Monday, May 14, 2018

Addiction Narratives Versus Reality.......





I recently posted my take on this issue of race in addiction treatment. The main argument that I was responding to was that the current opioid epidemic is whitewashed so to speak. In other words white opioid addicts are considered to be "victims" of the opioid epidemic and black addicts are considered just to be addicts at best and criminalized at worst.  Part of the way that white people are framed as victims is by calling addiction a disease.  The author who I was critiquing at the time suggested that the opioid epidemic was marketed to white people along with the medication (buprenorphine) that would "cure" them.  Further, that buprenorphine was more easily available to white people by the nature of the prescribing requirements.  The article went on to selectively highlight one segment of the population where "non-Hispanic blacks" had a higher rate of overdose deaths, despite the fact that the majority of people dying in most categorizes were white.  I consider my counterargument to be a solid one and that is - there is no known difference in the biological predisposition to addiction of any kind that is based on race and if that likelihood is equal - the only consideration is who is exposed to the drug.

The racialization of the opioid epidemic picked up more speed over the weekend.  One of the theories proposed was that there were no previous "epidemics" of opioid use and that this is another way to sanitize the problem and make it more acceptable to white people.  The article was written for a newspaper - the Guardian and the headline says it all:  "Amid the opioid epidemic, white means victim, black means addict."  That is the basic thesis that runs through the entire essay.  You are either a white, Christian, Republican racist, who considers himself to be a victim of prescription opioid tablets or drug dealers or the hypocritical structure of American society insults you for being black and an addict.  It is suggested directly in the article that common rationalizations of addicts - the ones that everybody uses irrespective of race or substance are the exclusively used by whites to deny responsibility for addiction.  Self-loathing of the addict is described as though that never happens with white people.  Guilt, shame, and self loathing happens to everyone with an alcohol or drug misuse problem.
          
A couple of the arguments can be debunked at the outset. The idea that the term epidemics is applied only to white people so that they can rationalize being victims ignores the medical literature of the 1970s.  In those days researchers were using the terms epidemics and microepidemics and applying the terms across racial groups (3-6).  Successful naturalistic studies were conducted in both white and black neighborhoods and the success in a Chicago study (6) was  correlated with use of the term medical management.  Those same authors used what they called an infectious disease model for intervening in heroin epidemics (5).  The Chicago study was so successful that it was suggested as an alternative to involuntary treatment (4):

 "This work suggests that heroin addiction can be prevented in many who are at risk; it further suggests that prevention may be possible by using psychological and social concepts based on humanist principles without the use of coercion. The authors' approach deserves close attention not only because it offers hope in the face of a mounting national tragedy but also because of its relevance in the current high-level and little-publicized debate over the use of compulsory urine testing and compulsory treatment of drug dependent persons."   - p.1156
     
It appears that at least in psychiatry - humanism was emphasized as the critical element in treating drug dependent persons (not addicts) as far back as 46 years ago.  The design of the naturalistic study in question was impressive and methadone maintenance treatment was used in a majority of the patients.

The issue of differences in the story about the self perception of a white versus black addict does not have the equivalent empirical basis.  I can say unequivocally that any attitude in treatment about being a "victim" of substance use of any type  would be vigorously confronted by treatment staff.  It is not possible to actively participate in treatment with that attitude.  The same is true of the self loathing patient.  Guilt, shame, and self loathing need to be actively explored and corrected to allow participation in the recovery process.  Both attitudes can lead to distress or increased cravings to use drugs and alcohol and relapse.

What about the contention that cultural differences and disparities are the primary problem with treatment differences.  I refer any interested reader to an in depth analysis of the issues by Coleman Hughes (2) and what he describes as the disparity fallacy - in other words that the difference in outcomes between blacks and whites (or any two groups) is due to discrimination being the causal factor.  He lists an impressive number of examples, but I see the underlying principle as being one of undeterminism (7) that is there are multiple theories to account for differences, and people tend to have a favorite and ignore all of the other possibilities.  There is probably no better example than the race rhetoric around addiction.  The promotion of these arguments ignores the primary causes of addiction - a biological predisposition and exposure to the addictive substance.  I am not suggesting disparities are irrelevant to exposure or treatment access but focusing on them as casual ignores the major factors.           

