10/31/17

Mistaken Beliefs About Addiction Relapse

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The coroner’s report on Carrie Fisher’s death listed sleep apnea as the primary cause of death with drug intake as a contributing factor. In addition to the medications prescribed for her bipolar disorder (Abilify, Lamictal and Prozac), toxicology results found cocaine, methadone, heroin, oxycodone, and MDMA (ecstasy) in her system at the time of her death. Fisher’s family objected to a full autopsy, so the coronor’s conclusions were based on the toxicology results and an external examination of her body. “Based on the available toxicological information, we cannot establish the significance of the multiple substances that were detected in Ms. Fisher’s blood and tissue, with regard to the cause of death.”

The above information was from an article in Variety, but several media outlets were citing the coroner’s report and the same information. People said the coroner’s report indicated Ms. Fisher used cocaine sometime in the 72 hours prior to her death. During her 10-hour flight, she had multiple apneic episodes, which her personal assistant said was normal for her. Towards the end of the flight, she could not be roused. The report also noted she suffered from atherosclerotic heart disease, but then said: “The manner of death has been ruled undetermined.”

Although the official coroner’s report listed the manner of death as undetermined, it seems reasonable to assume from the toxicological information that Ms. Fisher had relapsed into active substance use. Billie Lourd, her daughter, said in a statement to People: “My mom battled drug addiction and mental illness her entire life. She ultimately died of it.” The cocktail of substances in Carrie Fisher’s system at the time of death, along with her history of heart disease, coupled with the increased risk of sudden cardiac death due to the medications used to treat her bipolar disorder lends credibility to Ms. Lourd’s statement.

The use of psychiatric medication to treat her bipolar disorder may have been a contributing factor to Ms. Fisher’s heart failure. See the article, “Blind Spots with Antipsychotics” Part 1 and Part 2 for more on the health problems with antipsychotics. But the range of substances she used just before her death may also have been enough to precipitate a sudden cardiac death, particularly since she already suffered from heart disease. Struggling with a concurrent bipolar disorder and a substance use disorder is a double whammy to anyone in recovery. Instability with either issue is a serious risk factor for relapse. I knew of someone with a bipolar diagnosis and cocaine dependence. They bounced back-and-forth between active cocaine use and inpatient psychiatric treatment for depression ten times within a single year.

Ms. Lourd said her mother would want her death to encourage people to be open about their struggles, and to seek help for them. Historically, Carrie Fisher talked openly about her proneness to relapse. She told People in 1987: “I couldn’t stop, or stay stopped. It was never my fantasy to have a drug problem.” She would stop for a couple of months and then celebrate her abstinence by using again. “I got into trouble each time. I hated myself. I just beat myself up. It was very painful.” With that in mind, let’s assume the immediate cause for her untimely death was due to an apparent relapse into active drug use, and then discuss some mistaken beliefs about addiction relapse.

Terrance Gorski is a leading expert on addiction relapse prevention. He’s written several books on the subject, many of which are available through Herald House Independence Press at relapse.org. He also has a blog, Terry Gorski’s Blog, where he has made a significant amount of his material available for free. Here we’ll concentrate on his article, “Relapse Does not Mean Failure?

Gorski said there were three mistaken beliefs that often interfered with helping relapse prone individuals. They are: (1) Relapse is self-inflicted; (2) Relapse is an indication the person is a failure who doesn’t want to recover; and (3) Once relapse occurs the patient will never recover.

In most cases, relapse is not self-inflicted. There isn’t a fully conscious, willful decision to throw over abstinence and return to active drinking or drug use. Relapse-prone individuals “experience a gradual progression of symptoms in sobriety that create so much pain that they become unable to function in sobriety. They turn to addictive use to self-medicate the pain.” They can learn to stay sober by recognizing these symptoms as early relapse warning signs. Next is identifying the self-defeating thoughts, feelings and actions used to cope with the symptoms and then learn more effective coping mechanisms, more healthy ways of responding to them.

Unfortunately, most relapse-prone patients never receive relapse prevention therapy, either because treatment centers don’t provide it or their insurance or managed care provider won’t pay for it.

Relapse is not automatically a sign that treatment has failed or the person really doesn’t want to recover. It is more likely that the root-cause of the person’s problems wasn’t addressed by the “standard package of treatment offered.” If this is the case, the risk of relapse increases dramatically. Learning to recognize relapse warning signs and how to cope with them would minimize this risk.

Gorski said that between one half and two-thirds of all individuals treated for alcohol and drug use problems will relapse. At least one half of those who relapse will establish long-term recovery within five to seven years of their first treatment experience. Believing that relapse means both the person and the treatment failed ignores the reality that for many, recovery involves a series of relapse episodes. “Each relapse, if properly dealt with in a subsequent treatment, can become the a learning experience which makes the patient less likely to relapse in the future.”

Chemically dependent people can be grouped into three types based upon their recovery and relapse histories. The first type is recovery prone and maintains total abstinence from their first serious attempt at change. Another type is relapse prone, with a series of short-term, low consequence relapse episodes before finding long-term abstinence. The third type is chronically relapse prone, who can’t seem to find long-term sobriety regardless of what they do.

Recovery prone individuals tend to be dependent on a single drug. They also have higher levels of social and economic stability. They may have steady employment, friendships and stable living situations. And they don’t have coexisting mental health issues, as Carrie Fisher did, or physical health issues, like chronic pain problems. These “garden variety addicts” have chemical addictions with few additional serious personal or social problems.

The second type of transitionally relapse-prone individuals, seem to have more severe addictions that are complicated by other problems. However, they learn from each relapse episode and take steps to modify their recovery programs to avoid future relapses. For example, they may downplay the risks of going around good friends who still drink or use drugs until they find themselves actively drinking or drugging again. Afterwards, they set and keep boundaries with those friends that better support their recovery.

The third type— chronically relapse-prone individuals—not only have the primary addiction for which they are being treated, but also a combination of the following coexisting issues. They may have multiple drug addictions, especially with opiates and methamphetamines. They can have an undiagnosed physical condition, a personality disorder or other mental health problem. There could be issues with severe post acute withdrawal (PAW), which becomes even more severe when the person is under high levels of stress.

Many relapse-prone patients fail to recover because these coexisting [issues] are not properly diagnosed and treated and they interfere with the primary treatment being given.

The third mistaken belief sees recovery as an all-or-nothing process—you either have it or you don’t. And if you relapse, you just don’t want recovery bad enough. Actually, recovery is a learned skill, acquired mostly by trial and error.  Rarely does someone with long-term recovery get there without one or more short series of relapse episodes. “They learned from these experiences and figured out how to put together a meaningful and comfortable long-term recovery.”

So when you think about Carrie Fisher’s toxicology report, don’t assume she threw away her sobriety like it was an old, worn out Alderaan gown. Her relapse was likely the result of a gradual progression of symptoms occurring in her life. In time, they created so much pain in sobriety that she wasn’t able to function. So she tried to self-medicate. She also wasn’t a failure who didn’t want to recover. The openness in her life about her struggles with addiction and mental health belie such an assessment.

Like thousands of others each year, she died with multiple psychoactive substances in her system. But that doesn’t mean she would have never made it back to abstinence. Remember, she was Princess Leia; and Leia Organa never gave in to the tyranny of the Empire. Carrie Fisher would never have given up fighting against her addiction and mental health demons.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, “Terry Gorski’s Blog”, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and website.

10/27/17

Ability to Choose … Within Limits

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It’s not too difficult to discover where Sam Harris stands on whether or not humans have free will. We unequivocally don’t. “Free will is an illusion.” In a lecture Harris gave for Skeptic Magazine that was based on his book, Free Will, he added that if the scientific community were to publically declare free will to be an illusion, “it would precipitate a culture war.” Science has revealed that we are “biochemical puppets” and “The universe is pulling your strings.”

Free will is an illusion. Our wills are simple not of our own making. Thoughts and intentions emerge from background causes of which we are unaware and over which we exert no conscious control. We do not have the freedom we think we have.

This illusion of free will is based on two false assumptions, according to Harris. The first is that we can behave differently than we did in the past. But since we live in a world of cause and effect, our wills are determined by a long chain of prior causes, “and we’re not responsible for them.” Alternately, what we perceive as free will is the product of chance; and again, we’re not responsible. Or there could be some combination of chance and cause and effect, but still no personal agency. Whichever way we conceive it, free will is an illusion in a world ruled by chance and cause and effect.

The second false assumption is that we are the conscious source of our thoughts and actions. “We presume an authorship over our own thoughts and actions that is illusory.” There is no self, no ego, no soul to generate thoughts and actions, according to Harris. They just emerge in our consciousness. And if we cannot control our thoughts, if we don’t know what our next thought will be until it consciously emerges, where is our free will?

How can we be free as conscious agents, if everything we consciously intend was caused by events in our brain, which we did not intend, and over which we had no control?

Sam Harris is an author, philosopher and neuroscientist who has written several popular books in addition to Free Will. Along with Richard Dawkins, Daniel Dennett and Christopher Hitchens, he has been referred to as one of the “Four Horsemen of New Atheism.” The reference draws on the title of a 2-hour unmoderated discussion between the four that is available here on the website for the Richard Dawkins Foundation for Reason and Science. They discussed the public reaction to some of their books critical of religion, and some common misrepresentations of them and their beliefs.

Harris’s position on free will assumes the universe is a closed system of cause and effect. Since there are no creator gods, everything that now exists is the result of what has come from “a long chain of prior causes.” The theologian Francis Schaeffer referred to the understanding of science that comes from this view of the universe as modern, modern science—science rooted in naturalistic philosophy. The uniformity of natural causes, which is an essential starting point for scientific investigation, must be understood as occurring entirely within the natural order of the universe. Nature is closed to any causal intervention from outside.

There is no Creator; no First Cause. There is only chance or cause and effect. Not only physics, but psychology, social science and human nature must be explained within the confines of this closed system. The biologist and neuroscientist Robert Sapolsky believes that every bit of human behavior has multiple layers of causality. He said what we call “free will” is simply biology that hasn’t been discovered yet. “It’s just another way of stating that we’re biological organisms determined by the physical laws of the universe.” See “Ruling Over Our Genes” for more on Sapolsky.

