Question Criminalizing a Medical Illness

One way I urge us to help all our citizens is to question the legality, effectiveness, and humanity of criminalizing the medical illness of addiction.

Freedom and peace

Here is a summary of my findings:

Many of our citizens with opioid use disorder are arrested, incarcerated, or given the forced choice of drug court or jail. Many receive limited or no treatment, or are denied the first-line, evidence-based treatment for opioid use disorder, methadone and buprenorphine. Some drug courts ban the use of medications for opioid use disorder. At the national level, the Department of Justice’s Civil Rights Division has begun an initiative to remove discriminatory barriers to treatment for those in the criminal justice system. Incarceration does not decrease substance misuse. Treatment is 7 times cheaper than incarceration.

Here are highlights of my literature review of research on opioid use disorder and the criminal justice system:

“A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use.”

– Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, November, 2016, Page 4-1

On-going, long-term maintenance on methadone or buprenorphine are the only two treatments currently known to reduce mortality from opioid addiction by 50 percent or more.

– Pierce et al., Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in EnglandAddiction, 2015

– Sordo et al., Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studiesBritish Medical Journal, 2017

Naltrexone, whether oral or extended release naltrexone, branded as Vivitrol and marketed directly to drug court judges by its manufacturer, does not result in decreased mortality rates for people with opioid use disorder.

– Degenhardt et al., Excess mortality among opioid-using patients treated with oral naltrexone in Australia, Drug and Alcohol Review, 2014

– Jarvis et al., Extended-release injectable naltrexone for opioid use disorder: A systematic review, Addiction, 2018

“[H]ealthcare providers, criminal justice officials, and the media should consider the potential for overdose when prescribing or promoting Vivitrol treatment.”
– Saucier et al., Review of Case Narratives from Fatal Overdoses Associated with Injectable Naltrexone for Opioid Dependence, Drug Safety, 3/20/18

Persons recovering from, or receiving supervised treatment for addiction to alcohol or drugs, are often qualified as disabled individuals according to the American with Disabilities Act. Courts, drug courts, probation departments and prisons may not treat individuals with opioid use disorder differently from other individuals who are allowed to take medications as prescribed.

Letter to the New York State Office of the Attorney General from the U.S. Department of Justice, October 3, 2017

80% of people with opioid use disorder who attempt abstinence-based behavioral treatment or detoxification relapse.

– Gavin Bart, M.D., Maintenance Medication for Opiate Addiction: The Foundation of RecoveryJournal of Addictive Diseases, 2012

“The majority of patients who discontinued BMT [buprenorphine maintenance therapy] did so involuntarily, often due to failure to follow strict program requirements, and 1 month following discontinuation, rates of relapse to illicit opioid use exceeded 50% in every study reviewed.”

– Bentzley et al., Discontinuation of buprenorphine maintenance therapy: perspectives and outcomes, Journal of Substance Abuse Treatment, 2015

People are more likely to fatally overdose prior to beginning maintenance medication and upon ceasing it than are those with continuous treatment. Cornish et al. caution, “Clinicians and patients should be aware of the increased mortality risk at the start of opiate substitution treatment and immediately after stopping treatment.”

– Sordo et al., Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studiesBritish Medical Journal, 2017

– Anders Ledberg, Mortality related to methadone maintenance treatment in Stockholm, Sweden, during 2006–2013, Journal of Substance Abuse Treatment, 2017

– Cornish et al., Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK General Practice Research Database, British Medical Journal, 2010

Individuals with opioid use disorder who are newly released from prison are at high risk of overdose death.

– Binswager et al., Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009, Annals of Internal Medicine, 2013

Incarcerated individuals with opioid use disorder should be treated with methadone and buprenorphine while they are incarcerated. “[R]esults suggest that comprehensive MAT [medication-assisted therapy] treatment in jails and prisons, with linkage to treatment in the community after release, is a promising strategy for rapidly addressing the opioid epidemic nationwide.”

– Green et al., Postincarceration Fatal Overdoses After Implementing Medications for Addiction Treatment in a Statewide Correctional System, JAMA Psychiatry, 2018

For those with opioid addiction in the criminal justice population, maintenance medication can reduce rates of re-incarceration by 20% or more.

– Larney et al., Effect of prison-based opioid substitution treatment and post-release retention in treatment on risk of re-incarcerationAddiction, 2011

To stay in remission from opioid use disorder, people must remain on methadone or buprenorphine for extended periods of time, sometimes life-long. According to SAMHSA’s guide, “Medication-assisted treatment should continue as long as the patient desires and derives benefit from treatment. There should be no fixed length of time in treatment. For some patients, indefinite medication-assisted treatment may be clinically indicated.”

