Blame and Disease

Posted on by
Reply

One of the most harmful and pervasive myths about the disease of addiction is that it isn’t a disease at all; instead, people see it as a moral failing, or a weakness of character. Often people see the addictive behaviors of their loved ones as only a bad habit, or maybe even as willful rebellion. In either case, they see the addictive behavior as being under the addicted person’s control. Maybe the addicted person is too “weak” or “lazy” to stop, but if they really wanted to stop, they could. It’s within their power, they’re just not exercising that power for whatever reason. They’re just not trying hard enough. They need to really try.

It’s an attractive myth. For one thing, American culture has been built around the idea that anyone can do anything if they just try hard enough. Individual power and responsibility are very familiar and comforting concepts to us, and we tend to apply them even where they are out of place. For another thing, this “myth of personality” can give a certain level of control to someone in the grip of a terrifying disease. It can be more comforting to think that the addictive behaviors could be stopped with trying than to think that these behaviors are mere symptoms of a disease that has biological roots and cannot be controlled without costly inpatient treatment or medication. For these reasons, and because they hear it from everyone around them, the people suffering from addiction come to believe this myth too. It’s easy for them to see themselves as “weak”, “lazy”, “cowardly”, etc. It’s easy for them to blame their own symptoms and relapses on a failure to “try” with the required passion. It’s also wrong. No amount of “trying” can reverse a behavior when that behavior is the result of a pathological biological process. The confusion comes about because opposite is sometimes true; in a condition like high blood pressure, willpower can change behavior (like diet or exercise), which can change the biological process of high blood pressure. But in addiction, the behaviors are a symptom of the underlying brain chemistry imbalances. Willpower does not have any affect on the underlying disease, so it is not generally useful for alleviating the symptoms.

This is not to say that people can’t curtail their addiction by sheer willpower; clearly, many people have done so in the past. The point I’m trying to make is that while we can applaud and support such efforts, it is cruel and viciously unfair to expect them. Yet in addiction treatment today, that is often exactly what we do; we expect patients to cure themselves by sheer willpower, with maybe a little assistance from some form of counseling, and then when they relapse they are told that they just didn’t try hard enough. They didn’t want sobriety enough. Our treatment was never insufficient; all problems are the patient’s fault.

This is sheer, unrepentant victim-blaming, and I have seen cases where this constant battle between patients and their loved ones or physicians has bordered on emotional abuse. It is the duty of physicians to provide support and help to those who are sick, not to attempt to shame and frighten them into health — especially when those shaming and frightening tactics have a success rate well below 10%.

Possibly the worst thing about this entire complex issue is its element of self-fulfilling prophecy. A person with addiction, having been told that they can get better if they just “try”, then tries as hard as they possibly can, and relapses. Well, that means they must not have been trying hard enough! So they try harder and harder, and relapse again. And again. And again. Eventually they become convinced that the moral failure just runs too deep, they’re not capable of the level of “trying” that everyone else expects of them, and they give up. That may be the point where they genuinely do stop trying to even seek treatment, and lose hope that they can ever be helped.

If there is one thing I want to do in the field of addiction medicine, it is to wipe out this pernicious myth of moral failure. Addiction is a disease, and if we are to have any hope of helping the majority of our patients, we must treat it as one.

Electronic Records and Drug Sales

Posted on by
Reply

I’ve written here a few times before about the responsibility that physicians bear in the spread of addiction, especially addiction to opiates and painkillers, which patients are often first exposed to for medical reasons. I’ve written about the dilemma that faces physicians who are dealing with a patient’s pain, and the need to balance relief of suffering with the possibility of future addiction. It is a complicated and ever-shifting balance, but it’s one that few physicians today are well-equipped to navigate.