In Escape From Reason, Schaeffer concluded this materialist unity of all things leaves us afloat on a deterministic sea with no shore. The only way this unity can be achieved is by ruling out freedom. “The result of seeking for a unity on the basis of the uniformity of natural causes in a closed system is that freedom does not exist.” Free will is therefore an illusory cognitive construct.  The nonmaterial mind or soul is also an illusion.

However, Harris and Sapolsky aren’t the only neuroscientists to ever consider the possibility of free will. Harvey McMahon is a staff scientist and group leader at the Medical Research Council Laboratory of Molecular Biology in Cambridge. He is also a member of The Royal Society, the world’s oldest independent scientific academy. Past members of the Society have included Isaac Newton, Albert Einstein and Charles Darwin. Current members include Richard Dawkins and Stephen Hawking.

McMahon discussed free will in: “How Free Is Our Free-Will?” He opened his essay by noting science has provided evidence that free-will may be an illusion. Yet free-will was fundamental to our sense of wellbeing, and underwrote our sense of morality, our judicial system, and our Judeo-Christian faith. “We may not be as free as we would like to think, but within boundaries shaped by our individual histories, our genetics, and our environment we can make decisions that determine our character, relationships and future.”

He noted the paradoxical nature of freedom. For example, if we marry we limit the relationships we will have with others, while at the same time opening up new avenues of freedom from being settled in our choice of partner. This principle, McMahon said, applies to all our choices. We change our future possibilities by the choices we make today. “Thus freedom is not unconstrained choice, for with each choice we limit our freedom, and in so doing shape our environment and ourselves.”

These constraints are from our culture, our relationships, our jobs and our families, and other influences. Added to these is the subconscious working of our brain, processing cues of which we are not aware. “Thus the brain may even be making decisions for us.” Do we really have a choice? Here McMahon acknowledged Harris’ above noted argument (and book), that free-will was an illusion. But rather than an illusion, he thought it better to say it was constrained by many factors.

Free-will, McMahon thought, “is a cognitive concept, involving the mind.” It is the ability to choose deliberately between options. “It cannot be regarded as the opposite of determinism, where events have cause and effect outside human control.” He illustrated what he meant with the following diagram. Free-will only applied to cognitive processes where we use our minds to make choices—in between the two extremes. Although not stated by McMahon, I’d say completely free choice is only possible within the mind of God.

Human free-will is then not completely determined, nor is it completely free. McMahon suggested free-will occurred within the boundaries of predetermined factors, where there was little or no freedom to choose. These factors could be biological or genetic. They could also be family, culture, or environmental factors. See the diagram below.

Within an outer sphere of predetermined boundaries, lies a continuum of interaction between prior free-will and proximal free-will. Prior free-will is where an immediate decision is constrained by past decisions and history. Going to work on a given day is more the result of a past decision than one made when you woke up that day. You can re-assess the decision and not go to work for some reason, “yet the choice does not have to be constantly re-evaluated.” In-the-moment or proximal decisions can be inconsequential, like choosing between tea or coffee, or involve active cognition, as when we weigh our options. “Both of these give a strong sense of free-will in the moment.”

Plasticity refers to the fact that our brains are moldable. “We are constantly learning new information, meeting new people and acquiring new skills, which all require that our brains are ‘plastic’.” New synapses can be formed or existing synapses can be modified or lost. “At a molecular level there can be changes in the expression of various proteins which in turn influence the excitability of a given synapse or circuit.”

The choices we make influence the behavior patterns we develop, which are laid down as neuronal pathways. In turn, these pathways influence other choices. “So in this sense we are masters of our own destiny… all because we have a ‘plastic’ brain (i.e. not completely preprogrammed).” Although there is difficulty in the process, we can change. If we make certain choices repetitively, they lay down neuronal pathways and turn into learned behaviors.

Plasticity is thus key to the possibility of free-will [see the above diagram]. While memories of past experiences may not be completely eradicated, they can be scaled back by the new experiences that occupy our minds as we choose to dwell on other things.

Jeffery Schwartz and Rebecca Gladding coauthored You Are Not Your Brain, a self-help book that applies the principles of neuroplasticity discussed above. Like McMahon, Schwartz and Gladding affirm the reality of the human mind and the existence of free-will. Dr. Schwartz is one of the world’s leading experts in neuroplasticity. You can read more about him and his books on his web page here.

McMahon said the relationship between this conception of free-will and intentionality is complex. To the extent we willfully choose and can foresee certain outcomes, ”we can be held responsible for the outcome.” However, if we could not foresee the potential consequences of decisions, to what extent can we say their outcome was intentional? Furthermore, what about when reason has been suppressed for some reason, or if it has been erroneously applied (if we haven’t reasonably weighed our potential thoughts or actions), and non-intended consequences result.

Despite the caveats, in general each of us is responsible today for what we did yesterday because these were acts of free-will, or actions resulting from an absence of self-control. The responsibility for evil can be lessened by considering our circumstances but it never excuses us because at some point in the past we have actively participated in shaping who we are today.

McMahon goes on to describe how he believes our brains and free-will interact with each other. He suggested that while individual neurons do not have free-will, “it is an emergent property of neuronal networks.” He suggested free-will sits upon a tripod of past memories, present inputs (combined with the ability to compute and learn) and future predictions and aspirations within the plasticity of the brain.

There is more to read and think about in his article. McMahon also shares his thoughts on how God constrains us and yet frees us. He wrestles with the question of whether free-will is compatible with divine sovereignty. Read more on how he applies the above discussion to this theological dilemma. His conclusions are worth repeating here.

With the above in mind the following definition of free-will can be offered: Free-will is the ability to choose intentionally within limits placed by a sovereign God, with resulting human responsibility. Free-will is not the opposite of determinism: one can have free-will within the limits set by determinism. Indeed our relationships and our decisions are not absolutely predetermined, and this is a reflection of the freedom given to us by being made in the image of God. So, we have the best of both worlds, where we have freedom to make decisions and yet our personal future and that of the world are secure.

The above understanding of free-will indicates we are less free than we may like to think we are at any given moment, because of prior decisions and predetermined factors. And while neuroscience hasn’t extinguished free-will, it does help us see why we do the things we do. So we are not biochemical puppets, but biology constrains us. “We are not determined by our past, but certainly influenced by it.”

10/24/17

Feuding Ideologies, Part 3

© Navakun Phuangchan

“Dying To Be Free,” an article on the opioid addiction crisis, was well written and effectively communicated its message. That message was that abstinence-based treatment “didn’t work well for opioid addicts.” Medication-assisted treatment (MAT), especially with Suboxone, should be the standard of care. Nominated for a Pulitzer, “Dying To Be Free” was said to have influenced “a series of state and federal policy changes” away from abstinence to embrace MAT. But it has a glaring blind spot with regard to MAT, particularly Suboxone.

Pragmatically speaking, abstinent-based treatment and MAT need to learn to work together in order to effectively address the opioid addiction crisis in the U.S. “Dying To Be Free” systematically put these two approaches as being at odds with each other. It suggested we need to choose between the two, and argued that we should choose MAT. In order to support Suboxone MAT, it failed to acknowledge several serious concerns with Suboxone and other MATs. In this sense the persuasive rhetoric of the article had a blind spot.

In what follows, I hope to shine a light on what was missed with regard to Suboxone and other MATs. My intent is to bring to light the potential cons with Suboxone treatment in order to counterbalance the many pros found in “Dying To Be Free.” In order to make a truly informed addiction treatment choice both the strengths and weaknesses, the pros and cons need to be known and understood.

On September 20, 2017, Scott Gottlieb, the FDA Commissioner released a statement that said combined with counseling and behavioral therapies, MAT (medication-assisted treatment) was one of the main pillars of the federal response to the opioid epidemic. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), it cuts the risk of death from all causes in half among individuals who use MAT to treat their opioid use disorder. But methadone and buprenorphine are themselves opioids and when they are combined with benzodiazepines or other central nervous system (CNS) depressants, there is a risk of serious side effects, such as difficulty breathing, coma and death.

Since the harm caused by untreated opioid addiction can outweigh these risks, the FDA advised against withholding buprenorphine or methadone-based MAT from individuals taking benzodiazepines or other CNS drugs. Nevertheless, the agency is requiring changes to the MAT drug labels to help decrease the risks of combining these drugs. Heath care professionals should educate patients about the risks of combined use, “including overdose and death.” They should taper the benzodiazepine or CNS depressant to discontinuation, if possible. They should verify the diagnosis if a patient was prescribed these drugs for anxiety or insomnia, and consider other treatment options for these conditions.

The new labeling recommends that health care providers develop a treatment plan that closely monitors any concomitant use of these drugs, and carefully taper the use of benzodiazepines, while considering other treatment options to address mental health conditions that the benzodiazepines might have been initially prescribed to address.

The FDA prescribing information for buprenorphine already notes that: “significant respiratory depression and death has occurred in association with buprenorphine,” particularly when it is used intravenously (IV) or in combination benzodiazepines or other CNS depressants, including alcohol. “Many, but not all post-marketing reports regarding coma and death associated with the concomitant use of buprenorphine and benzodiazepines involved misuse by self-injection.” Unintentional exposure of buprenorphine to children, which can cause possibly fatal respiratory depression, was warned against. It also notes the potential for dependence:

Buprenorphine is a partial agonist at the mu-opioid receptor and chronic administration produces physical dependence of the opioid type, characterized by withdrawal signs and symptoms upon abrupt discontinuation or rapid taper. The withdrawal syndrome is typically milder than seen with full agonists and may be delayed in onset. Buprenorphine can be abused in a manner similar to other opioids. This should be considered when prescribing or dispensing buprenorphine in situations when the clinician is concerned about an increased risk of misuse, abuse, or diversion.

Buprenorphine and methadone are both opioids, with the potential for physical dependence. Therefore, they are both diverted from legitimate medical treatment for illicit use. Buprenorphine is a Schedule III controlled substance, while methadone is a Schedule II controlled substance. Buprenorphine is said to have a tolerance ceiling with respiratory depression, meaning it has a lower potential when used alone to cause respiratory depression and death. Given that buprenorphine is a partial agonist, its physical euphoria is less intense than other opioids. But tolerance to many of the effects will develop with prolonged and repeated use.

