Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

I like how I skipped ahead a few segments and Mark went from normal Mark to the floating head of the demigod Mark.

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

Thanks for answered prayers!

I suspect time limitations prevented a more in-depth discussion of a combined criminal/social/medical issue.

http://www.pcssb.org/

Even though that is a website directed to Physicians, it has reliable information that will be of use for anyone interested.

One issue that was not addressed is the risk of death from a narcotic overdose in narcotic addicts.

I recently attended a presentation by a retired DEA agent from NY, Mr. Bob Stutman, he presented a most compelling story:

(photographs were used in the original event)

http://www.thestutmangroup.com/

My bottom line is that addicts deserve a chance to get sober, your best friend, sibling, neighbor, child, relative, etc., etc... could be addicted and help is available.

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

Yes, and it's encouraging to see more and more young people specializing in addiction medicine, psychiatry and ancillary healthcare professions. It really does take a village of teachers, healthcare professionals, peer counselors, law enforcement, parents and researchers to begin to address the problem.

I was also encouraged to hear Mark and Harold talk about changes in public sentiment and policy since the Stone(r) Age of the 1970s and the Crack Age of the 1980s. Still, political realities being what they are, real change comes very slowly. The Mexican drug war rages on, prescription drug abuse is at record highs, lives are ruined every day by drugs, and our per capita incarceration rate is the highest in the world.

I thought Harold did a good job of not letting Mark be dismissive of treatment programs. Mark insists that treatment is not nearly as effective as carrot-stick law enforcement programs like Hope, which maintains the threat of incarceration as a deterrent to using. Harold suggested, however, that the answer is to improve the quality of prevention and treatment. As Harold said, good treatment is VERY expensive, but not nearly as expensive as non-treatment.

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

This looks good. Wish BHTV had an East Asian policy guy's take on Kim Jung-Il, but it's a big world and I'm greedy.

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

Yeah, there's good money to be made Romancing Opiates

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

In the other thread you said you would be interested in my thought about this diavlog, so here.

Pollack talked about his impression of the Russian drug czar's views of the problem of drug addiction. He explained that due to the risk of AIDS, rejecting alternative treatments such as methadone or suboxone or needle exchange programs is rather ridiculous. He also criticized the idea that methadone maintenance is like substituting one drug for another.

I pretty much agree with all those observations. The only caveat is that both positions are right. Methadone and needle exchange are the best programs if you know you won't be able to stop opiate addiction. It's a damage control measure. And it makes a big difference compared to the damage caused by intravenous heroin use, sharing needles, and all the social consequences.

On the other hand, methadone and suboxone are, indeed, about substituting one drug for another. The idea should be that once heroin use is no longer an option, the person will come off methadone and resume a drug free life. But, a lot of the time, that point isn't reached for years and years. I think that overall there has been a more active effort to taper people off methadone in the last decade or so.

Kleiman tried to make a point about the overall ineffectiveness of treatment. I quite wasn't sure what he was trying to get at, in part because Pollack kept interrupting him. I will assume that what Kleiman was trying to say is that if the person isn't motivated for treatment, the only treatment that will work is that which is based on punitive consequences of use. So, he seems to be pointing at motivation/ desire for treatment. And indeed, people who have strong addictions have to be motivated for treatment (developing skills to stay away from drugs in spite of the strong physiological urges to use, or the strong psychological craving for a high/relief of some other unpleasant mental state), or coerced into not using.

The issue of motivation is key. Treatment programs try to give everybody an opportunity, because "you never know". And indeed, there is a balance between strength of addiction, external pressures, internal motivation, pre-existing skills, expertise of the treatment team, treatment approach and how treatment matches the needs of the person seeking it. But, the reality is that the stronger the motivation the more likely it is that there will be success.

Anecdotally I make the distinction between a highly motivated person, and someone who, well, is just bullshitting.

Person A: " I can't continue to do this. "X drug" is killing me. It's destroying my life and my family. I'll do whatever it takes to stop. I can't go on like this."

