Tag Archives: World Health Organization

11/16/21

If Not Psychiatry, What Then?

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In June of 2021, the World Health Organization published a document, “Guidance on Community Mental Health Services.”  The WHO document is seeking to provide quality care and support for person-centered, human rights-based and recovery-oriented mental health care and services worldwide. In a video launch of the event, Sir Norman Lamb said: “Our collective aim must be to end coercive practices, including seclusion and restraint, forced admission and treatment. And we must combat violence, abuse and neglect. This is an urgent imperative for all countries. It’s a global human rights priority.”

Reports from around the world highlight the need to address discrimination and promote human rights in mental health care settings. This includes eliminating the use of coercive practices such as forced admission and forced treatment, as well as manual, physical or chemical restraint and seclusion and tackling the power imbalances that exist between health staff and people using the services. Sector-wide solutions are required not only in low-income countries, but also in middle- and high-income countries.

The Executive Summary of the WHO report said global mental health services often face substantial restriction of resources, and operated with outdated legal and regulatory frameworks. There was an overreliance on the biomedical model, where the predominant focus of care was on diagnosis, medication and symptom reduction. Overlooked were the social determinants that impact people’s mental health, hindering progress towards a fuller realization of a human rights-based approach. “As a result, many people with mental health conditions and psychosocial disabilities worldwide are subject to violations of their human rights – including in care services where adequate care and support are lacking.” Key messages of the Guidance said:

According to the WHO Mental Health Atlas 2017, the global median government expenditure on mental health is less than 2% of total government health expenditure. In order to develop quality mental health systems with enough human resources to provide the services and provide adequate support of people’s needs, allocating adequate financial resources is essential. But the problems with mental health provision cannot be dealt with by simply increasing resources. “In fact, in many services across the world, current forms of mental health provision are considered to be part of the problem.”

The majority of existing funding is invested in the renovation and expansion of residential psychiatric and social care institutions. This represents over 80% of total government expenditure on mental health for low- and middle-income countries. “Mental health systems based on psychiatric and social care institutions are often associated with social exclusion and a wide range of human rights violations.” While some countries have taken steps towards closing psychiatric and social institutions, this action has not automatically led to dramatic improvements in care. The history of closing psychiatric hospitals in the U.S. illustrates this point.

The predominant focus of care in many contexts continues to be on diagnosis, medication and symptom reduction. Critical social determinants that impact on people’s mental health such as violence, discrimination, poverty, exclusion, isolation, job insecurity or unemployment, lack of access to housing, social safety nets, and health services, are often overlooked or excluded from mental health concepts and practice. This leads to an over-diagnosis of human distress and over-reliance on psychotropic drugs to the detriment of psychosocial interventions – a phenomenon which has been well documented, particularly in high-income countries. It also creates a situation where a person’s mental health is predominantly addressed within health systems, without sufficient interface with the necessary social services and structures to address the abovementioned determinants. As such, this approach therefore is limited in its consideration of a person in the context of their entire life and experiences. In addition, the stigmatizing attitudes and mindsets that exist among the general population, policy makers and others concerning people with psychosocial disabilities and mental health conditions – for example, that they are at risk of harming themselves or others, or that they need medical treatment to keep them safe – also leads to an over-emphasis on biomedical treatment options and a general acceptance of coercive practices such as involuntary admission and treatment or seclusion and restraint.

Reports from countries in all income brackets around the world highlight extensive and wide-ranging human rights violations that exist in mental health care settings. These violations include the use of coercive practices such as forced admission and forced treatment (as with Britney Spears), as well as manual, physical and chemical restraint and seclusion. In many services, people are exposed to poor, inhuman living conditions, neglect, and in some cases, physical emotional and sexual abuse. People with mental health conditions are also excluded from community life and discriminated against in employment, education, housing and social welfare. These violations further marginalize them from society, “denying them the opportunity to live and be included in their own communities on an equal basis with everyone else.”