Methadone was first synthesized by the Nazis, who never brought it into widespread use because of side effects, which included its addictive potential. After WWII, the Americans took control of the factory where methadone, then known as dolophine or polamidon, had been invented. A 1947 study demonstrated its addictive potential, warning if the manufacture and use was not controlled, “addiction to it could become a serious health problem.” See “The Consequences of Ignoring the Past,” for more on methadone.

The addictive potential and the abuse potential for buprenorphine or methadone was not readily discussed in “Dying To Be Free.” Nor were the above-noted concerns of mixing buprenorphine and CNS depressants. The author, Jason Cherkis, did say that neither drug was a miracle cure. Suboxone blocks both the effects of heroin withdrawal and an addict’s craving and, if used properly, does it without causing intoxication.” But saying both drugs were comparable to “the insulin that a diabetic needs to live” was inaccurate and disingenuous. Chronic, long term use could lead to a lifelong dependency.

There is no getting around this. Chronic, long term use of buprenorphine and methadone produces physical dependence. A too rapid taper or an abrupt discontinuation will produce symptoms of withdrawal. Extended, chronic use over months or years could result in a lifelong reliance on the medication to avoid the discontinuation or withdrawal crisis—and the danger of returning to active illicit opioid use. In the documentary Methadonia, about methadone maintenance in New York City, one individual referred to methadone as “liquid handcuffs.”

Another disturbing blind spot in Dying To Be Free” was its discussion of a 2009 study, “Illicit Use of Buprenorphine/Naloxone Among Injecting and Noninjecting Opioid Users.” Cherkis cited it, stating the majority of addicts surveyed were buying Suboxone on the black market “in an attempt to get sober.” 74% of those surveyed said they were using Suboxone to “ease withdrawal symptoms; 64% said they were using it because they couldn’t afford drug treatment. “Even when purchased on the black market, regardless of the intentions of the user, the medication works as intended — as harm reduction.”

The study abstract contains the information Cherkis noted. But let’s take a closer look at the further results reported in the full article. First recognize the sample size was small: 51 injection opioid drug users (IDUs) and 49 noninjection opioid dug users (non-IDUs). It was also drawn from a limited area, opioid users in Providence, RI. Only 7% reported current employment and 52% reported current homelessness. The 64% who were using diverted Suboxone because they couldn’t afford treatment are easily explained by the high unemployment and homelessness figures.

In addition to the results reported by Cherkis was the following data. Among those who had used diverted buprenorphine, 60% reported using it for less than 1 week; 13% for 1 week; and 28% for more than 1 week. Of those using diverted buprenorphine less than 1 week, 32% said they only used it for one day. Fifty seven percent said they used diverted buprenorphine because they couldn’t obtain heroin; a greater percentage (68%) of IDUs than non-IDUs (41%). Forty seven percent said they used diverted buprenorphine to ‘get high’; a greater percentage of non-IDUs (69%) than IDUs (32%). Seventy six percent said it was easy or very easy to obtain Suboxone on the street.

The following quote by Tom Frieden, the former director of the Centers for Disease Control and Prevention (CDC), appeared after the selective reporting on the above study, arguing for the need of more MAT programs: “If buprenorphine is being used and being bought on the street to self-treat addiction, that’s a reflection of a need to have better medically assisted treatment programs out there.”

I don’t really think these patterns of and reasons for diverted buprenorphine use are best described as harm reduction, as Cherkis said. Technically, there are high percentages of individuals saying they used it to reduce withdrawal, and/or self-treat opioid addiction, as well to stay “clean” for some time. But most also said they used buprenorphine because they couldn’t obtain heroin. The reported time of buprenorphine use for the majority of individuals was less than a week; 32% said it was for only one day! In addition, 32% of IDUs and 69% of non-IDUs said they used it to “get high.” It seems it would be more accurate to describe this behavior as attempting a time period of controlled opioid use, rather than harm reduction.

About fourteen months before “Dying To Be Free” was published, “Addiction Treatment With A Dark Side” appeared in The New York Times. It too looked at Suboxone treatment, but presented a different, more nuanced side to Suboxone treatment. Cherkis selected out one aspect of the article, that it “linked hundreds of deaths in the U.S. to buprenorphine and Suboxone.” He focused in on the phrase used to say buprenorphine was a “primary suspect” as a cause of death in CDC data analyzed by the NYT. He then noted there should be caution used before attributing a “primary suspect” drug as a cause of death, which he neglected to show is exactly what the NYT article did do.

The NYT article said the 420 deaths with buprenorphine as a “primary suspect” paled in comparison to those reported to the FDA from methadone for the same time period. It also said “The F.D.A. information, which is spare, does show that more than half of the American buprenorphine deaths involved other substances and that only two of 224 cases specifying ‘route of administration’ indicated injection — the primary concern of regulators.” Fifty deaths were noted as suicides, 69 as unintentional overdoses from drug abuse, and 30 were fetal or infant deaths after exposure in the womb.

The NYT claimed some experts believe buprenorphine is not being monitored systematically enough to gauge the full scope of its misuse. The CDC does not track buprenorphine deaths. Most medical examiners, emergency rooms, prisons, jail and drug courts don’t routinely test for it. The director of the Center for Substance Abuse Research at the University of Maryland said: “I’ve been studying the emergence of potential drug problems in this country for over 30 years. . . . This is the first drug that nobody seems to want to know about as a potential problem.”

Then “Addiction Treatment With A Dark Side” had a section noting some of the aggressive actions taken by Reckitt Benckiser, the company that brought Suboxone to market, “to protect its lucrative franchise.” I’ve noted these and similar actions by Reckitt Benckiser in previous articles: “A Double-Edged Drug,” “The Seduction of Opioid Substitution” and “The Opioid Buzzard.” The Times article documented the widespread association between Reckitt Benckiser and the federal government in bringing Suboxone to market, and in providing a place for lucrative employment when government officials left public service for employment in the private sector.

At one point in “Dying To Be Free,” Cherkis said the “squeeze of regulation” was responsible for opportunistic forces, such as “cash only Suboxone clinics and shady doctors,” as well as the “vibrant black market for illicit buprenorphine. Read the section, “Troubled Histories” in the NYT article and the follow up NYT article, “At Clinics, Tumultuous Lives and Turbulent Care” to get a clearer, more accurate picture of the problems with some of the existing Suboxone treatment centers and providers.

You also find a lengthy section describing the benefits of Suboxone treatment. Cherkis did say in “Dying to Be Free” that the NYT article did not question the efficacy of Suboxone when it was used properly. But why didn’t he discuss or cite some of the concerns? I think it was because “Dying To Be Free” was intended to be a persuasive piece of rhetoric to promote the widespread use of buprenorphine in MAT.

Undoubtedly, “Dying To Be Free” has had a significant influence on opioid treatment. But it seems that it did not present a well-rounded picture of both the problems and the benefits with MAT, specifically Suboxone. It seems to have a biomedical bias with regard to conceiving and treating opioid addiction. In Part 1 of “Feuding Ideologies,” I indicated how its rhetoric was a straw man attack on abstinent-based treatment while it extolled MAT. In Part 2, I showed how it misrepresented the recovery philosophy of Alcoholics Anonymous. Here in Part 3, I looked at how its biomedical bias seemed to dismiss or ignore many of the problems with Suboxone as a MAT for opioid addiction.

10/20/17

Beginning of the End?

credit: Chuck Sigler

According to David Meade, September 23, 2017 was a momentous day—the day that the prophecies written in chapter 12 of the book of Revelation will be evident. He said the world itself was not ending then, but the world as we know it will end. There was to be a series of catastrophic events over the course of weeks afterwards. “A major part of the world will not be the same the beginning of October.” … Still waiting … Anything happening yet?

As The Washington Post noted, the pregnant woman described in the twelfth chapter of Revelation was to appear in the sky on September 23rd. On her head will be a crown of twelve stars. She’ll be clothed with the sun; the moon will be under her feet. The woman represents the constellation Virgo, which will be “clothed in sunlight” and positioned over the moon and under nine stars and three planets. The planet Jupiter will emerge from Virgo, “as though she is giving birth.”

But then Meade revised his prediction, saying that while there were major signs in the skies on September 23rd, but the most important date of the millennium was October 15th, 2017—which would be the beginning of the world’s destruction, the beginning of a seven-year period of tribulation. On his website, Meade wrote: “Hold on and watch — wait until the middle of October and I don’t believe you’ll be disappointed.” You could buy and read his book, but he warned, “You don’t have long to read it.”

Before Meade there was Harold Camping, who predicted the end of the world twice. The first time was supposed to happen between September 15th and 27th, 1994. The second prediction by Camping said it was supposed to happen in 2011. On May 21, 2011, at 6 pm local time, the Rapture and Judgment Day was to take place. Then on October 21, 2011 would be the end of the world. He would later write that while his statements were incorrect and sinful, they allowed God to get the attention of a great many people who otherwise would not have paid attention. “Even as God used sinful Balaam to accomplish His purposes, so He used our sin to accomplish His purpose of making the whole world acquainted with the Bible.”

Meade and Camping are examples of a repeated mistake made by Christians when they fail to read and interpret the visionary texts of the Bible correctly. They often confuse or misinterpret two related visionary genres, prophecy and apocalypse. In How to Read the Bible as Literature, Leland Ryken described visionary literature as picturing setting, characters and events in an imaginary context as opposed to ordinary, empirical reality. This, however, does not mean that the visionary literature of the Bible is pure fantasy.

Visionary literature pictures settings, characters, and events that differ from ordinary reality. This is not to say that the things described in visionary literature did not happen in past history or will not happen in future history. But it does mean that the things as pictured by the writer exist in the imagination, not in empirical reality.

Neither prophecy nor apocalypse is entirely visionary; nor are they necessarily futuristic in their orientation. But they will transform the known world or the present state of things into an imagined reality. “In one way or another, visionary literature takes us to a strange world where ordinary rules of reality no longer prevail.” Ryken said the simplest form of this kind of transformation is to give a futuristic picture of the changed fortunes of a person or group or nation. The motifs of transformation and reversal in visionary literature mean that when interpreting it, the reader needs to be “ready for the reversal of ordinary reality.”