A news article I saw this week details a recent spike in painkiller sale and prescriptions in certain parts of the country, including Appalachia and the Midwest. The article attributes the rise in oxycodone and hydrocodone use to “an aging population having more pain problems”, the increased willingness of doctors to prescribe these medications, and the “doctor-shopping” of addicted patients trying to secure a constant supply of opiates. In my post “Pain and Addiction“, I discussed how patients who begin pain treatment for legitimate pain can become addicted without even realizing it, and continue to pursue their addiction while under the impression that they are being treated for pain with a physical cause. The article linked above makes a point that there are only a tiny number of facilities able to medically treat addiction, while the availability of addictive substances is massive, and these substances are barely controlled, when they are controlled at all. The article points out one of the possible solutions, which I strongly favor and have been advocating for years: stronger computer systems built to handle and track medical records.

One of the major ways addicted patients can continue to feed their addiction is through “doctor-shopping”, or going to multiple doctors who will each prescribe pain pills, not knowing that the patient already has several prescriptions. Patients may be careful to choose doctors in different geographical areas or different specialties, or may be skilled at making sure doctors do not effectively communicate with each other. Especially at hospitals, in the ER, where the pace is frantic and there are constant emergencies to be dealt with, knowledgeable patients can manipulate the system to get massive amounts of these addictive substances.

This does not mean that these patients should be vilified; their drug-seeking a symptom of the disease. While patients must be held responsible for their actions, it is also the responsibility of the medical system as a whole to detect and prevent this form of abuse. Computerized medical records, and computer systems which allow all medical personnel to communicate with each other, are invaluable tools for detecting drug-seeking patterns among patients. Many older physicians have resisted the move towards computerized records, but only making the transformation complete will allow the system to accurately detect this kind of harmful behavior. The article linked above states that there is essentially no monitoring of addictive medications on a federal level, meaning that patients can often easily obtain more by going to a neighboring state. This is a terrible oversight on the part of the healthcare system, which requires regulatory oversight in order to ensure that it is helping the largest number of people while doing the least harm. Addiction and drug-seeking are essentially risky side effects of these pain medications, and by refusing to carefully monitor their prescription and use, we as physicians are rendering ourselves incapable of protecting our patients from these side effects. In many cases, patients are not even being informed of these side effects, so they may not know exactly what has happened to them, or that any help is available.

The current difficult economic conditions, which cause a great deal of unhappiness and uncertainty, have likely exacerbated the “epidemic” of substance abuse, leading to astonishing numbers like those reported in the article. But this is not a temporary problem. It is a systemic problem, with its roots deep in the way our healthcare system is structured. Until we can fix the underlying regulatory deficits, the problem of drug-seeking and other fraudulent, addictive behaviors will continue, and any improvement will be  temporary.

Life After Addiction

Posted on by
Reply

There are endless barriers to addiction treatment — financial, legal, medical, psychological, and social obstacles — that can stand in the way of a particular patient as they try to find the treatments that works best to improve their life and control their disease. I’m of the belief that just about any of these problems can be overcome with widespread addiction education and care from a competent, compassionate physician. But I see one particular obstacle crop up again and again during treatment; a patient mindset, that many patients don’t even notice in themselves, that prevents them from taking full advantage of their care. It seems to me like a failure of imagination when it comes to life without drugs.

Due to the nature of the disease of addiction, early detection is very uncommon. Most people don’t seek any kind of treatment for addiction until it’s become well advanced and started to have serious destructive effects in their lives and their relationships with others. This means that nearly all patients have been living with their disease for years — often for decades — and it’s become the center of all their routines and the fixture of every day. Their friends are often people they can do substances with, the places they go after work to relax depend on where they get their substances, their time with their family depends on how much of their drug of choice they’ve managed to get that day. Addiction consumes their life. After years and years of this, I find that some patients cannot even imagine what their lives might be like once their addiction is no longer in control. Losing it may produce a strange kind of grief, as they adjust to the absence of something that has been with them every moment of every day and provided a driving purpose to all their actions. The sense of loss can be unexpected and terrifying.