Person B: "Yeah, okay, I'll give the program a try. After all, I have nothing to lose. It would be nice if I could, you know, stop or cut down using "Y drug". It'll save me some headaches. I'm not doing this just because of my probation officer. The only problem I see, is that I don't know that I'll be able to make it three times a week. I have to get a ride, and my friend sometimes forgets, and I don't like to depend on public transportation. Taxis are expensive, and the bus leaves me on the other side of the mall... "

I think you get the picture. It would be rather easy to save resources to send person B to do some soul searching and come back when he/she's ready. But, person B is being mandated to treatment. The poor results seen in statistics about results of treatment are due in great part to people like this. Simply not ready, not willing to do what it takes. It would make sense to work on motivation first. Some programs have that preliminary step, others mix it with the rest of treatment. But in this situation, coercing person B into maintaining sobriety may be effective if maintained long enough and supported by ongoing treatment.

In terms of cost/benefits, I would have to defer to the discussants. I would imagine that they know what they're talking about and that indeed the cost is low considering the benefits.

Lastly, Kleiman mentioned in passing the situation in CA with medical marijuana. Indeed, this comes back to the discussion in the other thread, just to confirm that marijuana dispensaries are a joke.

Interestingly there wasn't much discussion about legalization. The conversation was about treatment and enforcement of prohibition. It would have been interesting and informative to have someone discuss the topic from the perspective of legalization, since it seems to be a recurring topic.

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

Thanks for your thoughts.

I think it's interesting to develop practices that would address motivation in Person B types. That's the kind of nuance in treatment approaches that I think Kleiman doesn't pay much attention to because he's mostly interested in the law enforcement bottom lines. I get that perspective, but I'm concerned that it is sometimes incompatible with a patient-centered approach.

Your take on long-term methadone addiction ("maintenance") is one example. For Kleiman, as long as the junkie is not mugging, tricking or dealing to support her habit, it's all good. From the public health standpoint, it's also probably a win, but for the individual a lifetime on methadone does not constitute recovery from the disease.

I too was happy to see Kleiman dismiss the "medical" marijuana business as a "racket," which is the same term I used to describe it in the previous thread, much to the ire of a couple of other commenters.

I thought the discussion of the Colorado initiative to legalize was interesting, in that both Mark and Harold seemed to agree that if it passes (or if a similar CA initiative were to get on the ballot and pass), it would be a game changer nationally.

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

There are some therapeutic approaches that address motivation directly, avoiding the traditional confrontational style of addiction treatment modalities. Motivation can be addressed in other ways as well, but this particular approach has become quite popular due to its contrast with confrontational techniques.

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

The conversation about the drug violence in Mexico and what to do about it was gripping. Why is that? For me I think it's because we talk about the drug violence like it's rational behavior. Like it's part of the business because the business is illegal and implying that it could change quickly if we changed the incentives. I don't know if that's true, but somehow it's more exciting to talk about than other horrible and deadly dynamics on the globe. I'd like to hear Mark and Harold's thinking about what to do about the sex/slave trade. Is there any hope there?

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

One thing missing from the discussion is the "Why?".

Mr Stutman also shared with his audience another story; a Prep School senior described the sensation of using narcotics as "feeling embraced by his mother".

Not everybody feels that, most people that are exposed to opiates in the absence of pain get nauseated and even vomit.

One of the theories of the origin of morphine addiction in the USA was the Civil War and wounded soldiers that were given morphine kits to relieve pain, some caught in the opioid "rapture" and became addicted.

Most of the narcotic overdose deaths in the US are directly related to prescription narcotics, not illegal heroin contraband. More people will die from prescription narcotic overdoses than from accidents.

Some Physicians have not been adequately trained in the proper use of narcotics and have inadvertently made some patients addicts.

"48 hours" produced an episode that illustrates some of the dark aspects of improper narcotic prescription: http://www.cbs.com/primetime/48_hour...odes&play=true

Some individuals will seek the narcotic embrace, they are afflicted with a true medical illness that can be treated safely with narcotic agonists or partial agonist/antagonists, only 25% of them can be completely weaned off all narcotics, unless their privileged livelihood ( Anesthesiologists, Commercial Pilots are the best examples) is in jeopardy. These individuals can be treated with monthly Vivitrol injections that block any opiates ( http://vivitrol.com/ ), this is not for everyone, there is trial and error process.

Most of my patients were spending between $200-$1,000 a month on narcotics, many times, they were using narcotics just to prevent withdrawal sickness, the average maintenance dose of Suboxone is 12 mg, forty five doses retail cost around $7-$12 each dose, $315-$540 a month, add a routine office visit charge and the medical management is a cost effective and safe alternative. Methadone is a different story, I don't know the finances for that treatment.

