TIPS & TOPICS
Volume 5, No.2
In this issue
— Until Next Time
Welcome to the May edition and to all our growing number of subscribers.
This month I enjoyed speaking at the UK/European Symposium on Addictive Disorders in London. It reminds we USA folks that there is a wide variety of approaches and attitudes about prevention, treatment and public health policy on addictive disorders. There are varying opinions and approaches in the USA also. But other countries do not share a predominant abstinence- mandated, 12 Step recovery approach in funding and treatment.
From time to time I am asked what I think about methadone maintenance and harm reduction. While these treatment approaches exist in the USA, they are much more prevalent in the UK, Europe, Canada and Australia. In the 30 years since completing my psychiatric residency training, I have tried to integrate and synthesize my training and experience in abstinence-based, 12 Step recovery treatment with methadone maintenance and harm reduction approaches. Below is not a scientific review; or official policy of the American Society of Addiction Medicine or any other organization I belong to. It is just my opinion, as I make sense of disparate and often warring factions within addiction treatment.
- Methadone maintenance and other opioid treatments can be either pathways to total abstinence or a recovery path itself.
People who are addicted to opiates – either illegal drugs like heroin, or prescription narcotics – almost universally get involved in illegal, antisocial and deceptive behavior to maintain their supply of drugs. If you are addicted to alcohol or nicotine, you can still be a relatively civilized, law-abiding citizen . You can buy your drug from the supermarket. Opiate-addicted people have to maintain their addiction by conning doctors into giving more prescriptions; they may fake pain, deal drugs, share needles. They function in antisocial mode to rob, steal and do whatever it takes to keep their supply of drugs flowing.
To keep opiate addiction going for many years is demanding and unrelenting. This individual might already have a risk-taking temperament, and/or is likely to develop criminal or unethical behavior to survive in his/her addiction. Add to this the biological and neurotransmitter changes in the brain which for some people are not reversible with abstinence.
Here are some thoughts about using methadone or buprenorphine in medication-assisted addiction treatment (in no particular order):
–> It allows the opiate-addicted person to stabilize their lifestyle and neurobiology. At the same time they can acquire knowledge and recovery skills in their treatment appointments. The methadone or buprenorphine prevents withdrawal; it can allow the person to immediately stop illegal drug-seeking and antisocial behavior.
–> Detoxification and abstinence is certainly an option for opiate dependence as it is for alcohol or methamphetamine dependence etc. However long- term, intravenous opioid addiction has enduring biopsychosocial effects. These are tenacious, not easily reversed just with detoxification and recovery treatment.
–> Opiate substitution treatment may be necessary for clients whose neurobiology does not return to normal. A person with Type I diabetes may need insulin indefinitely; a person with severe opiate dependence may also need methadone or buprenorphine indefinitely.
–> From a purely public health perspective, methadone treatment is a crucial resource to decrease the spread of HIV, Hepatitis B and Hepatitis C infection.
–> Methadone and buprenorphine are still only “bio” treatments. Recovery is much more than the prevention of withdrawal and craving. If a client is not growing personally, interpersonally, spiritually, vocationally and socially, the clinical team should question whether treatment is succeeding. If the only goal of substitution therapy is a public health goal – the prevention of infection- then recovery growth will take second place. Stand alone “bio” treatment may even create more harm by perpetuating dependence on a drug.
–> Some methadone programs have been known to condone or turn a blind eye to alcohol use and positive drug screens (cocaine, benzodiazepines, cannabis etc.) This ignores that addiction is a holistic illness.
–> On the other hand, other programs automatically discharge or detox a client off methadone for concurrent use of other drugs. If substitution therapy is discontinued by policy or regulation, the client is destabilized. This will compromise the motivational enhancement work under way, and much needed to help the client look at their other non-opiate drug problems.
–> Many clinicians believe that a client cannot be in recovery while using methadone and buprenorphine. Recovery means mental, social, physical and spiritual growth. Would you really force a client to end medication-assisted addiction treatment if he/she was doing well in all aspects of their family, vocational, social, physical, psychological and spiritual growth? Certainly explore with the client the advantages of abstinence, and the freedom of not having to attend a methadone clinic.
Harm reduction is as much a clinical approach as it is a policy issue. I realize there are arguments about legalization or decriminalization of drugs; public health and cost issues; and arguments about personal freedom to use mood and mind-altering drugs etc. I have never understood how legalizing more drugs would decrease our substance use problems. Our greatest drug problems causing death and negative societal consequences are with the “legal” drugs of alcohol and nicotine. However these public policy arguments are not the focus here- the clinical skills aspects are.