That sense of loss, however, is a necessary side of effect of treatment. The goal of treatment is not to “cure” underlying imbalances in brain chemistry, which isn’t possible yet, but to take addiction out of the position of control over the brain. Therapy, especially maintenance therapy, is meant to return control of the patient’s life to the patient, rather than leaving it to the disease. For some patients, this means that they are forced to make decisions about their own lives that they haven’t had to make for many years. Who do they like to spend time with, now that their need to get and use substances isn’t picking their friends for them? What will they do with the time they used to spend buying and consuming substances, getting drunk or high, and going through all the behavioral rituals and symptoms of their illness? What will their relationships with their family be like now that the person they are isn’t dominated by substances? Not only do some patients not know the answers to these questions, they can sometimes be afraid of finding out. The stress of essentially having to reinvent their lives can come as a shock during a time that’s already turbulent due to the start of treatment.

This is a patient population that I do think could benefit from counseling as a part of their treatment, but not the kind of ‘counseling’ often required by non-medical practices. This is, in fact, one of the aspects in which I think we can learn something from halfway houses and 12-step providers. Instead of focusing on past issues that might have caused the addiction problem in the first place, I think long-term addiction patients could benefit from counseling designed to help them confront the drastic changes that come from simply removing the addiction at the center of their life. I have known many long-term addiction patients who responded well to medical treatment, but were unable to cope with the new and unimagined stresses of sober life, and relapsed as a result.

To be very clear, there are also many, many patients who don’t require this kind of intervention — patients who sought treatment for their addiction earlier, or who are just better equipped to deal with the adjustment in their life that comes along with successful treatment. Any counseling of this kind should be strictly optional, and the decision to undertake it should be made between each individual patient and their physician. But it would be a valuable resource in a field where specialized patient problems are really just beginning to be recognized.

Statistics Revisited

Posted on by
Reply

At the beginning of this year I wrote a post, 12-Step Statistics, detailing some of the issues in the way that 12-step programs present their track records. The fact is that, in this country, “rehab” and other facilities are subject to very little oversight. Any facility providing drug or alcohol treatment requires a state license, but they are not subject to nearly the level of scrutiny that is routine for doctors and hospital healthcare providers. And, as I discussed in the post linked above, their reports of success are often dubious at best and misleading at worst.

Of course, we can’t single out those who run rehab centers above all other professionals. Just this week, a post on LinkedIn raised the question of whether healthcare professionals were submitting deliberately fraudulent papers to PubMed, an online database of medical research. It was discovered that from 2000-2010, 788 papers were removed from PubMed for either errors or fraud, with 243 determined to be fraudulent and 545 simply wrong. These numbers seem very worrying, especially when the linked article uses phrases like “one-third of these were for fraud”. It’s worth keeping in mind that that phrase is referring to one-third of the 788 removed, not one-third of all papers. In fact, between 2000 and 2010, about 5 million papers were submitted to PubMed. 788 is far less than 1% of the total, meaning that the proportion of papers not retracted was about 99.98%.

The framing of statistics is a game, one that many different people and organizations are constantly playing for very different reasons. A 99.98% accuracy rate on PubMed does not mean all doctors are right all of the time, and a dubious success rate does not mean that a rehab center has never had a single success. In my opinion, the difference is in the attitudes of the two communities towards themselves. The scientific community, by opening up all research and data to the researcher’s peers, encourages a climate in which fraud is uncovered and errors corrected as soon as possible, out of competition if nothing else. It isn’t a perfect system, but it places a very high premium on objective reality and applicable, repeatable data. On the other hand, the systems used and made by 12-step rehab centers are not very self-critical; it is not in their interest to be self-critical, because if they made decisions based purely on success rate, the model would not have persisted as long as it has. Statistical framing is a useful way to avoid the need for self-criticism, and also to deflect the criticism of outside sources. And, unlike within the medical community, no particular rehab center is in very much danger of being challenged by its peers. They do not hold each other accountable.