There are several elements or themes within Biblical visionary literature that form its otherness that must be cautiously read and interpreted. There is the portrayal of a transcendental or supernatural world, usually of heaven. This transcendence primarily takes the reader beyond the visible, spatial world and not forward in time. The scope of Biblical visionary literature is cosmic rather than localized. There are supernatural, fantastic agents and creatures. Inanimate objects and forces of nature become actors in the visionary drama.

In the strange and frequently surrealistic world of visionary literature, virtually any aspect of creation can become a participant in the ongoing drama of God’s judgments and redemption. It is a world where a river can overflow a nation (Isaiah 8:5-8), where a branch can build a temple (Zechariah 6:12) and a ram ‘s horn can grow to the sky and knock stars to the ground (Daniel 8:9-10).

The strangeness of such writing leads to a related rule for reading it: visionary literature is a form of fantasy literature in which readers use their imaginations to picture unfamiliar scenes and agents. And the reader must remember that the vision is an imagined reality—different than ordinary, empirical reality. “The best introduction to such visionary literature in the bible is other fantasy literature, such as the Narnia stories of C. S. Lewis.”

The purpose of visionary literature is to break through our normal way of thinking and shock us into seeing that things are not as they appear. The world may not continue on as it is now; there is something wrong with the status quo; or reality cannot be confined to what we can see with our senses. This element of the unexpected extends even into the structure of visionary literature. It has brief, shifting units. There is a range of diverse literary material in the Biblical visionary texts. There can be visual descriptions, dialogues, monologues, brief narrative segments, letters, prayers, hymns, or parables. Visionary elements may be mixed with realistic scenes and events. “Instead of looking for the smooth flow of narrative, be prepared for a disjointed series of diverse, self-contained units.”

There is more that could be said, but this gives us a sense of what constitutes visionary literature in the Bible. Now back to Meade and his prophesied end of the world. He is taking an explicitly apocalyptic text, Revelation 12, and treating it as if it were a prophetic text.  There are specific features of apocalypse that distinguishes it from its literary cousin, prophecy. The Biblical scholar Leon Morris summarized the features found in apocalyptic literature as follows:

  • The vision or revelation is of the secret things of God, inaccessible to normal human knowledge. There are secrets of nature, of heaven, of history of the end.
  • Pseudonymy
  • History is rewritten as prophecy
  • There is a determinism in history ending in cosmic cataclysm, which will establish God’s rule.
  • Dualism (good and evil).
  • Pessimism about God’s saving rule in the present.
  • Bizarre and wild symbols denote historical movements or events.

Apocalyptic is a rather loose category, meaning that texts designated as such won’t always share all the same features. Revelation, for example is not pseudonymous. And the book of Revelation often modifies the apocalyptic features it does have. The golden age for apocalyptic literature was roughly between 200 BC and 400 AD. It is primarily found in Jewish and early Christian texts. Some examples include: Assumption of Moses, 1-2-3 Enoch, 2-3 Baruch, 4 Ezra, Apocalypse of Peter, Apocalypse of Paul, Apocalypse of Thomas, and Ascension of Isaiah. Within the Bible, the following show some features of apocalyptic literature: Numbers 23-24 (Balaam’s oracles), Daniel, Ezekiel, Isaiah 24-27, 1 Thessalonians 4-5, 2 Thessalonians 1-2, the Olivet Discourse (Matt. 24; Mark 13; Luke 21), Revelation. Some scholars would also add parts of Zechariah. With these particular in mind, here is how another Biblical scholar, J. J. Collins, defined apocalypse:

A genre of revelatory literature with a narrative framework, in which a revelation is mediated by an otherworldly being to a human recipient, disclosing a transcendent reality which is both temporal, insofar as it envisages eschatological salvation, and spatial insofar as it involves another, supernatural world.

Now let’s turn to the text of Revelation 12 used by Meade in his prediction that October 15th, 2017 would initiate a seven-year period of tribulation, resulting in the destruction of the world. Here is a four-minute YouTube video by Unsealed that illustrates how Meade and other Christians believe September 23rd represents a spiritual sign of the ending of the “Church Age.” On his website, Meade said: “We’re all watching for the September 23 Sign because we know it means the end of the ‘Church Age.’  That is a spiritual sign only.  But it is huge.” Now compare the video to the following verses in Revelation 12 that it interprets.

And a great sign appeared in heaven: a woman clothed with the sun, with the moon under her feet, and on her head a crown of twelve stars. She was pregnant and was crying out in birth pains and the agony of giving birth. And another sign appeared in heaven: behold, a great red dragon, with seven heads and ten horns, and on his heads seven diadems. His tail swept down a third of the stars of heaven and cast them to the earth. And the dragon stood before the woman who was about to give birth, so that when she bore her child he might devour it. She gave birth to a male child, one who is to rule all the nations with a rod of iron, but her child was caught up to God and to his throne. (Revelation 12:1-5)

This passage in chapter 12 of Revelation is one visionary unit in a series of visions give to John by an angel (Revelation 1:1). After the letters to the seven churches, which represent the Church universal, John looked up and saw a door open in heaven (Revelation 4:1). Then came a series of visions including the throne room in heaven. The scroll and the Lamb, the seven seals, the 144,000 of Israel, the seven trumpets, the angel and the little scroll, the two witnesses, and more. At the sound of the seventh trumpet, the twenty-four elders worshiped God. Then God’s temple in heaven opened to reveal “the ark of his covenant.”

The context of Revelation has many of the characteristics of apocalyptic literature. There is a vision framed within a narrative. It’s mediated by an angel to John, and discloses a series of scenes of what is happening in heaven. Chapter 12 describes the conflict between good and evil; the pregnant woman and the dragon. There was the symbolic representation of the encounter of the woman and the dragon; and what happened afterwards.

Revelation 12:1-5 is a condensed retelling of the story of the gospel using apocalyptic. There will be enmity between the seed of the woman and the serpent. In pain she will bring forth children (Genesis 3:15-16). Jesus is that seed, and the verse in Genesis 3 has been traditionally identified as the protoevangelium—the first gospel. Satan intended to “devour” him, but failed. Jesus was caught up—by God—to his throne at his ascension (Acts 1:9-11). A final clue that the passage is not a prophetic foretelling of a future time to John, namely the September 23, 2017 initiation of the end of the church age, is the parallel here to the Greek myth about the birth of Apollo. Gordon Fee, in his commentary on Revelation related the following.

It is important for the modern reader to know that the whole scene is a common one in ancient mythology as well; thus the first readers of this book, mostly Gentile converts in the province of Asia, could hardly have missed here an echo of the well-known myth from their own history. In that myth about the birth of Apollo to Leto, wife of Zeus, the dragon Python hoped to slay the child (Apollo) but he was protected by Poseidon. When grown Apollo then slew the dragon. But whatever the coincidences that may exist between that myth and the essential Christian story, John’s imagery has effected its total transformation into the basic (historical) story of Christ, who through his cross and resurrection thus defeated the dragon. At the same time, the astute biblical reader will see something of a replay, but in a radically new way, of the scene in the Garden of Eden in Genesis 3; but now the woman withstands the snake, and her child is rescued by God, who also protects the woman in “the wilderness.”

The interpretation of Biblical apocalyptic literature is fraught the dangers of misunderstanding and misinterpretation, as Harold Camping discovered and hopefully David Meade will himself acknowledge. In his own apocalyptic narrative in the Olivet Discourse of Matthew 24, Jesus said: no one knows the time of his return and the end of the age; not even the angels in heaven, nor the Son, but the Father only (Matthew 24:36). Not even David Meade knows.

10/17/17

Tell It Like It Is

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Recently I saw one of the ubiquitous “ask your doctor if … is right for you” commercials for Rexulti. The slick 90-second ad tells you that when Rexulti is added to your antidepressant, it has been shown to reduce symptoms of depression. The smiley faces used by the actors illustrate how: “Even when you’re taking an antidepressant, you may still be struggling with depression.” You learn that 2 out of 3 people taking an antidepressant may experience unresolved symptoms of depression; and that antidepressants can cause unusual changes in behavior, worsening depression and thought of suicide, especially in those 24 and younger. But you never learn that Rexulti is not an antidepressant.

The commercial never claims Rexulti is an antidepressant, but it clearly leads its viewers in that direction. Counter intuitively, in order to make the case for using Rexulti, it not-so-subtly tells you that antidepressants alone aren’t always effective, since 67% of people taking them have “unresolved symptoms” of depression. But then you learn Rexulti has been shown to reduce symptoms of depression when it is added to an antidepressant. The message is that Rexulti is effective relieving symptoms of depression. But let’s deconstruct what the commercial is telling you even further.

In the mix of the marketing rhetoric, you hear a litany of possible adverse medication side effects. The initial side effects are found with antidepressants: there could be unusual changes in behavior, worsening depression, even thoughts of suicide. “Antidepressants can increase these in those 24 and younger.” This information is legitimately about the side effects from antidepressant medications. See “Antidepressant Misuse Disorder” and “Antidepressants: Their Ineffectiveness and Risks” on this website.

Actually, Rexulti is an atypical antipsychotic or neuroleptic; in the same drug class as Abilify, Zyprexa, Seroquel and Risperdal. The other described side effects and warnings in the commercial are commonly found with atypical antipsychotics. See “Adverse Effects of Antipsychotic Medications” by Muench and Hamer for further information.

Looking further, the commercial said: “Elderly dementia patients taking Rexulti have an increased risk of death or stroke.” Antipsychotics were being used to control behavior problems in elderly patients with dementia. Then research demonstrated there was an increased risk of death in the elderly patients given antipsychotics. So the FDA issued a black box warning to that effect. There was also evidence that antidepressants increased the risk of stroke with elderly patients, thus the Rexulti warning. See “Seniors and Antipsychotics” and “Stroke Risk in Elderly Treated with Antipsychotics” for more information on this.

“Uncontrollable muscle movements” in the commercial is likely referring to tardive dyskinesia, a serious and potentially permanent neurological side effect from antipsychotics. The risks for developing metabolic syndrome (high blood pressure, high blood sugar, excess body fat at the waist, and abnormal cholesterol levels) are mentioned as well. Tardive dyskinesia and metabolic syndrome are widely acknowledged as potential adverse effects from antipsychotics, but not antidepressants. Try “Blind Spots with Antipsychotics,” Part 1 and Part 2 for a discussion on metabolic syndrome and other side effects from antipsychotics. Stiff muscles, confusion, and high fever are symptoms of “a possible life threatening condition” known as Neuroleptic Malignant Syndrome (See “Neuroleptic Malignant Syndrome”).

