#1 By: Maggie Koerth-Baker, February 6th, 2014 13:08
#2 By: IMB, February 6th, 2014 13:55
Maggie, there were reports that Buprenorphine was also found in the apartment. I can't speak to the accuracy (http://abcnews.go.com/Entertainment/anti-addiction-drugs-found-hoffmans-apartment/story?id=22358737). It would seem that he did have access to replacement therapy, whether or not he had a legal prescription for it, if what was initially reported is true.
I'm not offering this as a dispute of the success rate, in general, of going this route for addicts, just that it would seem PSH did have replacement therapy.
#3 By: Boris Bartlog, February 6th, 2014 14:22
I don't think this is a surprising result, and it certainly does argue in favor of methadone over cold turkey. However, a simpler solution and maybe a better control than substituting methadone for heroin would be a treatment program that provides a maintenance dose of heroin. Maybe this doesn't technically constitute 'recovery', but as long as we're just looking at life outcomes I believe it also works well. I guess I'd have to look at the results from the UK (where they had such a system for a long time) if I wanted to provide some supporting references...
#4 By: Steven Bach, February 6th, 2014 14:37
If you understand addiction to be a compulsive use of something (alcohol, drugs, etc.) that reaches the point of being self-destructive, then you'd see methadone as an effective treatment, it's very effective harm reduction.
Unfortunately, 12 step programs embed a kind of puritanical moralizing about abstinence that redefines addiction as a permanent disease, an innate attribute of the person they are powerless to change, with the puritanical terror of the power of temptation of any intoxication to pull the addict into sin. So the 12 step view is that any kind of intoxication is a complete moral downfall (that will inevitably cascade to death), even if that intoxication is a maintenance drug. Many 12 step participants actually have had sponsors push them off their psych. meds to great harm.
Because of the way that puritanical moralizing about abstinence got embedded in 12 step programs, and the way 12 step thinking dominates our culture's approach to addiction and recovery, ideas of harm reduction, moderation, self-empowerment to permanently change behavior, and other things that are contrary to the 12 step dogma get very little traction, even when evidence suggests that they can be very effective.
#5 By: Maggie Koerth-Baker, February 6th, 2014 14:37
The article by Maia talks about how some of the maintenance drugs allow people to live normally, i.e., without being high. So they can drive and go about their daily lives. Which, I would argue, is a pretty good reason to use those instead of heroin.
#6 By: IMB, February 6th, 2014 14:51
I'm not an addict (nor have I tried heroine) so I can't speak to the intricacies, but I think small doses of the actual substance doesn't create a high in perpetual users. In fact, part of the heroine addiction involves being physically ill without it. At certain doses the addict doesn't feel 'high' but normal, depending upon their level of tolerance. I knew someone who used and it was incredibly difficult to see that she was using since she was functional in all aspects, but this was at low dosage. I understand that at higher doses, people can achieve a high on methadone, so are we splitting hairs?
#7 By: Bobo the talking chimp, February 6th, 2014 15:15
Not a addiction specialist, but I'd assume that a low maintenance dose of heroin or methadone dosed to fulfill a physiologic need rather than to provide a high could be administered under medically supervised conditions. Supervised long term dose tapering would help wean folks off of opioid dependence in the long run.
The big problem with this sort of concept is the idea that you'd have trained medical professionals "shooting up" drug users. Oh Noes! There are a lot of things in accepted medical practice that go with a "lesser evil" to ensure improved long term survival rates or quality of life (think chemo...). If not for the aforementioned "puritanical moralizing" I'd bet that this sort of treatment plan could be funded for study and would eventually get put into place.
#8 By: Neil Mcconnell, February 6th, 2014 15:24
Generally I think maintenance dosing is done orally rather than injected, for slower absorption. I think that the idea of methadone rather than heroin for long term maintenance is that it's more difficult to get high on, and the high is not as much fun
What you're describing actually sounds a lot like the way methadone / Suboxone clinics already work though? Even in the US, methadone can be legally prescribed for treatment of opioid addiction, and Suboxone is available in some places - I seem to recall that California was the first state to make it available
#9 By: IMB, February 6th, 2014 15:31
I think the issue is not just access to low dosing. That would seem to be the answer for physical addiction, shortly after going into treatment, but not for someone who has been sober, but then goes back for the high. I don't know, reading about all of the projects PSH was involved in, it seemed like a heavy load. Maybe some addicts should be advised to set a limit on certain elements in their lives, rather than being told to go to AA meetings and whatnot. A low dose of anything isn't going to satisfy someone who is using those substances to take a vacation from life and reality and can't find another outlet to relax or not feel anxiety.
#10 By: anotherbozo, February 6th, 2014 15:38
I'm a drug addict and an acoholic who quit with the help of a 12-step program. Are you advising me to stop going? What should I do instead?
#11 By: IMB, February 6th, 2014 15:49
I think you should do what works for you. I think the point is that there probably isn't a standard issue protocol for everyone.
#12 By: Bobo the talking chimp, February 6th, 2014 15:55
Yeah, not a lot of experience with heroin/methadone, so I'm running a bit in the dark as far as route of administration/nuances of how the programs actually work.
And yeah, this would be a proposal for how to tame the physical addiction, not any psychological cravings for a high or the social/cultural aspects. Those are so far out of my milieu that I'm not even going to hazard a guess on how addressing those issues would best be handled. Obviously there needs to be a "whole person" approach to addiction treatment, not just the medical/physiological aspect of things.