I do not know of any online database rivaling PubMed for 12-step based rehab centers, probably because not much “research” is being done into their largely unscientific and non-standardized methods. But if there were such a database, I wonder how many articles would be retracted due to fraud — whether any would be checked for it, and how the checking would proceed, without an objective standard to measure against. I am not accusing all 12-step rehab staff to be frauds, just pointing out that the philosophy and business model of most 12-step programs builds an environment in which it would be unusually easy for fraud to pass undetected. There will be fraudulent and dishonest practitioners in any population; it then becomes our responsibility to build communities in which they cannot pass undetected in order to inflict harm on others with bad information. I am therefore very pleased to see that PubMed has removed articles in considers harmful, and I hope that in the future 12-step centers will have the courage to rid themselves of their own tenants not fully proven to do more good than harm.

Homeostasis in Addiction

Posted on by
Reply

Like all aspects of healthcare, addiction-based healthcare is part of a larger system of patients, physicians, and lawmakers. Problems with treatment can come from individual patients and physicians, but they can also be systemic problems — widespread  effects that are consequences of the way our healthcare and regulatory systems are set up. The main systemic concerns we are seeing in addiction right now have to do with regulation. Should medications like buprenorphine be restricted, and if so, how much? Should addictive painkillers be restricted so fewer people get addicted in the first place? How and how much? Who should be punished for violations, the doctors or the patients? Or both? And how can we enforce these rules?

Attempts to answer these questions have led to what seems to me like an endless loop of adjustment and readjustment. If people seem over-medicated, and the amount physicians can prescribe is curtailed, then physicians will back away from prescribing those types of drugs that draw regulatory attention. Suddenly the supply of medications is cut off, and people who are sick or in pain feel they are under-medicated and put more pressure on the ERs, regulations are relaxed, and we return to the problems of drug diversion and addiction. And then it starts all over again.

This repetitive cycle of problems is nothing new — we see it in economics, in the seesaw of supply and demand. We also see it in biology as the concept of ‘homeostasis’. Homeostasis is the idea that the human body needs to be in a certain precise and delicate state — a specific temperature, a specific acidity, a specific level of water, etc. — and that whenever that balance is thrown off, the body rushes to correct it. When the corrections go too far in the other direction, countermeasures are activated against that change to bring it back down towards the starting point — and so on. The result is an ever-changing system eternally seeking the perfect balance point.

What works for the human body resembles what we need to achieve in the field of addiction medicine. In this case, the ‘balance point’ is a state in which each patient’s perfect amount of medication is decided between that individual patient and a compassionate, well-trained, well-informed physician. In order to reach and maintain that state, the system requires a certain amount of flexibility; we need measures in place to deal with physicians who overprescribe out of selfishness or carelessness, but we also cannot restrict other physicians from performing at their highest capability. The current 100-patient limit for buprenorphine certainly prevents a certain amount of overprescription and black-market pill sales, but it also prevents physicians like me from providing services to all the patients who require them.

One of the mistakes people have when thinking about this ‘endless loop’ of over- and under-regulation is in thinking that one blanket solution will ever be enough to enable everyone to administer the correct amount of medication to all patients in all cases. If that solution exists, we’ll never find it — there is no one answer. We may have to choose on the side of overprescription — focusing more on preventing pain, even though free use of painkillers may lead to addiction — or we may have to choose underprescription, where we withhold our strongest painkillers in some cases, so that people are in pain but are not at risk for developing a lifelong dependence. Such decisions should only be made between a patient and their physician, and in order to make them effectively each physician and patient need access to the full range of options along the spectrum of painkiller prescription. Regulation is a useful tool in combating the addiction that comes from physician carelessness, but it is not a catch-all solution for the complex problems that arise during the treatment of a chronic condition like addiction. Right now, the best thing we can do is continue to educate lawmakers and physicians so that they can design a system for the maximum flexibility and utility that has the most power to help the most patients.