– Federal Guidelines for Opioid Treatment Programs, SAMHSA, 2015

“Medication-Assisted Treatment (MAT) is an evidence-based substance use disorder treatment protocol, and BJA [Bureau of Justice Assistance, U.S. Department of Justice] supports the right of individuals to have access to appropriate MAT under the care and prescription of a physician. BJA recognizes that not all communities may have access to MAT due to a lack of physicians who are able to prescribe and oversee clients using antialcohol and anti-opioid medications. This will not preclude the applicant from applying, but where and when available, BJA supports the client’s right to access MAT. This right extends to participation as a client in a BJA-funded drug court.”

Adult Drug Court Discretionary Grant Program FY 2017 Competitive Grant Announcement, U.S. Department of Justice, 2016

“Examining any two-year post-program recidivism (defined as an arrest, conviction, or incarceration), over one third (37.6%) of graduates and almost all program terminators (95.3%) had two-year post-program recidivism ( p < .001). [my emphasis]. For the overall sample, age, outpatient treatment, marital status, number of times treated for a psychiatric problem in a hospital, substance use (i.e., past-30-day cocaine use and intravenous opiate use), number of positive drug tests, and receiving any sanction/therapeutic response were associated with two-year post-program recidivism.”

– Shannon, et al., Examining Individual Characteristics and Program Performance to Understand Two-Year Recidivism Rates Among Drug Court Participants: Comparing Graduates and Terminators, International Journal of Offender Therapy and Comparative Criminology, 4/1/18

“The analysis found no statistically significant relationship between state drug imprisonment rates and three indicators of state drug problems: self-reported drug use, drug overdose deaths, and drug arrests.”

– More Imprisonment Does Not Reduce State Drug Problems, The Pew Charitable Trusts, 3/8/18

Treatment is up to 7 times less expensive than incarceration.

– NIDA, “Is drug addiction treatment worth its costs?”, 2018

Watercolor painting by Jesi Pace-Berkeley

The above includes data I used for a talk I gave on the opioid crisis on Tuesday, March 13, 2018. I reviewed common beliefs about opioid use in the U.S., and compare those beliefs to what research reports. I published highlights from my background research for the talk as Opioid Crisis: What People Say vs. What the Research Says.

Last updated 5/15/18

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Opioid Crisis: What People Say vs. What Research Says

“Addiction is bad people doing bad things.”

“Addicts use drugs for pleasure.”

“Addiction is a choice.”

  • Brain studies reveal that addiction compromises brain structures including the basal ganglia, extended amygdala, and prefrontal cortex.
    – Nora D. Volkow, M.D., George F. Koob, Ph.D., and A. Thomas McLellan, Ph.D., Neurobiologic Advances from the Brain Disease Model of AddictionNew England Journal of Medicine, 2016
  • “People suffering from addictions are not morally weak; they suffer a disease that has compromised something that the rest of us take for granted: the ability to exert will and follow through with it.”
    – Nora Volkow, M.D., Can the Science of Addiction Help Reduce Stigma? Advances in Addiction & Recovery, Fall 2015

“Lock ’em up. That’ll serve ’em right. That’ll cure ’em.”

  • The primary symptom of the illness of addiction is persistence in use despite negative consequences – including persistence despite the punishing, negative consequences of jail, prison, loss of custody of children, loss of one’s job, license to drive, license to practice a profession…
  • For those with opioid addiction in the criminal justice population, maintenance medication can reduce rates of re-incarceration by 20% or more.
    – Larney et al., Effect of prison-based opioid substitution treatment and post-release retention in treatment on risk of re-incarceration, Addiction, 2011
  • Treatment is up to 7 times cheaper than incarceration.
    NIDA, “Is drug addiction treatment worth its costs?”, 2018

“Abstinence treats addiction.”

“Abstinence from opioids treats opioid addiction.”

“People with addiction need to go to rehab.”

“Drugs cause addiction.”

“Big Pharma and prescription pain pills are to blame for the opioid crisis.”

“Doctors are to blame for the opioid crisis.”

“Prescription pain pills are a gateway to heroin addiction.”

“Overdose deaths are skyrocketing.”

  • The spike in opioid-related deaths is presumed to be caused, not by prescription pain pills, but by inadvertent overdose through street supplies of heroin poisoned with illegally-made fentanyl and its analogues.
    Opioid Data Analysis, Centers for Disease Control, 2017

“If we declare war on opioids, we’ll solve the opioid problem.”

