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TIPS & TOPICS from David Mee-Lee, M.D.
Volume 5, No.3
June 2007
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In this issue
-- SAVVY and SKILLS
-- SOUL
-- Until Next Time

Welcome to the June edition. Thank you to all who write expressing appreciation and offering your opinions. I read and appreciate them all, even if I can't respond personally to each and every one.

SAVVY and SKILLS
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In the addiction and mental health fields, issues such as methadone treatment, medication-assisted addiction treatment, harm reduction, recovery, abstinence, smoking cessation etc., will surely generate lively discussion. Following up on last month's Tips and Topics (TNT), I share excerpts of responses accompanied by some editorial comments. (Names of the writers are not mentioned; some gave permission to print their names, but frankly I ran out of time to obtain all the permissions.) This is probably preferable as I want to focus on the comments without distractions about who said what from which organization. Like newspaper Letters to the Editor an author can remain anonymous in print, but does need to disclose his/her identity to the publisher. Each excerpt is from an identified writer.

Excerpts: TERMINOLOGY

#1: "I would be remiss if I did not share with you the opinion of the National Alliance of Methadone Advocates (NAMA) about the use of the term "Substitution Therapy" for your consideration."

#2: "Glad to hear you using the medication- assisted treatment reference. Although, please purge memory files of the old reference to "substitution" therapy (since we really don't substitute anything) and "replacement" therapy (also because we are not replacing anything)."

My comments

I have not done any significant work in methadone clinics. With my clinical experience being predominantly in 12 Step recovery settings, I have not focused much on medication- assisted treatment for opiate dependence. Therefore I learned the latest on terminology from those in that sector of the addiction treatment field; and the attitudes and values that underlie old and new terms. Here is a Press Release from NAMA (not NAMI - The Alliance for the Mentally Ill):

PRESS RELEASE

NAMA Calls for An End To Using The Term Substitution Treatment Asking That Governments and Their Agencies and Organizations End It's Use

National Alliance of Methadone Advocates

Contact: Joycelyn Woods MA-CMA (212) 595- NAMA/6262

For Release: May 4, 2007

The National Alliance of Methadone Advocates, our international affiliates and chapters in the United States call on all governments, governmental agencies and international organizations to end the use of "Substitution Treatment" when referring to medication assisted treatment (MAT) for opiate addiction.

The term "Substitution Treatment" infers that any medication used in the treatment of opiate dependence is a substitute. No other medication is referred to in this manner creating significant misunderstandings towards the medication and especially the patients. The use of "Substitution Treatment" stigmatizes patients receiving treatment for the opiate dependence, promotes ignorance and pollutes the development and growth of this life saving medication for those needing help for their opiate dependence.

Governments have rejected buprenorphine and particularly methadone because they are viewed as merely a substitute for heroin or other illicit drugs. Officials, in rejecting these medications, have expressed the belief that their citizens should have the right to an effective treatment. Thus hundreds of thousands of opiate dependent individuals "are being denied" the most effective treatment because "Substitution Treatment" is misleading and confusing.

In the United States the term Substitute and Substitution Treatment is only used to denigrate both methadone and buprenorphine treatments. Calling these medications a substitute has been used to hurt patients by denying them opportunities and other benefits that they deserve and have worked for. Thus, in the United States only those against methadone and buprenorphine call them a Substitute.

At Bratislavain 2006 Dr. Icro Maremmani, the President of Europad called for his European colleagues to end the use of "Substitution Treatment". He asked his colleagues to follow the philosophy and principles of Drs. Dole and Nyswander who believed that opioid dependence and addiction was a medical condition and conceptualized the drug dependent person as a person with a brain metabolic disorder.

We, at the National Alliance of Methadone Advocates believe that the use of Substitute or Substitution Treatment denigrates this treatment. And that by denigrating this treatment patients receiving medication assisted treatment are injured.

As patients we reserve the right to define ourselves and our treatment. It is therefore the spirit of our own self identity we ask governments and their agencies, organizations and professionals to cease using "Substitution Treatment". Methadone and buprenorphine are medical treatments and should be defined as "Medication Assisted Treatment" or "Opiate Agonist Therapy".