Local Crisis

Posted on by
Reply
My local community is currently undergoing a massive addiction crisis.
A large pain management clinic was recently shut down because the physician overseeing it lost his license. It was suspended last week on an emergency basis because an investigation revealed that many of the patients there were being over-treated, undoubtedly because of an addiction they had developed to the narcotic pain medications. The physician himself is under investigation for dispensing excessive quantities of controlled substances out of his office, and he was felt by the investigating body to be a danger to the community. With his center closed,there are four or five hundred poorly-managed chronic pain patients in this community who have suddenly lost access to their source of drugs. Some of these people surely have chronic pain issues that need to be addressed, while many probably have primary addiction problems, but either way, all are physically dependent on massive doses of methadone, Percocets, and Oxycontins. Without these medications, or any managing therapy to replace them, these four or five hundred people will be horribly sick, in great pain, and possibly driven to unacceptable behavior (theft, etc.) in order to find new sources of the drug they feel they need.

Physicians in the area are not excited about taking on new patients with poorly maintained or spotty medical records and poorly managed, poorly documented pain issues, especially since all these patients need immediate refills of their massive amounts of narcotics. The addiction doctors in the area, the few of them that there are, are not really qualified to evaluate these patients for the true status of their pain condition, and so have no real way to separate the primary pain patients from the primarily addicted patients. Most addiction-based physicians are at or near their 100 patient Suboxone limit in any case, and do not routinely prescribe other narcotics.

We also can’t forget about the ERs, where physicians are also wondering how they will handle this massive crisis. ER doctors will ultimately become the last resort for many of these patients who cannot get their prescriptions filled in a more controlled manner. The ER will be flooded with people with a multitude of pain complaints and withdrawal symptoms, trying desperately to get their narcotics filled. I cannot begin to imagine how much time and money will be wasted doing unnecessary testing for complaints of abdominal pain, back pain, and headaches — not to mention the delay in attending to others who will be competing for ER time with many of these patients.
This is not the fault of these patients — it is primarily the fault of the physician who so badly mismanaged their care, and his staff who were clearly not trained to recognize or deal with the addiction problems that so often attend pain management. (I very much doubt that he knew that he might want to be on the lookout for addiction problems.) Due to his recklessness and carelessness, the medical systems of this community are very shortly going to be overloaded with patients who desperately need to be managed and are extremely difficult to correctly diagnose.
A harm reduction model would suggest that somebody just needs to open up an office and provide all these people with the narcotics they want to keep them from flooding and incapacitating the rest of the system. That is essentially the role that the suspended pain management center was playing, and while it was logistically effective, no plan like that will ever be sustainable. Not to mention, of course,  that it is a gross violation of the goals and ethics of medicine.
I don’t know how this situation will resolve. I will do my best to take on excess patients when I can be sure that their problems are primarily addiction-related, and I’m going to make an effort to educate my fellow medical practitioners about this issue. If nothing else, I hope this can serve as a warning of what can happen even when we do the right thing by closing down a poorly-run pain management center. Maybe soon we will be able to move forward to find a more sustainable solution.

Casualties in the War on Drugs

Posted on by
Reply

Demi Moore was reported as having had “convulsions” after smoking an undetermined substance (probably “Spice”) late last week. Spice and K2 are both generic names used to refer to a wide range of synthetic cannabinoids, designer drugs intended to mimic the effect of marijuana on the brain. Many varieties of spice boast that they are made of “legal herbs”, which is always almost untrue — and even when the substances involved are legal, they are not intended for smoking, and tend to have severe adverse effects. A physician quoted in the linked article above states that spice usage can often lead to “prolonged seizure and seizure-like activity”, and that the lack of quality control makes purchasing these compounds a potentially lethal form of gambling with the amounts of chemicals involved.

