seen it, and your child, who thinks it’s under the bed (you’ve looked, it’s not). Finally, giving up, you go to your car, where your phone sits smugly right on the passenger seat. As troubling and frequent as this story might be, it’s nothing compared to the difficult experience of over 20 million Americans who annually look for addiction treatment but don’t find it . So what’s keeping so many Americans out of treatment?
Internal and external barriers to addiction treatment entry
In a study done in 2008, researchers surveyed a sample of 518 subjects varying in race and age, to find out about the barriers keeping them out of addiction treatment.  The study was conducted in Montgomery County Ohio, was a part of nationally funded “Drug Barrier Reduction” effort lead by the National Institute on Drug Abuse (NIDA). Most participants were using crack (38.4%), heroin (25.1%), marijuana (14.9%), and alcohol (11.2%). The researchers found a number of internal and external barriers that keep drug abusers from getting the help they need. Internal barriers included stigma, depression, personal beliefs, and attitudes about treatment, while external barriers (systematic or environmental circumstances that are out of a person’s control) include time conflicts, addiction treatment accessibility, entry difficulty, and cost of addiction treatment. 
The researchers concluded that both internal and external barriers can be addressed and improved, but that eliminating the external barriers to addiction treatment is most feasible and could substantially decrease the number of untreated addicts in the United States. Since addressing an internal barrier like “believing one can quit at anytime” (accounts for 29.3% untreated Americans) still requires the ability of the substance user to get treatment, it seems that addressing external triggers will be more immediately effective. Just as motivation to find an item such as keys, phone, or wallet is not the only factor in obtaining that item, a substance user with no internal barriers to treatment is still constrained by all those external barriers, and still not in substance abuse treatment.
The most commonly cited external barriers in the study were:
- Time conflicts – being unable to get off work for treatment, household obligations, busy schedules and simply not having time for substance abuse treatment.
- Treatment accessibility – living too far away for treatment, not knowing where to go for treatment, having difficulty getting to and from treatment, and not understanding the addiction treatment options. Subjects reported that being wait-listed for a facility, and having to go through to many steps contributed to deterring them from seeking treatment.
- Financial barriers included inability to pay for treatment and being uninsured.
Some common internal barriers include:
- Stigma associated with the label of being call an alcoholic or an addict, or stigma regarding addiction treatment. Thus being unwilling to share problems and ask for help.
- Psychological distress such as depression and neuroticism which produces a lack of motivation among substance abuse treatment seekers.
- Personal beliefs
- Religion- God will remove the addiction at the right time
- Denial – User doesn’t believe they are an addict
- Doesn’t need treatment – For example 30% of heroin abuser believed they would recover without treatment.
Although getting substance abusers help is difficult, it starts by understanding the nature of the problem. While one person may not believe they are addicted, another may not understand how sliding scale payment for treatment works. Different individuals may need different helpful resources when it comes to understanding their options.
Thoughts and limitations regarding the research
As we pointed out in a recent article, it’s important to know who is participating in addiction research. In this case, the individuals recruited were reporting for substance abuse treatment assessment at a county intake center. This means the clients are likely from relatively low Socioeconomic Status (SES) groups, but also that they are for some reason motivated to find treatment. Those reasons themselves could be internal (decided to make a change) or external (got arrested), but it’s important to know that these findings do not necessarily apply to more affluent, insurance carrying, or addiction treatment uninterested, individuals. We are currently in the process of conducting a more general study to assess needs in that group.
Also, the time and costs constraints identified by participants can often be overcome by increasing flexibility in searches and by better tailoring the treatment referrals (see our Rehab Finder articles). Costs can be reduced while saving time by looking into outpatient, rather than residential, treatment options. Unfortunately, Americans have been exposed only to the residential treatment model (a la the Dr. Drew and Intervention television shows), but outpatient addiction treatment is effective, costs less, and truly a better fit for many clients (especially those still working, attending school, etc.).
Finally, not all of the internal beliefs can be written off as unreasonable barriers – indeed, it is likely that most individuals who do not seek official substance abuse treatment, and certainly most of those who never enter official substance abuse treatment, will still recover from their addiction without it. As we pointed out in previous articles (see here, and here), most people who use drugs do recover and many do it with no treatment per se, especially when looking at our biggest substance abuse problem – alcohol. That means that some people termed “in denial” and “not needing treatment” were actually either correct, lucky, or both. Recovery doesn’t have to look like we expect it to, it just has to result in a person who is no longer suffering with addiction.
A3 Plug (you knew it was coming)
At A3 we believe information is the key; by dispelling myths about addiction, removing stigma and anonymity, reviewing the latest research in treatment, and finding 21st century solutions to barriers, we hope to reduce the number of untreated. Join us in the fight to educate and treat addiction.