The continued stories about racial differences in treatment and self perception are not really conducive to reshaping America's addiction treatment landscape.  It misses the big picture that there are no differences in race when it comes to addiction.  Any reasonable treatment approach would disabuse anybody coming through the door who believed they were either a victim or a self-loathing addict.  Identical treatment modalities should be offered irrespective of race and that includes medication assisted treatment of all types, necessary psychiatric and psychological treatment, medical evaluation and treatment, and drug and alcohol counseling focused on recovery.  One of the reasons why addiction is viewed as a chronic illness is the high likelihood of relapse and need for ongoing recovery services and support.  One of the main tenets of any 12-step recovery program based on the AA model is that nobody is turned away. The only requirement for membership is a desire to get sober.   

The real problem with drug and alcohol treatment is not racial disparity. It would be fairly obvious if racial discrimination was occurring in any comprehensive treatment program.  The real problem with drug and alcohol treatment is the lack of standards and consistency in treatment.  The most clear cut example is the availability of detox services.  Some forms of withdrawal are life threatening and need to be immediately recognized and treated.  I doubt that the majority of treatment programs in any state have that capability.  Hospitals have been defunded from providing detox services from anyone who is not experiencing life threatening withdrawal for about 30 years now. That has led to a proliferation of subpar and non-medical county detox facilities where limited to no medical care is rendered.  These kinds of inconsistencies in care occur across the board and it is common to see patients who have not received even basic addiction care - completing a treatment program and being released back to their home setting.

Racism has no place in medicine.  I have discussed the advantages of therapeutic neutrality on these pages before and certainly any physician who is not able to do that should not be practicing medicine in the 21st century.  The psychiatric standard for neutrality is higher.  Psychiatrists in particular are trained to understand cultural differences, but it is not possible to be an expert on every culture.  It is possible to appreciate the person in the room and proceed cautiously enough to assure that culturally sensitive care is being provided.         

In the end, there are clearly ways to prevent and treat addiction. Suggesting that race and the narratives around race are the primary factors that account for addiction or recovery is unfounded.


George Dawson, MD, DFAPA


References:

1:  Brian Broome.  Amid the opioid epidemic, white means victim, black means addict.  April 28, 2018.

2:  Coleman Hughes.  The Racism Treadmill.  Quillette May 14, 2018.

3: DuPont RL, Greene MH. The dynamics of a heroin addiction epidemic. Science.1973 Aug 24;181(4101):716-22. PubMed PMID: 4724929.

4: Freedman DX, Senay EC. Heroin epidemics. JAMA. 1973 Mar 5;223(10):1155-6. PubMed PMID: 4739378. 

5: Hughes PH, Crawford GA. A contagious disease model for researching and intervening in heroin epidemics. Arch Gen Psychiatry. 1972 Aug;27(2):149-55. PubMed PMID: 5042822.

6: Hughes PH, Senay EC, Parker R. The medical management of a heroin epidemic. Arch Gen Psychiatry. 1972 Nov;27(5):585-91. PubMed PMID: 5080286.

7:  Stanford, Kyle, "Underdetermination of Scientific Theory", The Stanford Encyclopedia of Philosophy (Winter 2017 Edition), Edward N. Zalta (ed.), URL = https://plato.stanford.edu/archives/win2017/entries/scientific-underdetermination/.



23 comments:

  1. At the risk of inappropriately being called a racist, it is a repetitive experience that African Americans more often than Caucasians are NOT receptive to mental health services, so, WHEN addiction programs force patients to be seen by psychiatrists, the former group are less accepting and agreeable to mental health interventions, not that the latter are dramatically more receptive, but, there is a measurable difference in my experiences.