Yet one of the most stunning things about this story is how little attention it’s getting. If Demi Moore had collapsed from a new flu strain, the public health resources of the entire country would be focused on dealing with the issue in a major way; people would be lined up to buy their hand sanitizer and get their flu shot. Because her collapse was addiction-related, and we see addiction as being “not a public health problem” or just a natural price of stardom, it is essentially ignored  — despite the fact that the same condition is epidemic in almost every community in the nation. Where are the people lined up to buy lock boxes for their prescription pills? Where is the public education campaign asking people to do this? Where are the resources of the CDC aggressively pursuing an answer? Where are the parents boycotting those stores that sell stuff like this to our kids? Where is leadership from the addiction treatment community to get any of this done? There is a bill currently in Congress to outlaw Spice, K2, and other compounds, but the designer drug industry will only continue to flourish, pushing more and more dangerous compounds that have been carefully engineered to evade the strictest legal rules, regardless of what effects that engineering has on the health of those who use it. Without widespread public education and public health resources available to everyone, substance-seeking and addictive behavior will just move on to more and more lethal experiments.

What we are experiencing now in the “War on Drugs” bears many similarities to what the country experienced during Prohibition. Outlawing alcohol did little to decrease drinking; instead, people moved on to bootleg methanol, which caused seizures, blindness, and death. What we are seeing in the proliferation of spice compounds is the same pushback against ineffective and harmful legislation. Marijuana is safer, less addictive, and less likely to cause violence than alcohol; it has been grouped in with other, much more dangerous drugs like cocaine, and been outlawed along with them. For those who claim it is a “gateway drug”, I would like to note that the marijuana substitutes being produced now are, technically, legal – those who want to smoke marijuana are very interested in staying within the bounds of the law. No one bothers with “legal” synthetics of heroin or cocaine, because those drugs cause a potent addiction that makes the drug a priority over all legal or moral concerns. Marijuana does not do the same.

If we believe that all mind-altering substances should be forbidden and illegal, then it makes no sense at all to have alcohol freely available and encouraged throughout our society. If we agree that some mind-altering substances can be taken recreationally, when well-controlled and in safe circumstances, then legalizing marijuana becomes a sound health and economic choice.

I do not personally endorse anyone taking mind-altering substances, or breaking the law. But I think it’s foolish that we seem willing to sacrifice countless people to harmful synthetic drugs rather than legalize a substance that wouldn’t even be the most damaging or addictive substance a 21-year-old could purchase anywhere in the country. Demi Moore is a highly visible personality, but for every celebrity whose drug use makes the news, there are millions of others who are being harmed out of the public eye. That’s an epidemic, and it’s time we worked towards stopping it.

Fear and Education

Posted on by
Reply

It’s clear that more adults, including physicians, need further education about the causes and consequences of addiction, but it may be even more important to educate our children before they make decisions that can end up tearing apart their entire lives. Drug education in schools is mandatory and ongoing, but it’s clearly inadequate, for much the same reasons that health and sex education standards are inadequate.

The approach most schools take to drug education is a unilateral, completely straightforward “Just say no!” campaign. They struggle to paint all use of any substance, even one sip of alcohol or one cigarette, as a horrifying and potentially lethal act of self-destruction. While it’s true that beginning to drink or smoke at a young age can have horrible long-term effects on health, painting the situation with such a broad brush just sets education up for failure, because it creates an illusion that can’t be maintained. Kids — especially pre-teens and teenagers, who are the target of most drug education — are immature, but they aren’t stupid. They will see adults having a drink, or smoking, in their everyday lives. They may see their friends trying a beer or a cigarette, and when that adult or that friend doesn’t immediately crash a car, vomit, or suffer some other horrible comeuppance, the kid who has been through that style of drug education will conclude that they have been lied to. They will also realize, possibly just by going home in the afternoons, that not all people who are addicted to substances are bad, dirty people. By refusing to deal with any of the nuance or complication of addiction, much of drug education sets itself up as a lie — a lie that will be easily disproven. And the worst thing is that, once a kid has realized that official education sources may exaggerate or lie, that kid may never trust an official source of education again. Any future attempts to correct the bad drug education will fall on deaf ears.

If we are going to have any hope of reaching kids, we must show them the basic respect they deserve, and tell them the truth. They have to understand that a large number of people want to get high, or feel an altered state of consciousness, and that there are safe ways to do it — drinking in moderation with friends (without driving afterwards), for example. Kids need to know that some things, like marijuana, are almost infinitely safer than others — like the “legal” marijuana analogues that use things like toxic bath salts and tar, and can cause seizures.

