Wednesday, June 26, 2013
Insite - pros and and cons
Insite is a heroin injection site institution with millions of dollars funding and large staffing. It provides heroin to heroin addicts. The closest comparison that could be made to Insite would be a million dollar medical facility devoted to safe smoking for smokers. Granted airports have 'harm reduction' glassed in chambers for smokers. The issue there is that there are no nurses or doctors to promote smoking as 'safe'. These chambers privately funded and are not called 'safe inhalation' sites. They do not divert millions of dollars from acknowledged and scientifically proven treatments for smoking addiction. As a consequence of the existing treatment for 'smoking cessation' millions have stopped smoking and the quitting smoking campaign has been spear headed by ex smokers and doctors and nurses committed to life.
At the turn of the century Sigmund Freud, the foremost psychiatrist of his day said that addiction was untreatable. Carl Jung the other most famous medical doctor and psychiatrist of his day said addiction required a miracle. Even today most countries treat addiction with jail and asylums. Yet in the 1930's Dr. Bob Smith and Bill Wilson demonstrated that alcoholism could be cured through 'abstinence' on a daily basis and involvement with other recovering alcoholics in a group process to help others stay sober. The Big Book of Alcoholics Anonymous was published in 1939 reported the remarkable success of 50 members recovered of chronic end stage alcoholism. AA also espoused a 'higher power' which encouraged individuals to believe in a 'power greater than themselves' because to date they had been unable 'on their own' to stop their addiction.
Follow up research reported by the American Society of Addiction Medicine in the late 1990 showed that those successful for 5 years or greater in maintaining abstinence belonged to a group that supporedt their 'recovery', that they have a 'higher power' they believe is more powerful than their addiction or the object of their addiction, and they believe that personally the substance is harmful for them, in much the way a person would consider an allergy.
As a consequence of this group grass roots process millions of people have remained alcohol and drug free for their lifetime. The AA movement spawned Narcotics Anonymous, Cocaine Anonymous, and countless other anonymous meetings that have served to help millions more with a variety of addictions other than just alcohol.
As a result of this 'success', literally thousands of programs have developed to help the previously believed 'incurable' alcoholics and addicts. Hospital based detox has been available since the beginning of AA when Dr. Silkworth and others treated individuals for the acute withdrawal of alcohol and drugs. In 1986 I was the acting head of the Winnipeg Detox, a medical ward semi attached to the Winnipeg General Hospital. Given the complications of overdose and medical complications of withdrawal including seizures, myocardial infarction, CVA's and kidney failure, these have been life saving facilities all but universally acknowledged for their benefits to individual and communities.
Since the AA movement began with the demonstrated success in treating and curing addiction, various treatment centres such as Betty Ford in the United States, Homewood in Canada, Edgewood and Orchard locally, to name just a fraction of a fraction have developed to start the process of recovery. It was long recognized that detox only treated the life threatening withdrawal physical illness and the biopsychosocial condition of addiction required months and years to overcome. Religious organizations such as Salvation Army, the Catholic Church, and other Christian, Jewish, western Buddhist organizations have provided a powerful backbone to the recovery movement. So often churches and temples provided the after care for patients who had been discharged from detox or treatment centres and now returned to the community. The other cornerstone of follow up care usually modeled on 12 step programs has been the sober recovery houses where patients stay for months in a supportive non using group.
MRI studies show frontal lobe reversible damage that persist following cessation of drug abuse for up to three months. Cannabis is detected in the urine for up to three months as well. Most treatment centres like the amusing movie of the same name only lasted for 28 days, though today it's not uncommon for programs to persist for 6 weeks, more consistent with the ideal stay lengths associated with other acute psychiatric conditions. There is clear evidence that the longer the stay in the 'sober houses' the greater likelihood of persisting abstinence and prolonged recovery. Some of the most successful programs have people stay for 2 years though members commonly in such houses return to work and reestablish themselves with family and community.
Following on the successful model of AA group therapy, the leader dominated facilitated SMART group process developed along with other group follow up and on going therapy process with varying success and as yet not comparable to the overwhelming long term success associated with the AA initial group process. Dr. Gallanter studied long abstinent AA members and demonstrated the success of AA and abstinence in those with decades of sobriety and success in community and work.
The gold standard of recovery success was the Navy Pilot Program with pilots whose training cost millions of dollars, flying planes worth millions of dollars, and because addictions knows no bounds, developing alcoholism and addiction. The program required first 28 days inpatient treatment followed by 3 meetings group involvement in AA, weekly counseling and monthly psychiatric visits. Greater than 80 % of pilots were flying successfully at 5 years follow up. These and other stats following from the initial success of AA treatment demonstrate without doubt the highly treatable nature of the disease of addiction. The success with treatment of alcoholism has through NA and CA been demonstrated with other chemical dependencies.