    At the end of the day, people with addiction issues who come in allegedly pursing mental health care interventions are the least likely to be compliant and receptive to treatment plan recommendations. Thus, why in my opinion psychiatry has been forced to be the gatekeeper for addiction treatment needs is not only a waste of time for everyone in this process, but, is a waste of resources and monies as well.

    This is not a statement saying patients who have addiction issues do not need psychiatric care, but, it should NOT be a blanket statement that ALL addicts have mental health issues and thus need mental health care at moment one of recovery. That is a lie perpetuated by several groups, and I leave it to others to decide who to name if interested...

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    1. In the program I currently work in seeing a psychiatrist is indicated based on an easily observable acute condition (typically mania, severe depression, or psychosis) or the fact that the patient is already taking (at least one) psychiatric medication. Nobody is forced but those two indications encompass about 80% of admissions.

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    2. I don't know if the best analogy, but, wonder how long a cardiologist would be willing to cover an ER if he/she was asked to see 80% of patients coming in with c/o chest pain...

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    3. There's a reason that African Americans are less trusting of all of medicine. Every Black person in Memphis seems to know about the Tuskeegee syphilus experiments.

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    4. That is part of what reference 2 is all about - the idea that things have not changed since then.

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  2. Regarding the cardiologist analogy - in major hospitals Cardiologists see a large number of people (including my former inpatients) for definitive clearance for medical and surgical treatment. I estimate that at least 80% of the 80% seen by psychiatry have never seen a psychiatrists before and many are misdiagnosed or incorrectly treated.

    That is not necessarily due to the primary care physician not knowing what they are doing. Most frequently it is due to the patient not telling the primary care physician about the misuse of alcohol or drug.

    I find myself in a consultative rather than gatekeeper role and many of my treatment plans are designed to be followed up in the community.

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    1. I've often been bothered by the idea that addiction is not on some level a moral/psychological failing when the 12 step process precisely addresses addiction as a moral failing and attempts to correct it by getting right with a higher power and the rest of the human community. Most people who did drugs in college (which is basically the vast majority of people who overdid alcohol or played around with drugs) then stopped when they grew up stopped because they realized it was immature or morally wrong or they needed to toughen up and get it together. So the dichotomy that it's either a disease or a sin is a fundamentally wrong brain dead dichotomy on every level. I prefer to thing it is a disorder and a human weakness and a lack of psychological resiliency. Even if one wants to call it a disease, based on the bogus definition of "disease" meaning "not" at ease, there is no getting better without toughening up.

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  3. I think there is an element of language precision that comes into play and well as the philosophical levels of language precision as theorized by Wittgenstein. I plan a post on that fairly soon. The obvious comparisons occur at the followong levels:

    1. In public opinion polls 70-80% of the public believes that mental illness, addiction, and alcoholism are diseases. I would speculate that is based on first hand experience with affected family members and friends.

    2. There are undeniable heritability, genetic, epidemiological and other biological markers whether they are clinically useful or not.

    3. The battle cry of the antipsychiatrists that there is no single biological test for a mental disorder and this disproves any biological basis of illness or disease. Any physician knows the fallacy in that argument.

    These are just a few levels in the disease versus something else landscape. You can pull out whatever you want to support your position.

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  4. In my experience ethical failings and bad habits are easier to correct than most chronic diseases. So I've often been fascinated by this weird idea that dealing with the ethical and behavioral dimension of addiction makes things worse. In my mind, this makes it easier, not harder to overcome. My viewpoint is probably related to the fact that I have accepted human existence as brutal and that we are all flawed and capable of horribly destructive and self-destructive things. And I don't exclude myself.

    As far as heritability, most of that is epigenetic, not genetic. I am genetically predisposed to being overweight based on FTO and other SNPs and yet my BMI is 22. This involved a lot of "toughen up, buttercup." Genetics as destiny is a depressing message IMHO, unless it is something that is not epigenetic like Huntingdons but that is the exception.