The drug education standards prevalent today are not strictly “education”, in my opinion. Education is a process designed to give people true and useful information with which they can make decisions and keep themselves safe. The statistics and medical consequences discussed in drug education are certainly true, but they are not presented in the context of giving useful information; they are presented in the context of propaganda and scare tactics. While I understand the deep concern and fear for the safety of children that is behind this style of teaching, I also feel certain that it does not work, nor will it ever work, the way it was intended. Giving students information you swear is true, which will be contradicted by their real-world experience, will only set them up for lifetime distrust of education. It may also lead to them throwing out the legitimate warnings along with the trumped-up fear tactics, and put them in a worse position than before.

Drug education, like health and sex education and all other important topics, must be discussed with children in a way that is serious and straightforward, but it must also take into account the complexities that that child will face as they attempt to make their way in a nuanced adult world. “Just say no” has some valuable aspects to it as a campaign, and I would certainly rather that no one under legal age used any substances at all, but a lack of proper education will only lead to more addicted people living more self-destructive lives.

Unforeseen Consequences

Posted on by
Reply

One of the first things I saw when I got online this morning was this article from the Comcast.com news page:

http://xfinity.comcast.net/articles/news-general/20120123/US.Meth.Severe.Burns/

It’s a report on how burn centers in some states are being forced to close due to a spike in patients who were burned making methamphetamine in their homes. Since meth-related injuries are among the most difficult and expensive to treat, and patients who sustain this kind of injury usually don’t have insurance, the cost is being absorbed by the hospitals and burn units, which is leading to the shutdown. The reason for the recent spike in meth-related burn cases is the rise of a new meth-making process which involves combining the volatile ingredients in a two-liter soda bottle, which is then shaken near the face. In contrast to fires in a meth “lab”, which people can often escape, a meltdown in the soda bottle process invariably causes debilitating burns to the face, chest, and hands, and often results in blindness.

There are several reasons why this new, more dangerous technique is taking hold in states where meth is a severe problem — the new method is more cost-effective, requires smaller amounts of controlled substances, and produces a smaller quantity of meth, for personal use rather than sale. But wouldn’t the vastly increased risk make it a less attractive option?

The fact is that one of the many symptoms of addiction is a decreased ability to appreciate risk, especially where the addictive substance is involved. The strength of an addictive craving will convince a patient to take greater risks to their health and safety in order to fulfill it, but it doesn’t end there — after prolonged use, addicted patients show a habitual desensitization to, and comprehension of, risks to themselves or others. If the risks of soda-bottle meth (called “shake-and-bake” by the linked article) were associated with any other product, they would act as a discouraging factor; but because we are dealing with a specifically vulnerable population, it cannot be assumed that the greater risk will act as a deterrent.

Knowing that, and desiring to keep their burn centers open and able to serve all patients, it seems like the only course for affected states and hospitals is to try and prevent these people from sustaining these injuries in the first place. One of the reasons given for the rise of shake-and-bake meth was “greater attempts to crack down” on traditional, larger meth labs. As an experiment, I googled “how to make methamphetamine” and found thousands of recipes and explanations. Clearly, enforcement after the fact is not working, and will probably never really work; with no way to limit the spread of information on how to make meth, and a segment of the population who are less sensitive to risk and incredibly desperate to attain their drug of choice, it is clear that all attempts to “crack down” will only drive addicts to more dangerous (and possibly lethal) methods.

I have no doubt that extensive care to prevent meth addiction are already in place in these states where it is an epidemic, but these burn center closures are sending a clear message that whatever services currently exist are inadequate. Care designed to alleviate financial stress and the living standard of residents might be an improvement, since substance abuse is often tied to socioeconomic stress. And while any such care would undoubtedly be extremely expensive, it would surely fall far short of the “hundreds of millions” of taxpayer dollars currently being used to absorb the cost of treating uninsured burn victims.