There are even a percentage of individuals especially as noted in the recent overwhelming success in the treatment of nicotine addiction, of spontaneous cures and individuals remaining abstinent from their chemical addiction simply by changing their social environment and abstaining from what they perceive is poisonous to themselves.
Dr. Ray Baker, a leading Canadian Addiction authority presents even more telling research showing that addiction is extremely successfully treated if the disease is "caught' in early stages, when the patients still have jobs and family. Historically addiction treatment was criticized for its limited success with 'end stage' cases. Dr. Baker, in his highly regarded lectures, given locally and internationally, demonstrates well that addiction therapy treatment fares even better than other medical treatments for other chronic end stage diseases, such as kidney failures, obstructive disease and chronic heart disease.
My father and his generation believed that addiction was 'untreatable'. It was called the 'cancer of the mind' at the time when 'cancer' was considered untreatable as well. Today cancer simply is no longer the big "C" and when I worked as a family physician I saw innumerable 'cures' that only a decade before would have been called miraculous. I am thankful to day to have been treated successfully for skin cancer myself knowing that only a generation ago I might well have died from this malady but thanks to my family physician and dermatologist I'm cancer free though must "abstain' from extensive sun bathing. This hasn't been that onerous this last year in Vancouver, BC.
Our generation, especially thanks to the tabloid lives of countless famous Hollywood alcoholics and addicts and national league athletes, is recognized by all as a treatable illness with great success. The ubiquity of AA members is simply astonishing with every walk of life commonly having someone who has successfully "kicked the habit' with the help of others, often family, physicians, groups but most important the positive belief that has followed from the success of abstinence based programs: AA, NA, treatment centres, Sober House and increasingly the Drug Courts and Safety Sensitive Job movements.
The recognition that abstinence based therapies are highly successful, that abstinent individuals save millions if not billions of health care dollars and account for the incredible advances in accident free workplace days, has created a ground swell of success building on success. . With this success has come mixed benefits, many more 'players', increasingly government funding tied to other political agendas. As a consequence of this recognition, publicity and success there has also been a development of a major industry in which the alcoholic or addict is no longer considered 'sick' or a 'victim' or a "patient" but rather is called a "consumer". These new and increasingly dominant business and socially engineered models have an inherent conflict of interest since there is never any reason to 'lose' a 'consumer.
Insite is simply the kazoo in this great orchestra of science, medicine and recovery that was making extremely fine music before this latest 'sell yourself out of debt' scheme came into the works.
That said, this loud and rich, and arrogant voice, needs responding to. The 'science' presented is highly controversial. This is not a 'science project' but rather a very intriguing political program. It is 'political'. Very political. It is not surprising that it has begun in British Columbia whose principal crop industry is illegal substance. Insite has faced little scrutiny locally but has not surprisingly encountered resistance in the rest of Canada where the costs of addictions outweigh the revenue of illicit marijuana sales and heroin trafficking. When I was at an addiction medicine conference in Washington DC, Vancouver Canada was identified as the most concern portal for illicit heroin import into the US.
In terms of it's political aims this is all part of the Trans-human and other social engineering agendas that would see individuals able to buy alcohol, marijuana, cocaine or heroin at the corner store much like one buys any other commodity. As a conservative libertarian I can't fault this agenda intellectually even though it does sound more like the kind of society most attractive to the Cheech and Chong elements without other responsibilities and limited experience understanding that freedom comes with responsibility and license is a different thing altogether. Unfortunately too the research of the great Harvard psychiatrist, Dr. George Vaillant, who I will forever be honoured to have met, demonstrated without a shadow of doubt that the more available mind altering substances were the greater the cost to individuals and society. This is particularly concerning when in Canada we have an already overburdened medical care system with deadly wait lists and a 24 hour dead body being found in a teaching hospital waiting room in Winnipeg. Expansion of availability of drugs and alcohol results in harm to the most vulnerable, brain injured, poor, homeless, jobless and the population that Dr. Gabor Mate so elegantly described in his book "Hungry Ghosts".
In contrast, Drug Courts which to date are grossly underfunded despite their overwhelming evidence of cost effectiveness are just one of many scientifically proven approaches to drug treatment that are less heard about when the idea of encouraging heroin addicts to shoot heroin in their arms in the presence of nurses is just too sexy to compare with.
Now the famous Doctor William Osler treated his equally famous surgeon colleague, Dr. Halstead, with morphine in his office near the turn of century when doctors simply approached the use of narcotics much like physicians to day do with pain treatment. No institution is necessary and no multimillion research is needed to deal with appropriately trained and licensed doctors who are already prescribing narcotics successfully without drama or politics to patients continuing to so so under the appropriate jurisdiction and guidelines provided by the College of Physicians and Surgeons and Federal and Provincial Ministers of Health.