    I don't think you need a biomarker to make it a disease, but even the very lax DSM is careful to label psych conditions as disorders rather than diseases. I can think of a lot of reasons that addiction is NOT like pneumococcal pneumonia or type 1 diabetes.

    All 12 steps of the program have a strong moral/ethical component. Look at step 4: "Made a searching and fearless moral inventory of ourselves." Obviously this wouldn't have any effect in type 1 diabetes (unless you are talking about noncompliance) so we are dealing with a disorder but not a disease in the classic sense.

    This all relates to reification concepts and I realize to some extent we are dumbing things down for general consumption. I'm not sure we are doing anyone any favors though it sort of sounds humane, but its not because it's kind of enabling. We tried that with "chemical imbalance" and look how that backfired badly.

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  5. I would add this from my 25 years of clinical care after residency: I see three basic models that explain addiction, perhaps overlaps of these at times, but, I still to this day see over 90% of substance dependency fall into one of these factors: genetic predisposition from nuclear family history; self medicating with documentable responses that validate the intent to use; and finally the role of sensation seeking, as part of extroversion, to be stimulated and exhilarated thru the experimentation with substances.

    The last model is the least frequent, and the least likely to wind up in prolonged addiction and need for recovery programs, but, when sensation seeking overlaps with one of the other two, then it is a dynamic that could be complicated per recovery efforts if one latches onto other addiction risks, like gambling or risky sex.

    My point in this comment is that should my premise have validity, then this narrow minded philosophy of a primary medication only model for intervention inherently fails the patient. Not that medication is not a needed intervention, just not the sole one. And yet, I will take a shot at one of the causes to the over consultation of psychiatry for addiction services, is in fact from our Addiction psychiatry colleagues. If they as a subspecialty feel so strongly that there is legitimacy and need for medication interventions for almost 80% of addicts, then, I strongly advised they make themselves more available to recovery programs, like rehabs as exhibit A of need.

    Again, I have no issue that others in our profession have different viewpoints and paradigms, but, we all don't share and agree with those who clamor for a "biological cause" to 90% of mental illness. Frankly, I am sick and tired of colleagues telling me I am selling patients short by not reflexively medicating 95% of my patient load at moment one.

    For those of you reading here on the East Coast, be prepared for duck weather the next 3-4 days...

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  6. SciAm on agency, addiction and disease:

    https://blogs.scientificamerican.com/observations/is-addiction-a-disease/

    And no disease is not "dis-ease" or anything that causes suffering, which is the definition of disease according the pious APA house apologist.

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    1. Extremely weak arguments.

      First off - they leave out stratification.

      Volkow's definition of addiction is equivalent to DSM-5 severe criteria. The people addiction specialists treat are not casual users who can stop when they want to. So much for the casual user argument.

      In the Robins study of heroin users - the majority of that sample never injected heroin - they sorted it or smoked it. I have requested their paper to see the frequency that they were using heroin, but for comparison sake how does occasional smoking or snorting heroin compare to injecting it 5-6 times a day for months or years? Or for that matter drinking 750-1500 ml of vodka per day?

      I don't know what to make of the social affiliation rat experiment buffering rats against addiction. I can say that there have probably been about 10,000 experiments of addiction in laboratory animals and the brain systems involved that show clear neurobiological involvement starting with Olds' experiments back in the 1960s.

      These simplistic arguments also don't match the clinical realities of treating people with severe addictions. It is like I keep saying - biological predisposition + exposure = addiction.

      It is as obvious as the suburban teens who get hydrocodone for minor athletic injuries or wisdom tooth extractions instead of ibuprofen and within a few years develop a heroin problem. All of the social advantage, family support, and education won't save them when they are injecting heroin 5 times a day and have a Smartphone full of drug dealer numbers. That Vietnam study from 1971 won't save them when they are looking for fentanyl instead of avoiding it.