Excerpts: SMOKING

#1: "The issue of smoking at an addiction treatment facility is one that we confront daily. As a public building, people are not allowed to smoke within 25 feet of our building (difficult to enforce) and one program within the building has gone tobacco free (Perinatal Substance Abuse Program). Our own employees were violating the 25 foot rule with full knowledge and consent of the management until an anti-smoking zealot (me!) brought it to the attention of the higher authorities.

Anyhow, thank you for shedding some light on Harm Reduction and Medication Assisted Treatment and making people consider how smoking too is dependence."

#2: "Our program wasn't tobacco-free until 1.1.07. We resisted for all the usual reasons, mainly, let's deal with one addiction now, do lots of education and then have our patients work on their smoking down the line. Then we had an in-service from a physician who specializes in this, and she pointed out that outcomes for chemical dependency are better in tobacco-free programs than in ones that aren't. (That's really what evidence-based treatment is). So we switched and, although we've had a few problems with a few clients, they've been about 5 to 10% of what we anticipated. (We're not nicotine-free, just tobacco- free; the physician recommended patches and gum for people whose withdrawal was tough.) But she pointed out that if we were tobacco-free, we'd have no cues in the form of smelling smoke, or from watching other people smoke. She also said that the attitude of the staff was the most important variable. She's right.

It seems that our experience is an example of how our team looked at inconsistencies in our thinking (alcohol and drug abuse is to be treated; nicotine abuse treatment is to be deferred until later) by adopting evidence-based treatment. The physician who conducted the in-service is Cathy McDonald, M.D. from Thunder Road 510/653-5040 ext. 315).

#3: "On the smoking issue, if 490,000 people were killed by planes crashing into buildings rather than people making billions, we would be at war or something!"

My Comments

The culture of smoking is deeply rooted in our society, and in the addiction treatment field in particular. This will change slowly. It is interesting that programs which have embraced smoking cessation have often been pleasantly surprised when their fears of financial doom and client revolt have not materialized. Perhaps the day will come when programs will be as concerned about a counselor smelling of tobacco after lunch break, as they are now were a counselor to return from lunch smelling of alcohol.

 

Excerpts: ENGAGING PEOPLE in TREATMENT; HARM REDUCTION; MEDICATION- ASSISTED TREATMENT

#1: "I thought the May issue of TNT was particularly thought-provoking. The key point with regard to the issue of whether opioids are pathways to abstinence or a recovery path (a destination) is your point about whether the patient continues to grow spiritually, emotionally, etc. after being on buprenorphine or methadone. My own recovery was initiated by a psychiatrist, who developed a relationship (positive transference) with me for three months before he sent me to AA.

During those 3 months he: 1) saw me at least once a week; 2) had me keep a journal of the circumstances surrounding my drinking; and 3) gave me a script for Valium (this was in 1973) which he encouraged me to take instead of drinking. The initial treatment goal was to develop enough trust in the relationship so that I would follow the recommendation to go to AA. If he had made that recommendation too early, I never would have gone. During those 3 months and for the next 8 months, while I continued to take Valium, he continued to monitor whether I was growing spiritually, emotionally, etc. I initiated the request to discontinue the Valium, he put me on a comedown and it was discontinued. The physical discomfort was reduced by going to more meetings. That was October 1974. So I can certainly relate personally to your approach of meeting the patient where they are and working with what you've got."

My comments on #1

I appreciate the reader's openness about his own recovery, and I know he is not advocating Valium for every ambivalent alcohol-dependent client who might be reluctant to attend AA. But this is a living testament to the importance of engaging and attracting people into recovery, rather than sending them away "until they are ready", as we would often do in the old days. There is no one way to engage a person. It has to be individualized to what makes sense for that client. The AA slogans of "attraction, not promotion" and helping people to "keep coming back" can be just as powerful in clinical services as well.