A fundamental shift within the mental health field is required, in order to end this current situation. This means rethinking policies, laws, systems, services and practices across the different sectors which negatively affect people with mental health conditions and psychosocial disabilities, ensuring that human rights underpin all actions in the field of mental health. In the mental health service context specifically, this means a move towards more balanced, person-centred, holistic, and recovery-oriented practices that consider people in the context of their whole lives, respecting their will and preferences in treatment, implementing alternatives to coercion, and promoting people’s right to participation and community inclusion.

The End of Psychiatry as We Know it?

In Western society, this means challenging the biologically centered, medical model approach to psychiatry. Writing for Psychology Today, John Read noted how global critics of an overly biological approach to understanding and helping distressed people is often dismissed as radical or extremist. Critics of the dominant medical model approach, promoted by the drug companies and biological psychiatry, are often labeled as “anti-psychiatry.” However, Read replied, “We, however, view ourselves as anti-bad and anti-ineffective, unsafe treatments.” He then quoted Steven Sharfstein, then president of the American Psychiatric Association, who said in 2005:

If we are seen as mere pill pushers and employees of the pharmaceutical industry, our credibility as a profession is compromised. As we address these Big Pharma issues, we must examine the fact that as a profession, we have allowed the bio-psycho-social model to become the bio-bio-bio model.

Read also cited Robert Whitaker, who thought the WHO report was a landmark event. There is a global rethinking of how to treat and think about mental health. Whitaker said, “Model programs highlighted in this WHO publication, most of which are of fairly recent origin, tell of real-world initiatives that are springing up everywhere.” Read said it will be become harder for defenders of the medical model to dismiss organizations like the UN or the WHO as extremist, anti-psychiatry radicals. This can be illustrated by looking at how Psychiatric Times launched “Conversations in Critical Psychiatry,” a series of articles and conversations with prominent individuals who are critical of various aspects of psychiatry.

Dr. Awais Aftab, who is a psychiatrist, not only interviews other psychiatrists such as Dr. Ronald Pies, Dr. Giovanni Fava and Dr. Allen Frances, he also talks with individuals from the critical, so-called anti-psychiatry side of the debate, namely Dr. Joanna Moncrieff, Lucy Johnstone and Dr. Sami Timmi. His first interview in 2019 was with Dr. Frances, the Chair of the DSM-IV Task Force and a vocal critic of the DSM-5, over diagnosis and the state of mental health treatment in the U.S. Follow Drs. Frances and Aftab on Twitter to see what they have to say about the current state of psychiatry. One of the concerns for Dr. Fava has been how the psychiatric establishment uses the term “discontinuation syndrome” to describe “antidepressant withdrawal.” In “The Impoverishment of Psychiatric Knowledge,” he said:

If you teach a psychiatric resident that symptoms that occur during tapering cannot be due to withdrawal, he/she is likely to interpret them as signs of relapse and to go back to treatment (exactly what “Big Pharma” likes). In the UK, the NICE guidelines are changing to reflect the potentially malignant outcome with SSRI and SNRI discontinuation. I do not see anything similar happening in the US.

One of the staunchest defenders against so called anti-psychiatry has been Dr. Ronald Pies, professor emeritus of psychiatry, SUNY Upstate Medical University; and Editor in Chief emeritus of Psychiatric Times. Among the many articles Dr. Pies has written over the years defending establishment psychiatry and psychiatric practice are these on Psychiatric Times from the past year: “What Kind of Science is Psychiatry?”, “Do Psychiatrists Treat Diseases?,” and “Why Thomas Szasz Did Not Write The Myth of the Migraine.” He also wrote “Is Depression a Disease?”, about a report from the British Psychological Society whose central argument was that depression is best thought of as an experience rather than a disease; and “Poor DSM-5—So Misunderstood!”, which challenges the claim that the DSM-5 “offers a biomedical framing of people’s experiences and distress and impairment.”

In “The Battle for the Soul of Psychiatry,” Dr. Aftab and Dr. Pies talked about various issues he’s faced over his career. Dr. Pies agreed with Dr. Aftab that they could have done a better job of counteracting “the so-called ‘chemical imbalance’ trope.” Pies wished he had tackled that issue earlier than 2011. He acknowledged the field of psychiatry took a “fairly sharp turn” toward the biological from roughly 1978 to 1998, “which, to a considerable degree, persists to this day.” Dr. Pies thought the movement toward the biological/biochemical was heavily influenced by the pharmaceutical industry.