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

Suboxone prescription has become a business, at least here in New Jersey. Physicians who prescribe it charge at least $100-$200 (cash, no insurance accepted) to hand a prescription on a monthly basis. Originally the idea of suboxone was, as far as I know, to taper people off opiates. "Maintenance" is a tricky idea. I personally think that maintenance should only mean slower taper.

I've seen young adults who have been using heroin for 6-12 months, and then go on suboxone and plan to stay on it indefinitely. Why? Their opiate addiction wasn't too established to justify long term use of suboxone. If there are psychological/ psychiatric factors contributing to the addiction, those should be addressed. But, there's no rationale for maintenance when someone has a very short exposure to opiates.

The use, abuse, and dependence on prescription narcotic pain killers and sedatives (benzodiazepines especially) is a major problem. These are actual examples of legal drug use and dependence. Accidental overdoses, and the deleterious effect on quality of life and the profile of side effects from long term use of these medications point at their dangerousness. And we have very little resources directed to preventing this problem or providing treatment. The standard substance abuse programs may not be appropriate for a lot of these patients who have never used any illicit drugs and don't connect well with heroin or cocaine users.

I've been seeing an increasing number of patients who have been maintained on benzodiazepines (Xanax!) by their PCPs for years. Now that there's growing awareness of the problems related to abuse and dependence, those PCPs are referring their patients to psychiatrists to figure out what to do. I've seen quite a number of women in their 80s, who have been taking Xanax for a couple of decades, they are experiencing break through anxiety, but now nothing else works. Xanax has increased their tolerance to other potential measures, both pharmacological or psychotherapeutic. As they get older the risks of cognitive decline, falls and fractures, disorientation, problems with sleep and rebound anxiety related to the use of benzodiazepines increases. At the same time the risks of withdrawal (autonomic instability, seizures, delirium tremens) increases. What to do? Those patients wouldn't be accepted in a regular detox unit due to age and medical problems. An outpatient taper more often than not doesn't work because the patient comes in already symptomatic (anxiety) and the taper will increase even if moderately those symptoms, so they can't tolerate the taper. Most of the time the only expeditious solution is to have them admitted to the hospital by their PCPs, and detoxed under medical supervision. But neither patients nor PCPs are very willing to do it. I usually inform them of their options, make my recommendations and send them back to their PCPs. There's nothing much that I can do as long as they continue taking those drugs.

It's sad and frustrating. One of the worst iatrogenic problems that we have these days.

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

In my area some Physicians charge $100 a visit, cash, sometimes weekly. I may delude myself, but Karma will get everyone. I don't think it is fair for anybody to charge legally the same or more than what an addict spends on the street to justify medical safety. The Physician in those cases is becoming the drug dealer with a license.

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

Yes, I agree.

I really don't know whether the $100 figure is weekly or monthly, but equally shameful. Those who seek those services have already figured that it is the same as going to a dealer, but they can do it in bright light. Similar to marijuana dispensaries in California. It sanitizes the addiction.

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

Is the author an ER Doc or NP?

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

I know of a specific practitioner who charges $100 biweekly, so those figures are right in line with what I've observed. There's a requirement to attend a pro-forma "group session" with each visit and no pressure or even advisement - that I've witnessed - to taper the suboxone dosage. Dozens of people show up for each session, which are held three three or four days a week. Prescriptions are recommended to be filled at a pharmacy less than a mile from the worst drug corner in my city (at which there are thriving black markets for both suboxone and clonazepam [which is apparently always prescribed in tandem with the suboxone]) It's an ugly racket. I think it's slightly preferable to a methadone clinic, though.

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

There are several death case reports from France involving buprenorphine.

There were US death cases when IV buprenorphine was combined with IV benzodiazepines, the respiratory depression could not be reversed with naloxone and some lucky patients survived on the ventilator until the drugs wore off, the unlucky ones were discovered too late to do anything...

2/3 of my Suboxone patients are also chronic pain patients, with radiologic or objective medical evidence of pathology. I bill their insurance if they have it, I have a few "self pay", I monitor their urine every visit and have no guilt if I dismiss anybody that uses other narcotics or benzos. My patients are grateful and repeat how Suboxone saved their life.