#2: "In my experience (still learning after 30 years), here's a couple of other tips I have realized especially when providing medication-assisted or harm reduction treatment as interventions for opioid addiction.

a. What I tell my Behavioral Pharmacology students as well as the counselors throughout the provider network is this: The reality is that some things work for some people some of the time. One of the greatest challenges to the clinician initially, is to discover what works best for the person sitting in front of them now. What the clinician believes treatment and recovery should look like, needs to be moved aside to allow what treatment and recovery needs to actually be from person to person on an individual basis. This may involve the use of harm reduction as a means toward total abstinence. It might also mean the use of medications to help the person achieve stabilization in order that they may then begin to internalize the principles of recovery.

b. The generic treatment goal for drug addiction is not total abstinence from all mind and mood- altering substances. This was the overarching treatment goal in the 1980's and for some programs, is still being embraced. If this is a treatment goal, then addiction treatment does not work. But we know treatment works and we know addiction is a chronic condition requiring multiple and varying types of interventions. Based on the consensus from research science on treatment for addiction, the general goal is the reduction or elimination of illicit drug use and the development of a healthy lifestyle. Since medication-assisted treatment is conducted under a physician's supervision, there is no illicit use.

c. Something learned in business management is you can respond to a market or create one. As an "old school" methadone provider, I always saw methadone as a "lure" regardless of motivational level. As a matter of fact, unlike traditional therapy, where motivation is a necessary condition, I was impressed from the very beginning how "ambivalent" patients were and the challenge faced to "sell" an alternative. The results of many evidence-based practices studies are less impressive than confirming the changes in brain chemistry and subsequent profound affects on reward centers. And, they are not and should not be equated in any way, shape, or form with encouraging change. On the contrary, it begs the question of what can we do that will effectively compete with excessive levels of dopamine stimulation - the cornerstone to the compulsive nature of the chronic condition of addiction.

d. That being said, you can be motivated, but it is essential that you be offered something useful in order to have a positive outcome. We need to be studying combinations of interventions, especially since that is what we actually do in our programs."

My comments on #2

Again, this reader is emphasizing the importance of staying client-centered, client-directed, abstinence- oriented, not abstinence-mandated. Understanding the biopsychosocial nature of addiction, he states we must provide a variety of interventions, including medication. I'm sure some readers will react to point (b) where he proposes that "total abstinence" is not the generic treatment goal for drug addiction. What I get from that comment is this: If the goal of diabetes treatment was total absence of high blood sugar levels, diabetes treatment would have to be considered a failure,because in the course of diabetes treatment, it would be rare to never have an elevated blood sugar level. But medication-assisted diabetes treatment, or medication-assisted hypertension treatment is a recognized, often necessary part of recovery for people with diabetes and hypertension. Likewise, the goal of addiction treatment is to promote recovery and the elimination of illicit drug use. Some of our clients may never need medication to achieve recovery. But others may need assistance with medication either temporarily or indefinitely.

#3: "It's good to see this topic addressed. I was an addictions counselor for 20 years and used this approach many times, long before it was being popularized. I found that an increasing number of my clients were deciding they were "constitutionally incapable of recovery" and were abandoning their treatment at times without even leaving the room i.e. hiding relapse and/or problems related to their life and treatment or just telling me what they thought I wanted to hear. When I got real about "meeting the client where they were" the better I got at this approach, the more changes they were able to make in their lives.

Part of this is the assessment of when to use this approach. I am not sure most people have the training to do it; or whether they trust their training. So they are working at being safe, rather than sorry. It's easier to blame the client despite the fact that they are just doing their jobs as clients, but we as their guides are not. Not everyone recovers from cancer and not everyone recovers from addictions. The medical community is seeing cancer as a conditioned to be managed, rather than cured. I believe this approach can increase the effectiveness of addictions treatment----they may not achieve sobriety, but less chaos in the lives of our clients and their families."

My comments on #3

It is not untypical for treatment programs to have a 40- 50% drop-out or premature discharge rate. It is also not untypical (despite our declaring: "this is an honest program") that many clients lie about, or cover up, a slip or substance use while in treatment. Either we can blame the client for their failure to engage in recovery, or do our own fearless and moral inventory of what we do, or not do, to attract people into recovery.

#4: "Just a personal response to your article on harm reduction. As with many of my fellow substance abuse therapists, I work with a population mainly comprised of court referrals, nearly all of whom receive urinalysis and Blood Alcohol Concentration testing to ensure complete abstinence. I can't count the number of people I have worked with who originally were not personally motivated toward complete abstinence, but as a result of a legal and treatment environment where abstinence is the norm come to discover abstinence is both easier than expected and produced more benefit than they would have imagined.