So you wouldn’t know Rexulti was an atypical antipsychotic or neuroleptic drug from listening to the commercial unless you knew the above were typical side effects with that class of drug. And you may not even discover this from reading the required Medication Guide, unless you knew what to look for. The FDA’s highlights of prescribing information for Rexulti, all 38 pages worth, does have a more complete discussion of the warnings and precautions as well as the adverse reactions. And Rexulti is referred to there as an atypical antipsychotic. However, in the shorter, two page medication guide, that is made available to individuals filling a prescription for Rexulti, there is no explicit reference to it being an atypical antipsychotic or neuroleptic.

The Rexulti Medication Guide does describe tardive dyskinesia, “problems with your metabolism” and Neuroleptic Malignant Syndrome as possible side effects, which are all potential side effects from antipsychotic or neuroleptic medications. But the only place in the medication guide that the word “antipsychotics” is used is in the section “What should I tell my healthcare provider before taking Rexulti?” There, the medication guide advised that if you become pregnant while taking Rexulti, you should “talk to your healthcare provider” about registering with the National Pregnancy Registry for Atypical Antipsychotics. The only place in the Rexulti medication guide the word “neuroleptic” in mentioned is when it notes how Neuroleptic Malignant Syndrome is a possible side effect.

This rhetorical sleight-of-hand is also present in the medication guides for three other antipsychotics approved by the FDA as adjunct medications for depression. Aripiprazole (Abilify), Olanzapine (Zyprexa) and Quetispine (Seroquel) all use the same descriptive technique of avoiding reference to the drugs as antipsychotics or neuroleptics in their medication guides. And several have an extended discussion of information on antidepressants. Again, someone not familiar with the medications might think they are taking an antidepressant rather than an antipsychotic medication.

The rational for this would appear to be because the initial market for antipsychotics, treating schizophrenia, is limited. Atypical antipsychotics are now the largest-selling class of drugs in the U.S. with more than $14.6 billion in annual sales for 2014. They also are the class of psychiatric drugs with the most side effects. See “Wolves in Sheep’s Clothing” and “Abilify in Denial” for more on these observations.

Another piece of information about Rexulti in contrast to the other antipsychotics approved as adjunct medications for depression is that it is the only one still on patent. Rexulti patents don’t expire until February of 2027 Abilify, Zyprexa, and Seroquel have all been approved as generics.  So Otsuka Pharmaceutical Company Ltd. has the potential for much greater profits from Resulti over the next ten years than the generic pharmaceutical companies have for the off-patent atypical antipsychotics.

There seems to be a general trend when discussing psychiatric medications to avoid any reference to them as atypical antipsychotics or neuroleptics. You can even see this in the FDA press release for the approval of Rexulti in July of 2015. This means a consumer looking for information on the potential adverse effects from an atypical antipsychotic may have some difficulty finding and then understanding what the risk is for them to take the drug.

For clarity’s sake, I think the FDA should require all consumer medication guides to clearly identify the drug class for approved psychiatric medications. They should also direct a patient to where they can find a more complete discussion of the potential adverse effects of the medication than what is contained within the brief summary of the medication guide. Confusing discussions of depression, its symptoms and the side effects from antidepressants included in antipsychotic medication guides should be clarified or removed entirely by the FDA. Additionally, there should be a truth in advertising requirement that tells it like it is for all psychiatric drug advertisements. An antipsychotic by any other name is still an antipsychotic and the commercials should say so.

10/13/17

Feuding Ideologies, Part 2

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In the first paragraph of “Dying To Be Free,” you are introduced to Patrick, a smiling 25 year-old who had just completed a 30-day drug treatment center. Among his possessions was “a talisman he’d been given by the treatment facility: a hardcover fourth edition of the Alcoholics Anonymous bible known as ‘The Big Book.” It pages were full of highlights and Post-It notes. He was said to be a “natural” 12-step convert. Four days later, his father found him dead of an overdose.

As you read about Patrick’s struggles with addiction, you get a picture of how he and his parents tried to help him establish sobriety. There is a reference to his residential treatment stay as a “30-day wonder,” where he received a crash course on the tenets of the 12-steps. “Staff at the center expected addicts to reach a sort of divine moment but gave them few days and few tools to get there.” In Part 1 of this article, I addressed concerns that an underlying ideology of addiction as a strictly biomedical disease contributed to a biased, distorted picture of addiction treatment in the U.S. by the author of “Dying To Be Free.” Here we will look at how he also misrepresents the recovery philosophy and history of A.A.

There is a preponderance of religious or magical rhetoric when describing 12 Step, abstinent-based change in “Dying To Be Free.” Already we’ve noted the main text of Alcoholics Anonymous, also called Alcoholics Anonymous, was referred to as a talisman and a “bible.” Patrick was a “natural 12-step convert.” Another reference described the AA Big Book as being the size of a hymnal, with an appeal to faith made in “the rat-a-tat cadence of a door-to-door salesman.” Addicts at a certain treatment center were supposed to “reach a sort of divine moment” in treatment or recovery. Entering the drug treatment system, which is dominated by the principles of abstinence embedded in the 12-Steps, was said to require a “leap of faith.”

In a description of the Grateful Life Treatment Center in northern Kentucky, it was noted that the wall above the desk of the center’s intake supervisor had a “Jesus bumper sticker.” Why add that detail unless you are trying to capture the scene in a particularly religious way? When describing treatment facilities modeling themselves on the 12 Steps, not only were recovering addicts said to be cheap labor, they were said to provide the “evangelism” to shape the curricula of the facilities. A resident of Grateful Life was noted to be “as close to a true believer as the program produces.”

At one point, the author of “Dying To Be Free,” Jason Cherkis, said AA came out “evangelical Christian movements.” More accurately, there is a clear historical connection between a nondenominational Christian movement popular during the 1920s and 1930s called the Oxford Group and Alcoholics Anonymous. The two cofounders of A.A., Bill W. and Dr. Bob met as a result of their personal association with the Oxford Group. A.A. approved books, such as Pass It On, Doctor Bob and the Good Oldtimers and AA Comes of Age freely acknowledge the connection and give further details about it. However, a crucial distinction made by A.A. within its 12 Steps is glossed over by Cherkis and others, namely the spiritual, not religious understanding of God and recovery embodied in the Twelve Steps.

Drawn from the thought of the American psychologist, William James, this distinction between religious and spiritual experience seems to underlie the widespread sense of generic spirituality in American culture today. The Varieties of Religious Experience  (VRE) by James had a fundamental influence on Bill W., the formulation of the Twelve Steps and the spirituality based upon them. In VRE James made a distinction between institutional and personal religion. Worship, sacrifice, ritual, theology, ceremony, and ecclesiastical organization were the essentials of what he referred to as institutional religion.

Personal religion/spirituality for his [James’] purposes was defined as “the feelings, acts, and experiences of [the] individual . . . in their solitude, so far as they apprehend themselves to stand in relation to whatever they may consider the divine.” In the broadest sense possible, this spirituality consisted of the belief that there was an unseen order to existence, and supreme good lay in harmoniously adjusting to that order.

Whether their disregard of the spiritual, not religious distinction is intentional or not, Cherkis and others give an incomplete and biased picture of Twelve Step recovery when they fail to note it. The very heart of Twelve Step spirituality is the permissibility of the individual to formulate a personal understanding of their “god.” So what unites members of Twelve Step groups like A.A. is the diversity of religious and spiritual belief permitted—even to accepting a lack of belief. I’ve written several other articles on the similarities and differences between the spirituality of the Twelve Steps and religious spirituality on this website. There are three particular articles that discuss the influences on the spiritual, not religious distinction of Twelve Step recovery: “What Does Religious Mean?”, “Spiritual Not Religious Experience” and “The God of the Preachers.”

Another example of how “Dying To Be Free” misrepresents the recovery philosophy of A.A. is the following. While introducing a discussion of Charles Dederich and the origins of Synanon, Cherkis said Dederich and others took a “hardline” message” from some of Bill W.’s written philosophy. Cherkis wrote: “Those who can’t stick with the program are ‘constitutionally incapable of being honest with themselves,’ reads the Big Book. ‘They seem to have been born that way.’” The two selective quotes were from the first paragraph of chapter five, “How It Works,” in Alcoholics Anonymous. Notice how the context of the complete paragraph changes your understanding of what Bill W. said in his “philosophy”:

Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average.

As Cherkis began to discuss the history of the expansion of drug treatment facilities in the 1960s, he quoted Nancy Campbell, a professor at Rensselaer Polytechnic Institute, as saying: “The history of 12-step came out of white, middle-class, Protestant people who want to be respectable.” She added that it offered community and belonging that was predicated on being normal, respectable and having a stake in mainstream society.  Campbell may be a historian, but she seems to have a distorted view of the early history of 12 Step recovery in A.A.

From the sociological perspective of labeling theory A.A. and other organizations based on their 12 Steps, like N.A. (Narcotics Anonymous), can at least partially be seen as social movements that seek to combat negative images associated with socially deviant drinking or drugging behavior, “in effect denying that their actions make them deviants.” This applies the idea of tertiary deviance, first described by John Kituse in: “Coming Out All Over: Deviants and the Politics of Social Problems.” Kituse noted that some people stigmatized as deviant (here as alcoholics) “rebel against their labels and attempt to reaffirm their self-worth and lost social status.” The above quote and reference to Kituse is found in a standard social science textbook by Clinard and Meier, Sociology of Deviant Behavior.  So part of Campbell’s assessment of 12 Step groups as social movements seeking to offer community and belonging, with a “stake in mainstream society” is accurate. However, the quote attributed to her glosses over the early history of A.A., which was the beginning of the 12 Step movement.