His hope for the future of psychiatry was to recover its pluralistic core. He said his department at SUNY Upstate Medical University emphasized the integration of psychopharmacology and psychotherapy, and explicitly endorsed “the biopsychosocial approach.” He supported constructive critics of psychiatry, whose aim was to improve the profession’s concepts, methods, ethics, and treatments. He rejected the “anti-psychiatry” critics, saying their rhetoric was clearly aimed at discrediting psychiatry as a medical discipline. This last charge by Pies seems to be true to a degree.

In their book, Psychiatry Under the Influence, Robert Whitaker and Lisa Cosgrove (two of the anti-psychiatry critics) said the time was ripe for a paradigm shift. Many Americans are seeking alternatives to psychiatry’s medication-centered care. Disagreeing with Dr. Pies, they believed psychiatry was facing a legitimacy crisis from a scientific standpoint. Second generation psychiatric drugs are no better than the first, belying the claim psychiatry is progressing in its somatic treatment of psychiatric diseases. “The disease model paradigm embraced by psychiatry in 1980 has clearly failed, which presents society with a challenge: what should we do instead?”

12/15/20

Tramadol Is not a Safe Opioid

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The 2020 World Drug Report said the non-medical use of opioids has always been associated with the most serious health consequences among the various types of drugs. But in the last few years new threats have emerged with regard to the non-medical use of pharmaceutical opioids, leading to alarming rates of dependence and overdose deaths. The problems in North America with fentanyl and its analogues have led to an unprecedented increase in opioid overdose deaths. But in West, Central and North Africa, the Middle East and Asia, another opioid has emerged as a major concern—tramadol.

Tramadol’s potency was said to be comparable to codeine, about 10% the potency of morphine. This led to initial belief that it had a low risk of abuse when it was brought to market in the 1960s by the German pharmaceutical company Grunenthal. However, researchers later found that tramadol releases a far more powerful dose because of how it is metabolized by the liver. An article in The British Medical Journal, “Chronic use of tramadol after acute pain episode” said tramadol undergoes demethylation in the liver to the active metabolite desmatramadol, giving it an opioid effect comparable to morphine.

The BMJ article reported a study by researchers at the Mayo clinic that found patients who received tramadol for the acute treatment of pain had slightly higher rates of long-term opioid use after surgery. The senior author of the study said their finding did not support the idea that tramadol is less habit forming than other opioids. The lead author of the study said: “And while tramadol may still be an acceptable option for some patients, our data suggests we should be as cautious with tramadol as we are with other short-acting opioids.” Tramadol use has been increasing and was the third most prescribed opioid in the study at 4%, after hydrocodone (51%) and oxycodone (38%). “Although all factors related to the safety of a drug must be considered, from the standpoint of opioid dependence, the Drug Enforcement Administration and FDA should consider rescheduling tramadol to a level that better reflects its risks of prolonged use.”

While many countries in West, Central and North Africa report the non-medical use of tramadol as one of the main threats in drug use, quantitative information on the actual size of the population using tramadol non-medically was not available in most countries, according to the 2020 World Drug Report. However, treatment data in West African countries revealed tramadol to be the main drug of concern for people with drug use disorders. “Tramadol ranks highly among the substances for which people were treated in West Africa in the period 2014–2017.” In North Africa, Egypt reported tramadol is the main opioid used non-medically. In drug treatment, tramadol was also the primary drug, accounting for 68% of all people treated for drug use disorders in 2017. In the Sudan, the increasing non-medical use of pharmaceutical drugs among young people includes: tramadol, benzodiazepines, cough syrups and antihistamines, trihexyphenidyl (an antiparkinsonian agent), anticonvulsants, pregabalin and gabapentin.