#13 By: Steven Bach, February 6th, 2014 16:01
If it worked for you, that's great. I don't have an issue with 12 step programs existing, only their dominance of the discussion of addiction and recovery when their outcome rates are so low, and their missionary zeal to claim they are the only effective approach.
There are more evidence based approaches that can be helpful and empowering for some people: SMART Recovery, Rational Recovery, LifeRing/SOS, Life Process, etc. I'd like to see evidence based addiction treatment approaches based on current research available to those trying to recovery from addiction, since religious programs like AA are a poor fit for many (though not all, and I am certainly glad it worked for you).
#14 By: AnonKopimi, February 6th, 2014 16:03
On a long enough timeline, EVERYONE'S chances of survival drop to zero.
Maybe Phil left at his peak. Some of us are envious.
#15 By: IMB, February 6th, 2014 16:30
How can you be so sure that you have already hit your peak? Could be a late spectacular one.
#16 By: Suzanne, February 6th, 2014 16:39
Planet Money did a story about Suboxone which is effective for heroin addiction - good overview of the issues involved in prescribing and obtaining it.
#17 By: EvilPRGuy, February 6th, 2014 16:45
Any discussion around addiction suffers from a few things, one if which is misinformation. Both the general public, and people in 12 step programs both have a very poor understanding of what drug replacement/maintenance therapy is, and what the different drugs are.
-Drug replacement therapy for opiates was never meant to be a stand alone option. It has always been meant to be used in conjunction with some sort of private therapy or a structured outpatient program. Unfortunately, this isn't normally the case, because therapy and programs are expensive and in short supply in the US.
-Methadone and buprenorphine (Suboxone) are both used in opiate replacement therapy, but are very different drugs. Without going into the how they work on the brain chemically, methadone gets you high and buprenorphine doesn't (after a day or so). Further, it's possible to stack additional opiates with methadone to achieve a high, where buprenorphine really bind to the receptors in your brain making it nearly impossible to achieve a high from another opiate. The catch is getting off of long term buprenorphine use is absolutely horrific. Acute withdrawal can last for 28 days, and long term withdrawal up to a year. It is also extremely expensive in the US, and can be hard to get a doctor to prescribe, because special training is required. A second issue is that chemically methadone and buprenorphine are more physically addictive than any other opiate, including heroin. These were meant to be used as short term replacements (especially suboxone) to get the patient through the worst withdrawals and start learning to live without opiates. They have become long term solutions, so people are staying on them for decades. This isn't necessarily a bad thing, but physically, mentally and financially there are a lot of negatives to using drug replacement therapy in perpetuity.
-"Recovery" This is really a term from 12 step programs - it isn't medical. "Recovery" refers to, in the 12 step context, of being abstinent from drugs AND actively "working the program" (attending meetings, going through the 12 step process). I think a lot of confusion sadly occurs because many people can completely turn around there lives with the help of drug replacement therapy, and stop actively abusing opiates, but people in 12 fellowships, and counselors who recommend them, don't consider these people in "recovery". They are "abstinent", which in the 12 step lens is considered no good.
#18 By: gwdsm, February 6th, 2014 17:28
I'm glad you brought up both those points. My own indirect experience with someone who was a heroin addict and tried these type of programs mirror that many of the programs need more going on than just being distribution centers staffed by nurse ratchet-like figures, and often they can devolve into that. Our initial optimism in these programs faded quickly. The overall problem being there is so much variation in the programs on a larger scale, state by state, with problems that develop with each link in the chain because of variation in the execution of the programs at each treatment clinic (some of the hole in the wall urban locations better labeled outposts) and sometimes inconsistency even at the same place depending on the staffing for the day. The ground game and implementation is lacking and/or confusing for addicts and families of addicts to navigate without even more stress in a stressful time.
I think these programs have great promise, but I worry advocates for them have fought hard for them to exist so much that in order to combat naysayers and people who frankly could care less about the plight of addicts, to secure funding, to keep the boat aloft, they advocate the programs as if they have no flaws. They are great programs, but the rollout, information deficits, and way these programs are juggled even within a given states system makes me concerned for their long term adoption.
That said, I hope they continue to develop, but I would rather see a slow but improving body of knowledge and protocol, uniform programs and methodologies, be created than the patchwork of paperwork, addicts falling through the cracks, and throwing stuff at a wall to see what sticks. I empathize with those who run the programs now, since the above can't happen without funding, and to get funding, you don't want to say their are flaws, so there is not a good play to make. It is just a bad situation all around. Here is to hoping PSH death sheds some light on the problem in a way the death of a young reckless actor would not have, or been shrugged off.
#19 By: Elusis, February 6th, 2014 17:45
#20 By: clifyt, February 6th, 2014 17:58
The only reason methadone is used vs. heroin is that is was supposedly harder to make on the street and more addictive allowing it to take over in the addicts mind as the preferred drug. Given that it is harder to make, it ensured that one would have to go to the legal dealer and do the drug in a controlled manner.
I'm of two minds on the methadone side of things...I believe in the legalization of drugs, but I also want to see people cured of addictions if they want to be. Methadone really only shifts the dealer to a physician and ensure pure product. And my time in grad school for psychology tells me that most methadone dealers aren't interested in curing anyone...they are interested in profits. It was always strange how no one was ready to get off the drug until their insurance ran out and then and only then were they ready to kick the drug (i.e., legally, the clinics cannot stop treatment in the US, but they can decide to ween their nonpaying patient off the drug now that they are 'ready').
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