To date Methadone and buprenorphone have been scientifically proven and not terribly controversial harm reduction techniques for people transitioning from addiction to needles to oral narcotics and eventually to abstinence. The tremendous reduction in crime and spread of blood related diseases is directly a consequence of oral narcotics being substituted for intravenous drugs. Such improvements in health of individuals and community and reduction in crimes, specifically theft have been demonstrated wherever appropriate oral narcotic substitution therapies have been instituted long before the introduction of Insite.
I find it odd that I have personally had so much difficulty arranging for family members to give IV drugs to patients with cancer yet here is a program that supports already sick and marginalized individuals injecting themselves with highly questionable and often lethal substance bought illicitly. Politically there may be a place for trained nurses and doctors to provide heroin IV to patients in offices though frankly I think such an approach to a treatable curable illness is disheartening and sadly abusive of patients who quite rightly would want a 'cure' if their doctors and nurses could 'believe' in them.
Harm reduction is indeed a fancy term which refers not so much to less harm for the individual , who indeed is often being written off, but rather to the community. Unfortunately the present emphasis on "harm reduction" and the celebration and publicity of institution injection sites may well serve to perpetrate disease, maintain addiction and even result in withholding funding the kinds of treatment that are proven curative. I can't help but hear Marie Antoinette's cry, "Give them cake!" Indeed appendicitis is cured by costly surgery but it can be treated in a 'harm reduction' manner by simply giving antibiotics without surgery. No doubt there was a time when surgery was a hard sell too and people wanted simply a 'magic' solution to a life threatening disease. Thankfully our medical forefathers took an oath 'do no harm' and aimed for cure rather than watching the patient die slowly.
Palliative care is a probably better term for Insite's "harm reduction'. It is a well established medical term in the treatment of end stage cancer patients. Insite might well be considered a 'palliative care' unit for those for whom no hope of cure is expected and all that can be done is to ease the suffering of those individuals who otherwise die would die. As it stands Insite appears to give the impression that it is doing something special and unique and helpful for addicts.
The World Health Organization has only acknowledged the benefit of "harm reduction strategies" so long as they are directly linked and lead to abstinence based recovery. To date despite the claims otherwise I have not been convinced that Insite is such, In contrast the Salvation Army and Union Gospel treatment centre and the Vancouver Daytox programs and such places as Last Door, Turning Point, Pacifica and so many other sites are clearly using harm reduction as a minor stepping stone to the greater world of recovery and abstinence.
Many doctors, judges, pilots have become successfully abstinent with the help of AA and returned to be leaders in their field. To date the normal approach to doctors, judges, politicians, pilots, and multi millionaires is to send them to treatment such as Betty Ford and then encourage them to continue in an aftercare program either associated directly with the facility or to attend AA/NA or such 12 step self help programs. I would be more optimistic about INSITE if I heard that the Physician Health Program or the Lawyer Assistance Program is recommending their members to participate in heroin injection facilities. Anesthetists who have developed opiate addictions have to date used methadone, buprenorphine and detox, then abstinence based treatment programs such as AA/NA and the recent SMART group follow up. This has caused some to be reasonably concerned that INSITE is like offering candy to diabetics rather than insulin.
Now personally I really would like to "live and let live" and can only admire colleagues who find ways to become rich in their practices so long as their patients benefit alongside their wealth creation schemes. However I have noted a strident loudness, much like the voices of drunks and drug addicts promoting the single handed success of free heroin injection sites in conquering all the dragons and monsters of addiction single handedly. There are even those who believe that Insite is a truly important player in the recovery success in the Downtown Eastside community. They overlook the amazing work of Harbour Light, Union Gospel, Doc Side Medical, Pender Clinic, Dug Out AA, the downtown east side drug court and countless other individuals and groups that have for decades been working together for the increasing success in the community which comes as a culmination of scientifically based abstinence programs and harm reduction programs leading to abstinence. This Insite kazoo is richly amplified but it's really not new, a variation on palliative care and highly controversial medically and psychiatrically. I am not surprised that the world over all has not jumped on the band playing political wagon. I like kazoo music I thought it might be important for others to remember that the poorly paid, often unpaid, huge and ever larger and more successful orchestra of recovery has been playing an increasingly happy tune thanks to years of work of countless individuals and the scientific approach to successful therapy of addiction. The 4 pillar strategy was right on the need for prevention and therapy but seems to have done little for prevention and put an unholy emphasis on one questionable 'get rich quick' basket.
As a tax paying psychiatrist and addiction medicine specialist I'm not so sure this Kazoo is even in tune with the music of this new generation. Last I saw they were into yoga, cycling, extreme sports and healthy food. Even Timothy Leary, the great GURU of the LSD generation said that 'if we'd had the computer and internet' we'd probably never have done drugs. I don't think we should be doing anything given the winds of change to encourage anyone to put needles in the arms when all of life awaits them. The success of the 'safety sensitive employment' programs, drug courts, public health measures for addicts, with truly drug free housing, detox, treatment centres, continues to show success which has been building since the breakthrough programs of AA began in the late 30's .
But please correct me if I'm wrong.