In Iran, a recent study estimated that or 200,000 people aged 15-49 in urban centers had misused tramadol, most of whom were young people. The past 12-month of non-medical use of tramadol in the general population was 4.9 percent among men and .5 percent among women. In recent years, tramadol intoxication and fatal overdose, especially among young people with a history of substance use disorder and psychiatric comorbidity, has been a major cause of emergency department admissions. Among these cases, tramadol has been misused with other substances, especially benzodiazepines. “Tramadol was also found to be the cause of death in around 6 per cent of the total drug overdose death cases in the Islamic Republic of Iran reported in different studies from 2006 to 2017.”

AP News reported in “How tramadol, touted as safer opioid, became 3rd world peril,” that mass abuse of tramadol spans continents from India to Africa and the Middle East, creating international havoc. Some experts blame a loophole in narcotics regulation and a miscalculation of the drug’s danger. It was touted as a way to relieve pain with little risk of abuse. Unburdened by international controls that track most dangerous drugs, tramadol flows freely around the world. “But abuse is now so rampant, that some countries are asking international authorities to intervene.”

Grunenthal is campaigning to keep the status quo with tramadol regulation, arguing that typically it is illicit counterfeit pills causing problems. International regulations make narcotics difficult to get in countries with disorganized health systems. Adding tramadol to the list, the company said, would deprive suffering patients access to any opioid at all. The secretary of the World Health Organization’s committee recommending how drugs should be regulated said this is a huge public health dilemma. “It’s a really very complicated balance to strike.” Tramadol is available in war zones and impoverished nations because it is unregulated—the same exact reason it is widely abused.

Tramadol has not been as deadly as other opioids, and the crisis isn’t killing with the ferocity of America’s struggle with the drugs. Still, individual governments from the U.S. to Egypt to Ukraine have realized the drug’s dangers are greater than was believed and have worked to rein in the tramadol trade. The north Indian state of Punjab, the center of India’s opioid epidemic, was the latest to crack down. The pills were everywhere, as legitimate medication sold in pharmacies, but also illicit counterfeits hawked by street vendors.

Authorities in Punjab seized hundreds of thousands of tablets, banned most pharmacy sales and shut down pill factories, pushing the price from 35 cents for a 10-pack to $14. When the government opened a network of treatment centers, fearful those who had become addicted would resort to heroin out of desperation, hordes of people rushed in seeking help. Tramadol had become as essential as food. A 30-year-old auto shop welder said, “Like if you don’t eat, you start to feel hungry. Similar is the case with not taking it.”

In 2016, Jeffery Bawa, an officer with the UN Office on Drugs and Crime, traveled to Mali in West Africa, one of the world’s poorest countries, which also struggles with civil war and terrorism. When he asked people what their most pressing concern was most said tramadol, not hunger or violence. At a United Nations meeting on tramadol trafficking, Nigerian officials said the number of people living with addiction is far higher now then the number with AIDS or HIV. In Cameroon, scientists thought they had discovered a natural version of tramadol in tree roots. “But it was not natural at all: Farmers bought pills and fed them to their cattle to ward off the effects of debilitating heat. Their waste contaminated the soil, and the chemical seeped into the trees.”

Police began finding tramadol pills on terrorists. It seems they now traffic tramadol to fund their networks and use it to bolster their own violent behavior. Most of the supply was coming from India, where pill factories produced counterfeits and shipped them in bulk around the world, “in doses far exceeding medical limits.” In 2017, law enforcement reported confiscating $75 million worth of tramadol from India on route to the Islamic State. Another 600,000 tablets headed for Boko Haram were intercepted. Three million more tramadol tablets were found in a pickup truck in Niger, in boxes disguised with U.N. logos.

Grunenthal has persisted with its campaign to keep tramadol unregulated. It funded surveys that found regulation would impede pain treatment and even paid consultants to travel to the WHO to make their case that tramadol is safer than other opioids. But that could change. Referring to the above-described Mayo Clinic study, AP News noted the researchers were surprised when they found their data indicated patients prescribed tramadol were just as likely to move on to long-term use as other opioids. The lead researcher of the Mayo study said: “There is no safe opioid. Tramadol is not a safe alternative. It’s a mistake that we didn’t figure it out sooner. It’s unfortunate that it took us this long.”