Your analogy about smokers is apt. But in an environment where smoking is monitored, "relapse" into nicotine use would result in potential legal consequences; and where peers are enjoying the benefits of abstinence from nicotine, countless people would quit and the quality of life for all would improve. Indeed, the simple increase in cigarette cost and public disapproval of smoking has produced a reduction in smoking over the past several years. I'm not totally opposed to the concept of harm reduction in some instances, and I am not naïve enough to suggest we make tobacco use blanketly illegal, but I do believe harm-reduction advocates need to give more credence to the power of environment and counselor/legal expectations in helping addicts break free of their addiction."

My comments on #4

Thanks to this reader for voicing his concerns about harm reduction. I suspect other readers have objections they were reluctant to voice here. Similarly I have worked predominantly in settings which were abstinence-mandated, not abstinence-oriented. I also saw clients who had a "spiritual awakening", and were thankful for having no choice about abstinence. The reader is speaking to the power of the therapeutic milieu which expects and mandates abstinence, and does not condone anything less than that. He links that to nicotine dependence. If programs equally expected abstinence with that addiction too, many people might be free of nicotine dependence. I agree that we should not forget the power of the environment and counselor expectations in shaping outcomes.

But as is said in Motivational Interviewing, how do we create an environment that is conducive of change rather than coercive of change? An environment that enhances responsibility and accountability for self- change, and elicits self-motivational statements and actions? What do we do about an even greater number of clients, especially mandated clients, who "do time" and don't "do treatment"? Clients who comply with all treatment and program expectations or at least appear to, and coast their way to "graduation" only to use not long after "completing treatment"? Some even explicitly say that they plan to use again once off probation or out of the program. What do we do about our high drop-out and relapse or continued use rates? There are many paths to recovery. We need all those paths to be available for the diverse populations and people we serve.

SOUL
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Through the wonders of my iPod and free Podcasts, I can now listen to past broadcasts of National Public Radio's "Talk of the Nation" program. April 18 a journalist guest, Cathryn Jakobson Ramin, discussed progressive memory loss among adults in their 50's and 60's. She just published "Carved in Sand: Why Memory Fades in Midlife." She apparently mentioned situations we "oldies" can relate to:

--> "Whomnesia" when you can't remember names of people you should know;
--> "What am I doing here?" syndrome, when you stand empty-handed at the door of a room wondering "What did I come here for?"; or
-->"Wrong vessel" disorder when you put a pint of ice cream in the pantry instead of the freezer.
You can listen to the program yourself for the content.

This program reminded me of some funny "getting old" jokes someone e-mailed me. I don't know who created the jokes, so I can't reference them. Enjoy them if they aren't too close to home!

Family

Three sisters, ages 92, 94 and 96, live in a house together. One night the 96-year-old draws a bath. She puts her foot in and pauses. She yells to the other sisters: "Was I getting in or out of the bath?" The 94- year-old yells back: 'I don't know. I'll come up and see.

She starts up the stairs and pauses: "Was I going up the stairs or down?"

The 92-year-old is sitting at the kitchen table having tea listening to her sisters. She shakes her head and says: "I sure hope I never get that forgetful, knock on wood." She then yells: "I'll come up and help both of you as soon as I see who's at the door."

"I can hear just fine!"

Three retirees, each with a hearing loss, were playing golf one fine March day. One remarked to the other, "Windy, isn't it?"

"No," the second man replied, "it's Thursday."

And the third man chimed in, "So am I. Let's have a beer."

Old Friends

Two elderly ladies had been friends for many decades. Over the years, they had shared all kinds of activities and adventures. Lately, their activities had been limited to meeting a few times a week to play cards. One day, they were playing cards when one looked at the other and said, "Now don't get mad at me. I know we've been friends for a long time, but I just can't think of your name! I've thought and thought, but I can't remember it. Please tell me what your name is."

Her friend glared at her. For at least three minutes she just stared and glared at her. Finally she said, "How soon do you need to know?"

Senior Driving

As a senior citizen was driving down the freeway, his car phone rang. Answering, he heard his wife's voice urgently warning him, "Herman, I just heard on the news that there's a car going the wrong way on Interstate 77. Please be careful!"

"Heck," said Herman, "It's not just one car. It's hundreds of them!"