      Neither will all of the moral explanations in the world.

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    2. I didn't read the article as overlysimplistic at all, in fact I thought they took a rational biopsychosocial middle ground. They clearly didn't take a Cotton Mather approach. It is true that most addicts stop on their own when they want to change the narrative of their life. All treatment of addiction does involve this.

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  7. "It is true that most addicts stop on their own when they want to change the narrative of their life."

    That is a false statement per my previous post.

    The best example that comes to mind is Vaillant's study of inner city alcoholics.

    At 8 years 25% sober, 29% dead, and 26% unchanged. Have not seen a good similar study of heroin addiction but probably significantly worse. Moreover the question that none of the choice advocates can ever answer is: "Why wouldn't you chose to stop before you end up dead or on skid row?" Numerous rationalizations typically follow. The outcomes of Type 2 diabetes are much better specifically:

    "For example, in the UKPDS Outcomes Model, diabetic men aged 55 years were predicted to live 3.6–11.5 years less than the general population. British and US studies reported this gap to range on average between 5 and 9."

    That is really why there is a disease model. Reminds me of the era of schizophrenogenic mothers and schizophrenia as a choice. The only reason psychiatry exists today is that all of the illnesses we treat are legitimate major problems. Without that basic reality the quacks and antipsychiatrists would have put us out of business decades ago.

    They are still trying and this conceptualization of addiction makes them nervous.

    1. Vaillant GE, Clark W, Cyrus C, Milofsky ES, Kopp J, Wulsin VW, Mogielnicki NP.
    Prospective study of alcoholism treatment. Eight-year follow-up. Am J Med. 1983
    Sep;75(3):455-63. PubMed PMID: 6614031.

    2: Leal J, Gray AM, Clarke PM. Development of life-expectancy tables for people
    with type 2 diabetes. Eur Heart J. 2009 Apr;30(7):834-9. doi:
    10.1093/eurheartj/ehn567. Epub 2008 Dec 24. PubMed PMID: 19109355; PubMed Central
    PMCID: PMC2663724.

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    1. I guess I'm missing something here between you and Dr. O'Brien. I agree that when addicts finally accept recovery as the primary narrative, they will hopefully maintain sizable abstinence.

      I know that treatment is obviously multi-dimensional, but at the end of the day, addicts have to accept that they want to help themselves.

      The way treatment has degraded, addicts are being told "we will treat you whether you like it or not..."

      Thus why recovery rates still remain less than 10% successful for more than a year, they accept the latter, not!

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  8. I think that argument answers the original question better than blaming old unethical syphilis studies that most people aren't even aware of. Quite possibly inner city residents versus suburban residents feel less capable of changing their narrative. I clearly remember when my family was urban poor the sense of fatalism from everyone in the neighborhood was greater. I didn't start hearing that I could be anything until we moved out of that environment.

    Let's not forget sample bias. We're seeing the people who couldn't quit on their own. Based on my patient population I could easily assume that back surgery NEVER works, but I'm seeing the failures. With diagnostic inflation, it can be said that just about everyone who overdid and woke up in weird places for a few months in college was an addict, and almost all of them knocked it off on their own.

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  9. ""The way treatment has degraded, addicts are being told "we will treat you whether you like it or not..." ""

    I work in one of the largest residential treatment centers in the country.

    The only way you can be admitted is if you have a severe substance use problem and consent to treatment. It is clear from the outset that patients are free to leave at any time. Admittedly there are other ultimatums (spouses, bosses) that can lead to people staying in treatment.

    In my experience there are many treatment setting where people are treated on a "soft" involuntary basis. By that - I mean that they are on probation or go as the result of a court edict that provides some incentive to complete treatment. It takes a lot of resources to keep people engaged in this programs and preventing a correctional atmosphere from creating an environment that is not therapeutic.