A.A. celebrates the anniversary of its founding on June 10, 1935. That was in the midst of the Depression. Bill W. and his wife Lois were living then in a house owned by her father on Clinton Street in New York City. In September of 1936, Lois’s father died and the house was taken over by the mortgage company, which allowed them to stay on for a small rental. In the midst of the Depression, they didn’t want the house to be empty. While struggling with “their acute poverty,” Bill was almost persuaded to accept a position as a paid alcoholism therapist at Towns Hospital, where he himself had been treated several times. He eventually declined the offer.

Almost two and a half years after the founding of A.A., Bill W. was jobless and Dr. Bob was in danger of losing his house. In 1938, through the charity of John D. Rockefeller Jr., $5,000 was approved for a fund that would pay off Dr. Bob’s mortgage and allow a weekly draw of $30 for each of them. Rockefeller told one of his associates afterwards: “But please don’t ever ask me for any more.” In 1939, as the Depression eased, the mortgage company was able to sell the Clinton Street house and Bill and Lois became homeless. They lived “as vagabonds,” as various places for two years. Bill W. and Lois eventually led a respectable, middle class lifestyle, but that wasn’t what it was like for them in the beginning of A.A.

This history is found in Pass It On, published by Alcoholics Anonymous World Services, Inc. In the early days of A.A., Bill W. repeatedly turned down offers to professionalize his work with A.A. This doesn’t entirely sound like a movement trying to gain white, middle class respectability. The Traditions of A.A., formally adopted in July of 1950, articulated this philosophy of non-professionalism and a focus on helping other alcoholics in the fifth, sixth and eighth Traditions.

Tradition Five Reads: “Each group has but one primary purpose—to carry its message to the alcoholic who still suffers.” Tradition Six reads: “An A.A. group ought never endorse, finance, or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose.” Tradition Eight reads: “Alcoholics Anonymous should remain forever non-professional, but our service centers may employ special workers.”

Alternative addiction treatment ideologies regularly attack A.A. as “religious,” ignoring or rejecting the spiritual-religious distinction A.A. made within the Twelve Steps from the very beginning. The abstinent-based recovery philosophy embedded in the Twelve Steps seems to be the primary target of these critiques. I see the same tendency in “Dying To Be Free.” The first part of this article addressed the biased portrayal of abstinent-based addiction treatment by Jason Cherkis in “Dying To Be Free.” The third and final part will address how it skimmed over the problems with MAT, specifically Suboxone.

10/10/17

Rejecting God in Addiction

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The Bible affirms that every human being has a sense of what is right or wrong. There are moral absolutes which God has clearly revealed, and which we know, regardless of whether or not we live our lives in obedience to his will. There are no circumstances in which a person can ultimately say, “I didn’t know that was wrong.” We all have a moral compass. It is with this moral compass that the alcoholic does his “searching and fearless” moral inventory in Step Four. We are without excuse and cannot deny culpability for our actions before God. Even in our rebellion, God has seen fit for us to know His will. God’s judgment was to give Adams and Eve what they wanted: knowledge of right and wrong independent of God’s revelation.

In The Abolition of Man, C. S. Lewis affirmed the reality of the doctrine of objective value, which is the belief that certain attitudes towards the universe and ourselves are really true, and others really false. Lewis referred to this conception of objective truth in all of its forms, as the Tao; a term he borrowed from Chinese thought. Other conceptions of what he calls the Tao in Western thought are: Natural Law, Traditional Morality, and the First Principles of Practical Reason. This doctrine of objective truth is also found in nonWestern thinking.

In Hindu thought, conformity to Rta (righteousness, correctness, and order found in nature) is human conduct that can be called good. The Chinese of course speak of the Tao, which is the greatest thing; the Way in which the universe goes on; the Way in which every person should walk in imitation of the cosmic order, conforming all activity to that great exemplar. The Navajo spiritual/religious concept of hózhó seems to be their conception of the Tao as a spiritually based, balanced lifestyle. Hózhó means to live in beauty; to observe the Navajo philosophy or religion of living and interacting with the world around you so that your life has beauty, balance, calm, and stability. To be out of hózhó is to be “sinful” to a traditional Navajo.

This Tao is not just one among a series of possible systems of value. “It is the sole source of all value judgments.” If rejected, all value is rejected. Lewis said that in the history of the world, there never has been—nor will there be—a radically new judgment of value. The logic here is that if the pursuit of scientific knowledge is a real objective value that proceeds from God’s general revelation, then conjugal fidelity, self control in sobriety and other “objective values” are points on God’s moral compass in his special revelation, the Bible. This sense of a moral compass lies at the heart of the downward spiral of sinful, unmanageable behavior specified in the following passage from Romans:

And since they did not see fit to acknowledge God, God gave them up to a debased mind to do what ought not to be done. They were filled with all manner of unrighteousness, evil, covetousness, malice. They are full of envy, murder, strife, deceit, maliciousness. They are gossips, slanderers, haters of God, insolent, haughty, boastful, inventors of evil, disobedient to parents, foolish, faithless, heartless, ruthless. Though they know God’s decree that those who practice such things deserve to die, they not only do them but give approval to those who practice them. (Romans 1:28-32)

Once again in Romans 1:28 Paul said: “God gave them up”, using the same Greek verb tense to communicate past completed action as he did in verses 24 and 26. First note the intensification of the repeated judgment by God. Then notice that “impurity, dishonoring their bodies among themselves, dishonorable passions and doing what ought not to be done” are all consequences of failing to acknowledge God (Romans 1:21).

v. 24 God gave them up (in the lusts of their hearts) to impurity, to the dishonoring of their bodies among themselves.v. 26 God gave them up to dishonorable passions.v. 28 God gave them up (to a debased mind) to do what ought not to be done.

The passage reiterates the “root and fruit” association of heart (or mind) and behavior evident in verse 24. Out of the overflow of the heart, the mouth speaks. Or in this case, they did what ought not to be done. As a result of failing to acknowledge God, and being given over to a debased mind, they were filled with all types of sinful desire. As Robert Mounce said in his commentary on Romans, “When people turn from God, the path leads inevitably downward into degeneracy.”

There is a subtle change in the Greek grammar of the passage that helps to distinguish the wrath of God in giving them up to a debased mind from the sin that came as a result of their debased mind. In essence, the verses say that God gave them up to a debased mind, filling them with unrighteousness, evil, covetousness and malice. As a result, they did what ought not to be done: envy, murder, strife, deceit, and maliciousness. This downward spiral of sin has a root and fruit, heart and behavior pattern: sinful behavior is inescapably influenced by a debased heart and mind.

The unrestrained nature of this downward spiral of sin is illustrated with a further litany of sins from gossiping to ruthlessness. For the most part, they are rarely used terms in Biblical Greek, again intensifying the sense in which it seems that sinful behavior gushes out from a debased heart. The summary here reads like a checklist of character defects for individuals preparing to complete their “searching and fearless moral inventory” in the Fourth Step.

Perhaps the most damning assessment of unrighteous is saved for last. Despite the whirlwind of sin that comes from God giving them up to a debased mind, they still know that these vices are worthy of God’s judgment; they are still capable of recognizing right from wrong. Even in the depths of their depravity, they know their sin and its consequences. What can be known about God is still plain to them (verse 1:19). Yet they encourage others to engage in the same cycle of sin and judgment. They know that by their actions they suppress the truth of God to their eternal damnation; and yet they still encourage others to do the same.

We are not only bent on damning ourselves, but we recruit others to follow in our footsteps.  As John Murray said in his commentary on Romans: “Iniquity is most aggravated when it meets with no inhibition from the disapproval of others and where there is collective, undissenting approbation [endorsement].” So the gathering of heavy drinkers to watch a football game and get drunk; the licentiousness of an out-of-control bachelor party; and an opioid addict shooting up a friend for the first time all find their condemnation here.

I’m struck by the strong parallels in this passage of Scripture to the heart attitudes and unmanageable behavior of active addiction. Beginning with verse 18, the wrath of God is revealed against the ungodliness and unrighteousness of people who deny (suppress) the truth by their unrighteous behavior. The order of the terms ungodliness and unrighteousness has some significance here, as moral decay (alcoholism and addiction) follows from the rejection (denial) of God. In the chapter “We Agnostics” of the book Alcoholics Anonymous, Bill W. wrote: “When we became alcoholics, crushed by a self-imposed crisis we could not postpone or evade, we had to fearlessly face the proposition that either God is everything or else He is nothing. God either is, or He isn’t. . . . Do I now believe, or am I even willing to believe, that there is a Power greater than myself?”

God has revealed His divinity in creation. Unrighteous (addictive) behavior suppresses this truth and seeks to be like God. Ernest Kurtz wrote that “the fundamental and first message of Alcoholics Anonymous to its members is that they are not infinite, not absolute, not God.” Every alcoholic’s problem begins with wanting God-like powers, especially the ability to control their drinking. But an alcoholic cannot control their drinking. At some point in their addictive career, they experience a loss of control over thoughts, feelings and behavior when they drink. Eventually they lose control over the act of drinking itself and will deny or minimize their inability to control it.

Craig Nakken, in The Addictive Personality, suggested that much of an addict’s mental obsession resulted from refusing to recognize the loss of control they experience. Denial, suppressing the truth of the addict’s inability to control their drug or alcohol use, is thus a fundamental part of addiction. Alcoholics Anonymous saw denial as the fundamental symptom and deep core of alcoholism. It is the initial issue addressed by the First Step: “We admitted that we were powerless over alcohol [addiction]-that our lives had become unmanageable.”

Recognizing this denial is then an essential part of recovery; failure to do so means that the addict becomes futile in their belief that they can control their drug use. Their foolish hearts are darkened to the reality of addiction. Alcohol or drugs become their God. Narcotics Anonymous simply says: “Isolation and denial of our addiction kept us moving along this downhill path. Any hope of getting better disappeared.”

God gives him what he wants; He gives the addict up to the lust of his heart and to a debased mind; to do what ought not to be done; to pursue the false god of his addiction. He is filled with all manner of unrighteousness, evil, covetousness and malice. He is and does everything noted in verses 1:29-31. This litany of consequences provides a summary of the unmanageability present in the life of the addict and alcoholic. He becomes hopeless and helpless as a result of his rejection of God (ungodliness) and the addictive behavior that results. His only hope is in the God he rejected from the beginning.