“Medication trades one addiction for another. Because methadone and buprenorphine are opioids, giving them to opioid ‘addicts’ substitutes one addiction for another.”

“Babies are born addicted.”

“Opioid addiction is the biggest problem facing America today.”

  • Marijuana overdose deaths: 0 (Source)
  • Terrorism-related deaths, U.S. citizens, overseas and domestic: 32 (2014: Source)
  • Prescription opioid drug-related deaths: 16,000 (2015: Source)
  • Opioid-related deaths: 35,000 (2015: Source)
  • Gun-related deaths: 35,000 (2014: Source)
  • Drug overdose deaths: 64,000 (Provisional, January 2017: Source)
  • Alcohol-related deaths: 88,000 (2015: Source)
  • Obesity-related deaths: 300,000 (Source)
  • Tobacco-related deaths: 480,000 (Source)

Oh, wait. Breaking news. Not 70s heroin? Not 80s crack cocaine? Not 2010s opioids anymore? Meth again?

Wait, not meth? Benzos?

  • “It would be a tragedy if measures to target overprescribing and overuse of opioids diverted people from one class of life-threatening drugs to another.”
    – Lembke et al., Our Other Prescription Drug Problem, New England Journal of Medicince, 2/22/18

“Deciding to use substances like tobacco, alcohol, marijuana or heroin
does not make people less human. It reflects the fact that they are
human.”
– Hakique Virani, M.D., People use drugs, get over it, CBC Radio-Canada, 2017

“The iron law of drug prohibition is that the more intense the law enforcement, the more potent the drugs will become.”
– Richard Cowan, National Review, 1986, Wikipedia

Last updated 3/8/18

Image: iStock

. . . . .

I will be giving a talk entitled “Opioid Epidemic? What Are the Facts?” for the Lifelong Learning Institute at Virginia Tech on Tuesday, March, 13, 2018, 3:15 – 4:30 PM, at Warm Hearth Village Center in Blacksburg, Virginia. The event is free and open to the public.

More information about the talk is here and here.

A follow-up discussion meeting will be held on Wednesday, April 25, 6:00 – 8:00 PM, in the Community Room at the Blacksburg Library, 200 Miller Street, Blacksburg, Virginia.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Talk on the Opioid Crisis in Blacksburg, VA, March 13, 2018

I will be giving a talk entitled “Opioid Epidemic? What Are the Facts?” for the Lifelong Learning Institute at Virginia Tech on Tuesday, March, 13, 2018, 3:15 – 4:30 PM, at Warm Hearth Village Center in Blacksburg, Virginia. The event is free and open to the public.

If America is facing an “opioid epidemic,” why isn’t evidence-based emergency, urgent, and routine medical care for opioid use disorder available in our town? Ask that question of lawmakers, judges, policymakers, public officials, journalists, treatment professionals, and society at large and watch the spluttering begin. For no other health care condition is belief, opinion, and myth accepted as the standard of care. This presentation focuses on the latest addiction research, with a focus on opioid use disorder, challenging what society has to say about addiction with the available science.

I have compiled my background research for this talk here.

For context, I recommend this article:

And this one, too:

For further reading, I’ve compiled suggestions here.

I gave a talk on opioids for the Montgomery County, Virginia Democratic Party on August 17, 2017. Here is the first half of an expanded version of the talk. The second half is here.

Speaking in Blacksburg, Virginia

Directions to Warm Hearth. As you enter the Warm Hearth complex on Warm Hearth Drive, you will pass Nuthatch Way on your left. Take the next left into the driveway and parking lots for Warm Hearth Village Center.

(LLI requests mail-in registration, but it is not required. Here’s the registration form and here’s a list of all events scheduled for LLI during Spring 2018.)

If you have questions or I can be of service, please feel free to contact me.

Photo: Bonnie Lyons

How to Help a Loved One with Addiction: An Evidence-Informed Approach

Learn. 

Learn what constitutes an evidence-informed treatment plan for the medical condition of substance use disorder, popularly termed “addiction.” Acknowledge that debate rages, even among experts and researchers, about what addiction is and what effectively treats it. Discourse is, of course, necessary, but your loved one needs help now. Learn what the evidence suggests helps most people with substance use disorder, most of the time, better than other treatments, and better than no treatment.

Co-create solutions

Understand.

Learn enough about addiction to understand what people with the disorder experience, why their actions may not make sense, why abstinence is neither a cure nor a relief, and why they might not want treatment. Understand that substance use disorder occurs with multidimensional complexity and variability. Use terms related to addiction accurately.