    I have also witnessed "hard" involuntary treatment through civil commitment and have seen that be very effective. It is not effective any more because the state hospital system has essentially crashed and there are no beds for the treatment of substance use problems - at least not to the extent that there used to be. The model that most substance use treatment programs use was invented at Wilmar State hospital in Minnesota.

    There is a general attitude (87 counties in MN) in commitment courts that substance use commitment should be rarely used and as a result more people are at risk today from severe substance use problems than there used to be. Commitment may not occur until after a near fatal complication of addiction occurs.

    The most compelling story of all of these setting in the 21st setting is the concern about post discharge deaths occurring in opioid users. That standard explanation is that the person loses tolerance is discharged and then resumes their previous opioid use and dies because of a loss of tolerance. That is logical but there are other explanations. The main point is that post discharge and post incarceration death rates in opioid users were unacceptably high and there was not known way to stop it.

    That is the reason for discharging patients on buprenorphine and with intranasal naloxone. It is also an acknowledgement that it takes more than a willing patient who is sincere and wants to stop using opioids. Probation and parole can't stop these tragedies and neither can voluntary treatment with comprehensive psychosocial follow up.

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  10. "Let's not forget sample bias. We're seeing the people who couldn't quit on their own."

    We are seeing DSM-5 severe substance use. The histories of many are distinctly different from the other college kids who stopped using after they were hung over or left college.

    I think the comparison illnesses are polygenic chronic illnesses. The kid who needed a rescue inhaler or the kid who grows out of his asthma compared to the one who is on lifelong polypharmacy for asthma. The person with transient hypertension related to OSA, weight gain, or stress compared to the person who is at ideal body weight but needs maximum therapy for the rest of their life.

    I would not equate that with diagnostic inflation but would see it as the opposite trend. Eliminating all of the people who easily quit along the way decreases the number of cases.

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  11. Well, all I can say is enjoy your likely exception to the treatment process these days. Court orders to rehab I would say are now at least 20 to 40% of the admissions. Therefore, with that being allowed, rehabs are being ruined.

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    1. The negative feedback that I get is about treatment centers with much higher rates (80-100%). 20-40 is still salvageable but it tales a highly skilled staff who can confront problems. In many ways it is reminiscent of the way the VA used to treat PTSD when I was a resident. They lacked a rational therapeutic plan and it became a repetition of the traumatic experiences.

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  12. I think we actually agree and once again DSM is confounding and not helping. I'm just saying those who partied too hard and quit would be classified as abusers or even addicts under DSM. In my own mind, they're quite different than true addicts under the old definitions in the construct validity sense. I like the asthma analogy. I would say that not all of them short of going into treatment had an easy time quitting. A lot of that involved dumping friends, changing sleep schedules, growing up and the like.

    Feighner's original definition of alcoholism is a lot different than the one used today. And the AA definition is so broad just about anyone who ever overdid it would qualify.

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  13. I think a separate category needs to be included for alcohol and that is binge drinking or episodic heavy use. Just counting the drinks consumed in a brief period of time identifies a category of very high risk drinkers and primary care staff don't have to know all of the other criteria. Quantity is important and I don't know why they leave it out. 750-1500 ml/day pretty much means all the criteria are met.

    As far as the AA definition there is a degree of subjectivity in that any AA group accepts anyone who is self identified as an alcoholic who wants to get sober. In the Big Book - controllability is a key feature that remains in DSM-5. In the Big Book it is stated this way:

    "The fact is that most of us alcoholics, for reasons yet obscure, have lost the power of choice in drink. Our so-called will power becomes practically non-existent. We are unable at certain times to bring into our consciousness with sufficient force the memory of suffering and humiliation of even a week or a month ago. We are without defense against the first drink." (p 15 orig manuscript)

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  14. "Quantity is important and I don't know why they leave it out. 750-1500 ml/day pretty much means all the criteria are met."

    I've often wondered this myself and I agree. DUIs are quantified but not alcoholism! I would quantify it as ml/kg though.

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