If you’re interested, more articles from this series can be found under the link for “The Romans Road of Recovery.” “A Common Spiritual Path” (01) and “The Romans Road of Recovery” (02) will introduce this series of articles. If you began by reading one that came from the middle or the end of the series, try reading them before reading others. Follow the numerical listing of the articles (i.e., 01, 02, etc.), if you want to read them in the order they were originally written. This article is “05,” the fifth one in the series. Enjoy.

10/6/17

Is Ketamine Really Safe & Non-Toxic?

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An article in The Morning Call, a newspaper for Allentown and the Lehigh Valley area of Pennsylvania, announced that a local company, the Lehigh Center for Clinical Research, would be conducting clinical trials for two pharmaceutical companies to gain FDA approval for modified versions of ketamine as a treatment for depression. The psychiatrist running the trials said the drugs could hit the market in the next few years. He said: “It’s exciting and promising but I think we have to wait to see it used in the widespread population to know whether it’ll be safe and non-toxic.” I thought the safety and toxicity of a new drug was supposed to be assessed BEFORE the FDA approved its release into the wider population.

There have been waves of excitement and concern over the past few years about the development and use of ketamine and ketamine-like drugs to treat depression. Ketamine has been an FDA approved medication since 1970, where it was used as an anesthetic in the Vietnam War. It is classified as a Schedule III Controlled Substance by the DEA, meaning it has a potential for moderate to low dependence or high psychological dependence. Ketamine is also a recreational drug known as Special K because of its dissociative properties. “Due to the detached, dreamlike state it creates, where the user finds it difficult to move, ketamine has been used as a ‘date-rape’ drug.” See: “Falling Down the K-Hole” and “Family Likeness in Depression Drugs?”

The excitement over ketamine, as a treatment for depression, centers on its rapid relief of depressive symptoms; sometimes within hours of it being administered. But the effects fade rapidly and require frequent, repeated treatments. Currently ketamine is administered intravenously, similar to its use as an anesthetic. There is an intranasal spray version (Esketamine) in the works. See: “Psychedelic Depression,” Ketamine to the Rescue?,” and Ketamine Desperation.”

The clinical trails being done by the Lehigh Center for Clinical Research would appear to be for Esketamine, by Janssen Research and Development, and Rapastinel, by Allergan. While Esketamine is a nasal spray, Rapastinel is administered by weekly IV injections. Both are currently in Phase 3 clinical trials. This involves randomized, double blind testing in several hundred to several thousand patients. Upon successful completion of their Phase 3 trials, a pharmaceutical company can request FDA approval for marketing their drug. Somewhere around 70 to 80 percent of drugs that make it to Phase 3 are eventually approved.

Although Esketamine and Rapastinel are similar to ketamine in several ways, they are still distinct NMEs (new molecular entities), patented by their respective pharmaceutical companies. Ketamine was first developed in the 1960s and has been off patent for decades, meaning there is no profit in Pharma companies pursuing ketamine-based treatment for depression. But since ketamine is an FDA approved drug, it can be used off label to treat depression. And there are a growing number of ketamine treatment facilities around the U.S. and Canada that do just that.

Earlier in 2017 All Things Considered on NPR featured a story on the off-label use of ketamine to treat depression, “Ketamine for Severe Depression.” Psychiatrist Gerard Sanacora said over 3,000 patients have treated at dozens of clinics with ketamine for depression. He has personally treated hundreds of people with low dose ketamine. Sanacora said when he is asked how he can offer it to people on the limited amount of available information and without knowing the potential long-term risk, he responds “How do you not offer this treatment” to individuals likely to injure or kill themselves, who have unsuccessfully tried the standard treatments?

Sanacora and others authored “A Consensus Statement on the Use of Ketamine in the Treatment of Mood Disorders” that was published in JAMA Psychiatry in April of 2017. They noted how several smaller studies have demonstrated the ability for ketamine “to produce rapid and robust antidepressants effects in patients with mood and anxiety disorders that were previously resistant to treatment.” It also cautioned that while ketamine may be beneficial to some patients, “it is important to consider the limitations of the available data and the potential risk associated with the drug when considering the treatment option.”

Zorumski and Conway published “Use of Ketamine in Clinical Practice” in the May 2017 issue of JAMA Psychiatry. They also noted the increasing evidence from small studies that ketamine has rapid antidepressant effects in patients with treatment-resistant depression. They commented how ketamine is having a major effect on psychiatry. “If clinical studies continue to support the antidepressant efficacy of ketamine, psychiatry could enter an era in which drug infusions and deliveries with more rapid responses become common.” They indicated the cautions of Sanacora et al. were noteworthy and should be emphasized.

Because of the limited data to guide clinical practice, these limitations extend to almost every recommendation in the consensus statement, including, perhaps most importantly, patient selection. The bulk of the literature describes the effects of ketamine in patients with treatment-refractory major depression. The definition of treatment-refractory major depression and where treatments such as ketamine fall in the algorithm for managing treatment-refractory depression remain poorly understood. . . . It is unclear whether patients with depression that is not treatment-refractory or patients with other psychiatric illnesses are appropriate candidates for ketamine treatment, and extreme caution must be exercised in patients with psychotic or substance use disorders.

So then comes the Short et al. study in the journal Lancet Psychiatry in July 2017, “Side Effects Associated with Ketamine Use in Depression.” It was the first systematic review of the safety of ketamine in the treatment of depression. After searching MEDLINE, PubMed, PsycINFO, and Cochrane Databases, they identified 60 out of 288 articles that met their inclusion criteria. “Our findings suggest a selective reporting bias with limited assessment of long-term use and safety and after repeated dosing, despite these being reported in other patient groups exposed to ketamine (eg, those with chronic pain) and in recreational users.”

Science Daily reported that the lead author for the study said there were major gaps in the research literature that should be addressed before ketamine was widely used as a clinical treatment for depression. “Despite growing interest in ketamine as an antidepressant, and some preliminary findings suggesting its rapid-acting efficacy, to date this has not been effectively explored over the long term and after repeated dosing.” Given that ketamine will likely involve multiple, repeated doses over an extended time period, “it is crucial to determine whether the potential side effects outweigh the benefits to ensure it is safe for this purpose.”

Commenting on the Short et el. Study for Mad in America, Peter Simons also noted the expressed concern with the selective reporting bias and a limited assessment of long-tem use and safety after repeated dosing. Researchers are generally careful to report safety and side effect data on studies of ketamine used recreationally or for chronic pain. However, depression research tended to ignore the safety and side effect concerns with ketamine, often not reporting such issues at all.  “Most people receiving ketamine had acute side effects.” Studies that did report adverse events said that after acute dosing, patients in ketamine treatment reported more frequent side effects.

Common side effects led a number of patients to withdraw from the study. Suicidal thoughts were common and there was one suicide attempt reported. Previously reported potential long-term adverse effects from ketamine include: urinary tract problems, liver toxicity, ulcerative cystitis, neurocognitive deficits and memory problems, and dependence or addiction. Some of the many additional side effects that were reported included:

 

  • Worsening mood
  • Anxiety
  • Emotional blunting
  • Psychosis
  • Thought disorders
  • Dissociation
  • Depersonalization
  • Hallucinations
  • Increased blood pressure
  • Increased heart rate
  • Decreased blood pressure
  • Decreased heart rate
  • Heart palpitations/arrhythmia
  • Chest pain
  • Headaches
  • Dizziness
  • Unsteadiness
  • Confusion
  • Memory loss
  • Cognitive impairment
  • Blurred vision
  • Insomnia
  • Nausea
  • Fatigue
  • Crying/tearfulness

Because of the extensive list of potential adverse effects, as well as the unknown possibility for harm from long-term use, the authors of Short et al. recommended large-scale clinical trials with multiple doses of ketamine. Long-term follow up to assess the safety of long-term regular use was also recommended. “As it stands, the safety of ketamine treatment for depression is unknown—and that is largely due to inadequate and biased reporting of safety issues.”

I hope that these concerns are seriously considered and factored into the FDA’s assessment process for approving Esketamine and Rapastinel. Otherwise, the real safety and toxicity assessment of these drugs will be done on the first wave of depression sufferers prescribed the new drugs for treatment-resistant depression. Given the short length of clinical trials, the long-term effectiveness and impact on a patient’s quality of life, including potential misuse of the drugs, will not be clear  for either Esketamine or Repastinel until Phase 4 Post Marketing Surveillance Trials are completed … after the drugs are on the market. Will they live up to their therapeutic promise or become another example of the Pharma patent medicine show?

10/3/17

Feuding Ideologies, Part 1

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In August of 2017, the now former Health and Human Services Secretary, Tom Price, said he didn’t think it was necessary to declare the opioid epidemic to be a national emergency. This was despite the president’s own opioid commission recommending it as the “first and most urgent recommendation.” Two days later, the President reversed Price’s statement, saying: “The opioid crisis is an emergency, and I’m saying officially right now it is an emergency.” The response was mixed. While President Trump’s announcement could be used to help free up federal resources and help to prioritize responses to the disaster, it could also permit the administration to push for new sentencing legislation in order to get “tough on crime” related to drug use.

What isn’t disputed is that the U.S. does have a serious opioid problem and something needs to be done about it. Drug overdose is the leading cause of death in Americans under the age of fifty. Forecasts by STAT News are the annual death rate will increase by at least 35 percent by 2027. The CDC reported that from 2002 to 2015 there was a 5.9-fold increase in the overdose deaths from heroin and non-methadone synthetic opioids.

The latest statistics for the U.S. opioid epidemic is now available in the 2016 National Survey on Drug Use and Health (NSDUH). Among the myriad of statistics reported there was news that heroin users increased 230% from 2002 to 2016, while heroin deaths increased 630%. An estimated 948,000 people aged 12 or over reported they used heroin in the past year. That translates to .4% of the country’s population. There were also an estimated 11.5 million people who misused pain relievers in the past year, 4.3% of the population aged 12 or over. Combined, there are 11.8 million people who misused opioids, 4.4% of the population, in 2016.

The 2016 NSDUH Report can be accessed here. A shorter, graphic-based report of key findings, including those noted above, is here.