In particular, understand that the neuroscience of addiction suggests that through compromising the brain’s basal ganglia, extended amygdala, and prefrontal cortex, addiction under-sensitizes people to pleasure, over-sensitizes them to pain, automates use of the substance to feel, not necessarily good, but normal, weakens decision-making abilities, magnifies emotional highs and lows and incapacitates the ability to regulate them, interferes with recognizing cause-and-effect relationships, and confounds the ability to make a plan and follow through with it.

“Do not attempt to take away a person’s main means of trying to cope with pain and suffering until you have another effective coping strategy in place.”
– Alan Marlatt, Ph.D., 2004

Encompass.

Be brave.  Beyond the medical condition of addiction which compels use, become aware of, seek, and acknowledge all the possible current conditions, risk factors, and pre-existing conditions – including trauma and mental illness – that might lead your loved one to find use of substances appealing, helpful, or meaningful. Without judgment, be open to discussing these with your loved one. What substances do for a person will need to be adequately replaced before a person can do without them. Expand and deepen your empathy and compassion for these conditions and reasons, and for the person who has them.

Love.

Offer love love, not tough love.

Co-create.

If your loved one is in an emergency state, dial 911 or get him or her to an ER.

If not, your loved one may be newly released from the hospital, newly released from treatment, or in need of urgent care.

Having grounded yourself in learning, understanding, compassion, and love, confer with your loved one about what next steps might be helpful. Although the situation might seem dire, co-decide on the smallest step that might make a slight improvement – perhaps finding an answer to a question through a phone call or a Google search – and do that. Don’t try to strategically build trust – be trustworthy.

This is subtle, but the goal of helping someone with substance use disorder isn’t to take over the person. The goal is to help the person be himself or herself and move towards health, in the increments that work for him or her, while having this condition.

Use the best of your heart, mind, knowledge, experience, wisdom, and presence, all together, all at once. The substance is perceived as needed to survive. The illness of addiction, the symptoms of co-occurring illnesses, and the impact of substances themselves can interfere with a person’s reasoning. Co-creating solutions with a person under such duress will take the very best of your full humanity.

Coordinate.

Serve as your loved one’s case manager and do what you can to make the components of the treatment plan happen. Make inquiries and appointments, make phone calls and follow-up phone calls, make copies of all documents, keep originals in a safe place, create a notebook of the copies, provide or find transportation, and accompany your loved one to as many appointments as possible, notebook of copies in hand.

Advocate.

Your loved one has a medical condition needing medical care, but society at large believes it is a moral and criminal problem needing redemption and punishment. Even your loved one may believe he or  she is a good person gone bad. Your natural inclination may be to walk away from care providers who hold these views. Since it’s a position held by the majority, doing so may leave you with no alternatives and no care. Instead, you may need to learn to skillfully and strategically advocate to procure the necessary treatment component from each individual or entity.

Insist on outcome-based treatment. If the treatment providers don’t have data that the treatment works – data that counts all the people who tried the treatment, not just the people who finished – ask them for the criteria used to decide which treatment protocols are offered. If a treatment isn’t known or proven to work, why would your loved one be required to do it? People mandated to treatment may have to attempt to make the best of what’s offered. You can convey, however, that you will be overseeing your loved one’s progress.

Commune.

Find others with loved ones with substance use disorders and connect with them in ways that are supportive, informative, and empowering. Community Reinforcement and Family Training (CRAFT) is an evidence-backed approach, developed first for alcoholism, and known since the 90s to foster engagement between people with substance use disorders and those who love them towards achieving treatment goals. Even if implementation of a CRAFT program is not possible in your area, finding others who value a CRAFT goal – “Minimize distress and increase positive lifestyles for all family members” – may be encouraging and strengthening.

“Love, evidence & respect.”
– Maia Szalavitz’s answer via Twitter to the question, “What fights addiction?”

Recommended reading

Watercolor by Jesi Pace-Berkeley

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

It Cannot Be Concluded That General Group Counseling is Effective for Reducing Substance Use

“Unfortunately, despite decades of research, it cannot be concluded that general group counseling is reliably effective in reducing substance use or related problems.”
– Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, November, 2016, Page 4-26

For research citations on the ineffectiveness of counseling – individual or group – for opioid use disorder, please see On Counseling and Medication-Assisted Treatment.

For more excerpts, quotes, and definitions related to substance use disorder, please see Addiction Recovery: Define Terms and End Conflation.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.