This is just a symptom of a wider problem that I encounter every day — namely, the disgraceful lack of attention that is given to addiction as a wide-reaching problem on the national stage. People in positions of power, as well as most people who have never been affected by this disease, appear to think that drug addiction is “under control”, or is a problem that will never have any consequences for them. The fact is that, besides being a huge drain of human life and economic resources, addiction has shattering and unpredictable affects on all people in this country. Now, as we are seeing, victims of fires in some states will have less access to adequate care. The fact is that addiction is in no way a small or insignificant problem, and any attempt to decrease it must have just as widespread and long-lasting benefits.

Interpretations of AA

Posted on by
Reply

I spend a lot of time on this blog discussing 12-step programs. But what exactly constitutes a “12-step program”? The term itself is rather vague.

I tend to use this as an umbrella term to describe the group-based, discussion-heavy, and non-medicated treatment style that claims to be the spiritual successor of AA. This approach has been expanded to treat narcotic addiction, nicotine addiction, and any number of other conditions. It has also been adopted very widely, and while it’s common for treatment providers to stay close to AA’s original 12 steps, they also tend to tweak and change and “put their own spin” on the 12 steps as much as they can. What this has led to is a huge variety of treatment approaches that, to an outsider with a critical eye, all appear to share a few core principles that they have taken from the founding tenets of AA. Usually this includes belief in a Higher Power; the righting of wrongs done to others in the past; establishing a social network with other ex-addicts; and a strong moral emphasis on being “clean” rather than “dirty”; and a refusal or demonization of medication.

I write about 12-step programs mostly from my own experience, because as a doctor advocating medication maintenance for addiction, I encounter a great deal of hostility and resistance from the staff. I also witness firsthand the effects that this style of treatment has on my patients, who refuse to stay healthy on maintenance because they believe they are still “dirty”. Most care that fights against medication maintenance do so using a kind of authoritative hair-splitting; they claim that, since buprenorphine affects the opiate receptors, it takes away a patient’s right to be called “clean” or “in recovery”. I would just like to point out the irony of this panicked accusation, seeing as the founder of AA originally made it very plain that excluding anyone on such superficial grounds was very much against the spirit of the organization. You can read Bill W.’s opinion on who should be allowed to be a member of AA here.

Alcoholics Anonymous was founded in 1935 by Bill W. and Dr. Bob as a way to help alcoholics find strength and comfort in community. As part of my education in the field of addiction, I’ve read a large amount of AA literature, including the “Big Book”, considered the central text of the organization. I have reached the conclusion that the original spirit of AA was an unflinchingly inclusive one, and that the founders would not have approved of keeping an addict out of “recovery” based on what other medication they were taking, or what other measures they might be taking to control their alcoholism. Addiction is a disease, and taking regular medication for it should be no more problematic than taking regular blood pressure medication. It certainly shouldn’t be used as an excuse to keep stable and thriving patients out of the nebulous category of “in recovery”.

Yet a great deal of resistance to medication maintenance comes from a widely-held belief that medication somehow violates the principles of AA, and the 12-step programs that have descended from AA. I would argue that this belief is factually wrong, but the factual correctness of a statement like that doesn’t even matter, because every interpretation of the “principles” of AA is equally valid. AA (used here as the flagship example of the 12-step type of program) is a nebulous, widespread organization without a central authority capable of making policy decisions. It is based on a certain amount of written material, all of which is open to interpretation, and there is no one with the authority to call any interpretation right or wrong. It actually resembles many religions in this way.

I would argue that the belief that medication goes against the spirit of AA is widely-held, not because the texts support such an interpretation, but because it has become a sort of canon that has been mixed into the original philosophies of AA and passed on due to tradition and financial advantage. Thankfully, since all interpretations are equally valid, I will tell all my future patients that this ugly and discriminatory policy does not come from a place of authority and should have no power to prevent them from seeking the most effective treatment they can.