One of the treatment approaches often touted to address the opioid crisis is medication-assisted treatment (MAT) with Suboxone. In January of 2015, Jason Cherkis wrote “Dying To Be Free.” His subtitle asked why we weren’t using a treatment for heroin addiction—Suboxone—that actually worked. The opioid problem in Kentucky was the focus of his article, which I found to be rhetorically persuasive and well written. You are introduced to individual after individual who wouldn’t or couldn’t use Suboxone and ended up dead from an eventual overdose.

“Dying To Be Free” was a finalist for a Pulitzer in 2016 for its “deeply researched reporting on opioid addiction” that showed how many drug overdoes deaths could have been prevented. The cover letter submitted for its entry for the Pulitzer by The Huffington Post said it triggered a series of state and federal policy changes that rejected abstinence for opioid misuse and embraced medication-assisted treatment. “‘Dying To Be Free’ offered readers an immersive experience that included audio and video documentaries and photo and data displays.”

This was not fake news. “Dying to Be Free” captured the agony of individuals and families who struggle with opioid misuse. But it also made abstinence-based approaches to treatment and recovery a bogeyman responsible for many of the unnecessary deaths from opioid overdoses. The rhetoric of the article was a straw man attack on abstinent-based treatment while it extolled MAT. Its biomedical treatment bias seemed to dismiss or ignore many of the problems with Suboxone as a MAT for opioid addiction. Nor did it tell the whole story behind Suboxone. It also misrepresented the recovery philosophy of self-help groups like Alcoholics Anonymous. Here’s what I mean.

In the last paragraph of his second chapter, Cherkis said: “There’s no single explanation for why addiction treatment is mired in a kind of scientific dark age, why addicts are denied the help that modern medicine can offer.” This succinctly captures the problem as he sees it with existing treatment approaches to the opioid crisis. Heroin addiction is a medical disease and should be treated as a medical disease. Modern medicine has a scientific treatment for heroin addiction that is resisted because of stigma, a deep-rooted adherence to self-help, and the criminalization of heroin addiction. If you question or oppose MAT, you are apparently mired in a kind of scientific dark age.

To enter the drug treatment system, such as it is, requires a leap of faith. The system operates largely unmoved by the findings of medical science. Peer-reviewed data and evidence-based practices do not govern how rehabilitation facilities work. There are very few reassuring medical degrees adorning their walls.

Dr. Mary Kreeft, one of the pioneers of methadone maintenance, was liberally quoted to support the medical model of addiction. She noted how opioid addiction alters multiple regions in the brain, including those that regulate reward, memory, learning, stress, hormonal response and stress sensitivity. According to Dr. Kreeft, after a long cycle of opiate addiction, a person needs specific medical treatment. Some people may be OK in time. But “the brain changes, and it doesn’t recover when you just stop the drug because the brain has been actually changed.”

An abstinence-only treatment that may have a higher success rate for alcoholics simply fails opiate addicts. “It’s time for everyone to wake up and accept that abstinence-based treatment only works in under 10 percent of opiate addicts,” Kreek said. “All proper prospective studies have shown that more than 90 percent of opiate addicts in abstinence-based treatment return to opiate abuse within one year.” In her ideal world, doctors would consult with patients and monitor progress to determine whether Suboxone, methadone or some other medical approach stood the best chance of success.

This is a rigid, strict medical model of opioid addiction. And it gives a mixed message regarding whether or not the individual will ever be able to stop taking Suboxone or methadone. Neither drug, said Cherkis, is a miracle cure. But they buy addicts time to fix their lives, seek counseling and allow their brains to heal. So far, so good. But here comes the caution: Doctors recommend tapering off the medication cautiously. The process could take years, as addiction is a chronic disease and effective therapy takes time. Then comes the typical analogy of the pure medical model of addiction:

Doctors and researchers often compare addiction from a medical perspective to diabetes. The medication that addicts are prescribed is comparable to the insulin a diabetic needs to live.

There is no mention of neuroplasticity—the brain’s ability to reorganize itself by forming new neural connections. “Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment.”

Jeffrey Schwartz and Rebecca Gladding use an almost identical description of neurological action to that given above by Dr. Kreeft to describe how to change the brain; to modify bad habits (including addiction) and unhealthy thinking. In You Are Not Your Brain, they describe how we teach our brains to act in unhealthy ways. The brain does not distinguish between beneficial and destructive habits, “it just responds to how you behave and then generates strong impulses, thoughts, desires, cravings, and urges that compel you to perpetuate your habit, whatever it may be.”

Clearly, the brain can exert a powerful grip on one’s life—but only if you let it. The good news is that you can overcome the brain’s control and rewire your brain to work for you by learning to debunk the myths it has been so successfully selling you and by choosing to act in healthy, adaptive ways.

Neuroplasticity, as described by Schwartz and Gladding, does not reject Kreeft’s neurological description of addiction.  But it does say it isn’t the whole story. An ideology of addiction as a purely biomedical condition seems to permeate “Dying To Be Free.” Addiction, when conceived strictly as a brain disease, rejects or ignores the non-scientific construct of mind. If we are conceived as only biological beings, then addiction is explained and treated within a biomedical worldview. Any treatment approach to addiction not based on this premise is therefore faulty.

Drug treatment facilities were said in “Dying To Be Free” to “generally” fail to distinguish between addictions. They have a one-size-fits-all approach.  Addicts in residential treatment experience a “hodgepodge” of drill-instructor tough love and self-help lectures. Programs appear simultaneously excessively rigid and wildly disorganized. “And with roughly 90 percent of facilities grounded in the principle of abstinence, that means heroin addicts are systematically denied access to Suboxone and other synthetic opioids.”

After describing two older, drug treatment programs with a therapeutic community model of care that used coercive techniques—Synanon and Daytop (Drug Addicts Yield TO Persuasion)— he said:

The number of drug treatment facilities boomed with federal funding and the steady expansion of private insurance coverage for addiction, going from a mere handful in the 1950s to thousands a few decades later. The new facilities modeled themselves after the ones that had long been treating alcoholics, which were generally based on the 12-step methodology. Recovering addicts provided the cheap labor to staff them and the evangelism to shape curricula. Residential drug treatment co-opted the language of Alcoholics Anonymous, using the Big Book not as a spiritual guide but as a mandatory text — contradicting AA’s voluntary essence. AA’s meetings, with their folding chairs and donated coffee, were intended as a judgment-free space for addicts to talk about their problems. Treatment facilities were designed for discipline.

In support of this claim, Cherkis referred to a 2012 study conducted by the National Center on Addiction and Substance Abuse at Columbia University. It apparently was a reference to “Addiction Medicine: Closing the Gap between Science and Practice.” He said the study concluded the U.S. treatment system was in need of a “significant overhaul” and questioned whether the low levels of care received by addiction patients constituted a from of medical malpractice.

While medical schools in the U.S. mostly ignore addictive diseases, the majority of front-line treatment workers, the study found, are low-skilled and poorly trained, incapable of providing the bare minimum of medical care. These same workers also tend to be opposed to overhauling the system. As the study pointed out, they remain loyal to “intervention techniques that employ confrontation and coercion — techniques that contradict evidence-based practice.” Those with “a strong 12-step orientation” tended to hold research-supported approaches in low regard.

The Columbia University study did state a significant overhaul was needed in current treatment approaches; and it raised the question if the insufficient care received by addiction patients constituted “a form of medical malpractice.” It also pointed to the need for medical schools to “educate and train physicians to address risky substance use and addiction.” Unsurprisingly, it went on to say that all aspects of stabilization and treatment with addictions should be managed by a physician “as is the case with other medical diseases.” Remember that the Columbia study and Cherkis were both advocating for a physician-centered, medical model approach to addiction treatment.

However, I couldn’t find where it was supposed to have said the majority of front-line treatment workers were low-skilled and poorly trained. There was a section stating that physicians and other health professionals should be on the front line addressing addiction. Then it said: “Paraprofessionals and non-clinically trained and credentialed counselors can provide auxiliary services as part of a comprehensive treatment and disease management plan.”

It did not say the majority of front-line treatment workers were low-skilled and poorly trained “incapable of providing the bare minimum of medical care.” Yet in the case study examples found in “Dying To Be Free,” that is what Cherkis presented. The Columbia study did cite another study, which found that recovering support staff had little enthusiasm for evidence-based practices. “They also were more likely to support intervention techniques that employ confrontation and coercion–techniques that contradict evidence-based practices.” But these paraprofessionals only made up “24 percent of the treatment provider workforce.”

Cherkis seems to have mis-remembered what the Columbia study actually claimed in this matter. I wonder if, because of his commitment to a strictly medical model ideology for opiate treatment, he was reading into the study. His quote above supported the description of the treatment facilities he highlighted in his article, but wasn’t found by me in the article he cited on the Columbia study.

Another example of how his treatment ideology distorted his portrayal of Suboxone treatment was with how he described Hazelden’s Suboxone treatment program. “Dying To Be Free” mentioned that Hazelden, now the Hazelden Betty Ford Foundation, developed its own Suboxone treatment program for opioid addicts. But it failed to note this wasn’t accompanied by a rejection of “Twelve Step practices.” Within “The History of Hazelden,” on the Hazelden Betty Ford Foundation website, was the statement of how it “integrates the cornerstone Twelve Step practices of mutual support along with multidisciplinary clinical care, evidence-based therapies and the latest research in brain science.” Why weren’t there some case study examples from Hazelden in “Dying To Be Free”?

The facilities Cherkis highlighted in Kentucky were not representative of abstinent-based addiction treatment centers in the U.S.; ones that use the 12 Steps to structure their treatment program. In reading “Dying To Be Free” I see an underlying ideology of conceiving and treating addiction, specifically opiate addiction, through a strict biomedical lens. That is not the whole story of addiction. As a result, the rhetoric of the article constituted a straw man attack on abstinent-based treatment while it extolled MAT. This bias presents readers with an implied choice, a dichotomy, between Suboxone as an MAT for addiction and 12 Step, abstinent-based treatment. Ironically, Hazelden, an historically important treatment center that pioneered 12 Step, abstinence-based treatment, did not choose MAT over the 12 Step-based treatment, but combined the two. But you don’t get that information in “Dying To Be Free.”

Parts 2 and 3 of this article will look at how “Dying To Be Free” misrepresented the recovery philosophy of self-help groups like Alcoholics Anonymous; and skimmed over the problems with MAT, specifically Suboxone.