1. Jiangmin Xua; Richard C. Rappa; Jichuan Wanga; Robert G. Carlsona. (2008) The Multidimensional Structure of External Barriers to Substance Abuse Treatment and Its Invariance Across Gender, Ethnicity, and Age.
2. An investigation of stigma in individuals receiving treatment for substance abuse
March 4th, 2012
I teach a class on the psychology of addiction (Psych 477 at California State University in Long Beach) and as I have been preparing the lectures something has become very clear to me – textbooks patently gloss over important details about the addiction research they cite. One of the most obvious gaps I’ve noticed this semester concerns the population of research subjects most addiction research is conducted on. An example will clarify:
A student group in my class had to read a study assessing the residual effects of methamphetamine on mood and sleep. They were amazed that no changes in mood were observed and that participants slept a full 6-8 hours the night after being administered meth! Would you have been surprised with these results given that we all have been told that crystal meth improves mood and causes insomnia?
Would it matter at all if I told you that the participants in the study were current meth abusers who use an average of 4 times every week?
For anyone not aware of the tainted history of health research in the U.S. (I’m including psychological research in this group), go ahead and read about the Tuskegee Syphilis Experiment and Stanford Prison Experiment (video here). There are other examples including Stanley Milgram‘s obedience studies, and more but as exciting as the discussion of these studies is, it’s time to get back to my main point.
It is mostly due to the ethically-questionable, psychologically damaging, research above that research institutions are now required to vet proposed research studies using Institutional Review Boards (IRBs) to assure that human participants in studies are consenting to participate of their own free will, are not coerced, and are not suffering undue damage. This is also true of addiction research. Rarely does the public consider this fact however when they are being reported on research relevant to addiction. I know this because the kids in my class never gave it a second thought.
Nearly all addiction research, especially studies utilizing “hard” drugs like cocaine, meth, opiates, etc., are required to make use of a very limited part of society – drug using individuals with a history of use of the specific drug of interest who are specifically not interested in treatment. Individuals who have never tried the drug or who want to be treated for drug abuse or dependence (addiction) are excluded due to ethical concerns. In most studies, participants can not qualify if they are addicted to drugs other than those being studies (except smoking, for which exceptions are usually made since we’d be able left with no participants otherwise) or have any associated mental health disorders, which are very common among addicted individuals. I would further assert that for at least a substantial portion of these research participants, the term “addicts” may not be appropriate since many addicts would not willingly give up using their favorite substance for a week or two to be replaces with a hospital bed and an experimenter controlled dose of drug or placebo. Taken together, our research subjects are pretty obviously not representative of all drug users, or all addicts, or all anything else. They make up a very specific group – less than perfect, but what we have to work with.
In some studies that attempt to make a direct comparison between controls (or drug naive participants) and drug users, this is likely less of an issue. This can happen when researchers try to examine brain structure differences, or performance on a specific psychological or physical test. In such cases researchers can at least statistically identify contributions of length of use, method of use, and other relevant data on differences between people who use and those that don’t. There are probably still some serious differences between “true” addicts, recreational users, and semi-chronic users that would be important to understand here, but we can’t so we don’t. But when it comes to assessing mood effects, or indeed any of a number of subjective effects of drugs, drug cravings, and withdrawal, this limitation in the population to be studied is something that often needs to be made explicitly clear to most public consumers of research. Since we can’t assess changes in mood, absorption rate, anxiety, or any other such measure (some exceptions for very low doses in very specific circumstances) among people who are new to the drug, we end up assessing them among people with a lot of experience, but not enough of a problem to want addiction treatment. Again, this should be considered a pretty specific type of drug user in my opinion.
There are other types of studies – those conducted with abstinent ex-users or addiction treatment intervention studies utilizing addicts who want, or who reported to, treatment on their own or in response to advertisements. While these studies make use of populations that can be considered at least closer to the individuals they are specifically aimed at – assessing the return of cognitive function after short or long term abstinence or testing a new intervention on those who want treatment – they still bring on limitations that need to be specifically considered.
An important point – most researchers recognize these issues and make them explicitly part of their research publications, in a specific section called “Limitations” but what seems troubling is that the public doesn’t have any awareness of these issues. So when someone tells you that “they just found out meth doesn’t actually make people lose sleep,” take a second to ask “for who?”
|Posted in: Education
Tags: addiction, addiction research, anxiety, Brain, cocaine, cravings, drug, drug use, insomnia, mental health, meth, milgram, mood, opiates, psychology, research, studies, treatment, tuskegee, withdrawal