I believe harm reduction is one of a broad range of approaches that should be available to people with substance use problems. However I would not want to be represented as championing harm reduction. What is most important is to engage clients, and concentrate on what works to produce improved outcomes in well- being and full recovery. If we focus on the results of the various models rather than argue about the models themselves, this is more productive and helpful to the people we serve.
Often discussions about harm reduction produce a lot of heat. But it seems we are just in our separate ideological “religions.” We need to remain humble; our theories and models have less effect on outcome than harnessing a person’s self-change process.
- If you are uncomfortable with “harm reduction” think of it as “progress not perfection.”
We often would like addicted people to perfectly embrace ,and perfectly achieve, total freedom from dependence on substances as the way to cope and live. But many clients show up at our agencies undecided whether they have an addiction problem, and just as ambivalent about wanting total abstinence from all drugs. How do we repond? We can either insist on abstinence as a precondition for receiving treatment; or send the client away and ask them to come back when they are “ready”. A 3rd alternative is to sieze the opportunity to engage them right away in treatment, commence where they are at right now, and aim all efforts at attracting them into recovery.
The following are examples of harm reduction or “progress not perfection” treatment:
–> A client wants to cut back on their drinking rather than work on total abstinence – even after your best efforts to advise them that abstinence would most likely give them the best chance of success. You have ruled out imminent danger of harm to the client or others and agree to work on the “just cutting back” treatment plan to help the client do the “research” on their level of control.
–> A client wants to stop using substances, but doesn’t want to go to Alcoholics Anonymous or Narcotics Anonymous – even after attempts to persuade him/her of the benefits of regular attendance. You avoid argumentation. Direct your attention toward methods of achieving recovery support and peer guidance in other ways e.g., spiritual communities, other recovery groups. You agree to use whatever groups the client wants. With them you identify the signs which would indicate success or failure of their preferred methods of support.
–> A client does not want to take medication for a co-occurring mental health problem – despite your best efforts to explain how an unstable mental illness is a relapse issue for both diagnoses, mental and addiction. Of course you have ruled out imminent danger of harm to the client or others. You then agree to the “no medication” treatment plan. If all goes well, you agree to continue. But if relapse problems arise and persist, the client agrees to change the treatment plan in a positive direction, plus consider medication if necessary.
–> A client suffers from intravenous opiate addiction. Her addiction controls her so much that she shares needles and prostitutes for drugs. You urge abstinence, sobriety and a total lifestyle change. But the client is so steeped in her antisocial and illegal way of life that change will be gradual and slow. You arrange for methadone maintenance in order to break this cycle of dangerous, life-threatening behaviors – both for her and for the others involved in the needle sharing and unprotected sex.
The harm reduction debate is much more complex than these clinical vignettes. However at the clinical skill level, you take an approach: either a purist, abstinence-mandated approach, OR fashion an abstinence-oriented, harm reduction, “progress not perfection” service which seeks to attract as many people into recovery as possible. Our current no-show, drop-out and premature discharge rates demand that business not proceed as normal!
Starting July 1, the United Kingdom will join a handful of European countries and USA states in banning cigarette smoking in bars and restaurants and some other public places. That is quite something in countries traditionally much less concerned about nicotine dependence than we are in the USA. I knew smoking was deadly, but it hadn’t hit me fully until a May 25 USA Today article outlined the statistics about the health burden of tobacco:
* Kills 490,000 Americans a year
* Kills more Americans annually than AIDS, alcohol, cocaine, heroin, homicides, suicides, car accidents and fires combined
* Almost half of the USA’s 44.5 million adult smokers will die prematurely of tobacco-related illness if they don’t stop.
Our soldiers in Iraq are precious and courageous. But more people die in one month from nicotine dependence than the total of military deaths in all the years of the Iraq war.
Isn’t it curious that many addiction treatment programs are adamant about discharging a client for substance use, or as William White says “punitively discharge clients for becoming symptomatic?” But — when it comes to seeing nicotine as a “drug is a drug is a drug”, or moving a program towards being nicotine-free and expecting staff to embrace nicotine abstinence, there is as much debate as harm reduction and methadone maintenance. It’s easy for me to say as I am a non-smoker. And I expect that if you are a smoking counselor, you may be much more of a harm reduction advocate and less fervent about total abstinence – at least for your “drug of choice”.
So our attitudes and values are at least as potent influences as facts and figures. Otherwise the American public would be as outraged by tobacco deaths as they are about Iraq deaths. And addiction counselors would be as vigilant about nicotine dependence as they are about addictions to alcohol, methamphetamine and heroin.
Who knows exactly what drives the opinions we each have. But a little introspection about our own inconsistencies might be useful before rushing to judgment about others’ – whether that be over harm reduction, methadone maintenance or nicotine dependence.
Until Next Time
See you all in June.