One of the "National Experts" stated you only need 4 mg to treat any withdrawal, 8 mg takes care of most "cravings" and 12 mg saturates almost all receptors, most of the time anything above 12 mg goes "on sale".

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

Probably nurse. They are the ones on the front lines, and many tend to really, really resent "seekers." What I see as a volunteer a few hours a week is that the concept of addiction as a disease hasn't really taken hold (except for lip service). Nurses often feel that addicts are pseudo-patients who are taking the place of "real" patients, and physicians are all over the map. Some are too easy to hit up for prescriptions, others get into a pissing contest with the addict and don't want to be "outsmarted" or "made a fool of," others provide compassionate care consistent with best practices.

It's so hard with addiction not to view it in some sense as a moral failing (despite all the science to the contrary).

Also, the ER personnel are right: addicts DO increase wait time and reduce quality of service for other patients. And they can be very expensive, costs which get passed on to other payers. For example, malingerer addict comes in with "the worst headache of my life." This symptom, apparently, can be indicative of a very serious condition and requires major workups, costing thousands of dollars and tying up scarce equipment and resources. Same for shortness of breath, seizures, etc.

Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)
 

Just like any other human being trying to do his/her job, doctors and nurses resent when someone comes to them, not seeking their advice, but rather lying and trying to find ways of manipulating them for their purposes. Sometimes, it's possible to get through to the person and find a way to communicate more honestly, but sometimes, really the person has no interest in medical advice or recommendations. Technically speaking, they are not patients under the care of a doctor, but rather someone who is trying to use the doctor's prescribing privileges for other purposes. The other purposes are most frequently to continue an addiction or to obtain medications that can be sold in the street.

I usually try to be as straight forward as I can, and I tell patients that I'm willing to work with them if they are open to accepting my recommendations. But if they are not, I can't really help them. To some I recommend counseling first, or going to a drug program.

By the way, I'm referring to those seeking sedatives. I don't treat pain.

Gingrich-Kleiman 2012
 

It would make a great ticket! Mark and Newt have so much in common. I have yet to see another public figure that oozes condescension and paternalism like these two. And their slogan? Making the patriarchy smarter.

Every time I have heard Kleiman speak on drug policy he throws a phrase or two that reveals his contempt for drug users. This time it was whether pot smokers could put the bong down long enough. This kind of animosity where the policy makers have to be neutral, erodes objectivity and damages their credibility.

Re: Gingrich-Kleiman 2012
 

Good to meet you wandering around the lonely halls of BHtv this Christmas! Since you seem to have a keen interest in economics I am wondering what you would think of this article I read last night...Dangerous Waffle. I need to reread it probably more than once but I found it quite educational and hopefully somewhat accurate. What say you?

Why is it necessary for policy makers to be neutral?

Re: Gingrich-Kleiman 2012
 

That is pretty long and Cato criticizing Krugman does not really inspire me to delve into it. I will do sometime in the future but if there is a specific point you wish to discuss let me know.

What would you say if the person recommending immigration policy hated immigrants??

Re: Gingrich-Kleiman 2012
 

That's too bad, but hopefully you will be inspired sometime in the future. If it is a critique it's certainly not the kind Krugman habitually lays on people with whom he disagrees.

I don't care how they feel about immigrants of they can solve the extant problems. Besides just because Kleinman recognizes that drug addicts like to get high doesn't mean he has contempt for them.

Have you ever heard George Carlin or Robin Williams talk about addicts? I doubt they have contempt, but rather are very familiar with the personality.

Re: Gingrich-Kleiman 2012
 

No you misunderstood me, Cato is "the" libertarian think tank and I think I know what they have to say about Krugman ...

Kleiman is not recognizing that drug addicts like to get high (which is not a point really, nobody gets hooked on broccoli) and it was not the way Carlin or Robin Williams talk about addicts either. I have watched Kleiman talk about this and I think he is not neutral about drug users at all. And objectivity is important, to make it clearer let me give you a more extreme situation: do you think having a racist in charge of immigration policy is a good idea?

Re: Gingrich-Kleiman 2012
 

But you are conflating neutrality and objectivity.

A tossed off remark seems a very narrow indicator for some wide ranging contempt assumption.