Do Drug Rehab Programs Work?

Our journal club, where we read the month's New England Journal of Medicine among a group of doctors from various specialties, now starts every article by examining not the names of the authors, or an examination of the universities from which they generated their studies, but a look at who sponsored the study--many if not most "investigators" are now funded by drug companies to assess the efficacy of the drug the company is trying to market. So if the drug is made by Merck, then Merck sponsors a group at Harvard to run a study to see if it works. 

As Upton Sinclair said, "It is hard to bring a man to understanding if his salary depends on not understanding."

One Squirrely Slide--coming from the NIH!

I now feel the same way when I read papers on the question of whether or not our approach, or our various approaches, to treating drug addiction are effective.

Even the web site of the National Institute of Health's National Institute of Drug Abuse reads like something between a marketing plan and  a legal brief more than an dispassionate examination of data.

Money spent on drug rehab programs, the site tells us, is far less than it would cost to incarcerate drug addicts.  We are also shown a bar graph which shows that during the time an addict is in the program, he stops  using drugs, but he relapses almost as soon as he quits.  The NIDA tells us, this is acceptable, if you think of drug abuse like hypertension; it never disappears. You have to continue treatment for life.

But the problem is: What is your goal?
If your goal is to get the drug fiend, as addicts call themselves, to stop using drugs forever, then what the NIDA is saying is, forget that. It's like alcoholism: You will always crave that fix.

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But if your goal is to reduce the illnesses associated with drug abuse: HIV/AIDS, hepatitis and subacute bacterial endocarditis, then treatment programs, most particularly clean needles, do that effectively.

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Whether drug rehab programs reduce drug overdose deaths is tough to say. 
If you are running a program, and one of your clients overdoses and dies, do you say, well, we failed? Let's record that as a failure, and make your statistics look like you are a worthless organization running a failing program, or do you say, well, that guy dropped out of our program a week ago--his death is not on us.

The question is: What do we do? Just give up? 

I would say we should do what Portugal did: Legalize drugs and treat addicts as a public health problem.

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Of course, that's not easy in a for profit, commercial health care system like ours.
You really need a government health care program for that, because drug addicts are going to make every bottom line in every ledger look bad, from ER visits, to hospitalizations to deaths.

Getting Real About Guns

If I had my way, there would be no privately held guns in the United States.
But, if I had my way we would have no drug addiction and I would be twenty pounds lighter when I wake up tomorrow morning. Oh, and I'd have a full head of hair and be twenty years younger.

Sadly, none of the above will ever happen.


Now about guns:  My father in law was a lifetime member of the NRA. He got his first rifle age 12 and hunted in the fields around his home in Utah. He kept several locked lockers full of guns in his basement. He kept notebooks on each gun, with targets shot with holes by each and careful notes about the gun's characteristics: At 150 feet this gun pulls to the left 1 inch, etc. 


He was appalled by the idea a gun is any good at defending you in your house because the home invader has a weapon more powerful than any gun: surprise. He thought the most likely outcome of a bedside gun was some family member would someday be shot with it. Guns at home were kept locked.


He raised his three sons and his daughter (my wife) to be good shots. In fact, he was pleased that for a few years, his daughter was rated higher than any of his sons at the skeet shooting range and she was listed in some rifle magazine as some sort of hot shot.

But he spent his life in the military, where, he noted no solider was every allowed back from the shooting range without the same number of spent cartridges as he was issued before he went shooting targets. The military tightly controlled bullets lest one of the recruits had it in for his drill instructor, as in "Full Metal Jacket."


If we restricted gun ownership and home possession, we would likely cut down on deaths among children shooting themselves or others at home and we might cut down on suicides by gun, although it's an open question whether we'd cut down on suicides by other means.

We may not prevent mass shootings by lunatics.  The reasons for this are obvious: A guy who plans out his mass shooting by booking a room plus an adjoining suite, rigging up hallway surveillance cameras, fits out his guns with bump stocks,  is not likely to have much trouble collecting guns of mass destruction.  As anyone who has read "The Friends of Eddie Coyle" knows, the trade in illegal guns is not much more inhibited by law than the sales of illegal drugs.


Beyond the sportsman and gun aficionado who was my father in law, I've met plenty of men who love talking about their guns in New Hampshire. Most of these guys are small or very obese or simply physically unimpressive men for whom a gun is their ticket to instant respectability: I may look like a loser, like a nobody, but put a gun in my hand or on my hip and you've got to respect me, because I might just kill you.

Big gun is the surrogate for big penis. 


Those are the guys you have to pry their gun from their cold, dead fingers, because they need that gun so.


For some of these guys, its a thin line from an inferiority complex and fragile ego to a shooting rampage, but they may go their whole lives without crossing it.
They are the guys who worry us, however. Ordinarily, they get through the day, but all it might take is that one very bad, no good, terrible day, when their car is rear ended, their boss fires them for being late to work and they go home to find their wife in bed with the mailman.

We do not need bump stocks and we do not need legislators packing heat in the State House to show what tough guys they are and we do not need guys at political rallies carrying assault rifles. All that can be legislated away, just as soon as we assure our gun loving fellow citizens, they can keep their security blankets.

What Would Victory Look Like in the War on Drugs?

Kima: "You motherf***kers kill me. Fighting the drug war one brutality case at a time."
Carver:"Girl, you can't even call this a war."
Kima:   "Why not?"
Carver: "Wars end"

Exchange between Detective Kima Greggs and Police Sgt. Carver, "The Wire."


Sgt. Carver

Det. Greggs

As   Sgt. Carver observes, the "Drug War" is an endless endeavor.  You do not settle things decisively with one battle, which is, of course, why like the "war on cancer" and the "war on terror," it's not really a war at all but a metaphor of a struggle, a conflict which we would like to win but never will.
So it is with drug addiction.

Alcoholics say, "I'm an alcoholic. I've been sober 30 years," to emphasize that demon is always with them, no matter how long they've kept it at bay.

When the National Institute of Drug Abuse (an institute within the National Institute of Health) defines "success" in treating drug addicted patients it says its goal is returning patients to function, to a viable place in society.  The NIDA does not talk about eliminating drug overdose deaths as a measurable outcome, or curing patients of addiction. They talk about managing this disease over time, as you would any chronic disease, like hypertension or diabetes.

No cures; Relapses as soon as the patient leaves the program

When critics say drug rehabilitation programs "don't work" or fail, the NIDA says, well, that depends on what you mean by failure. No the rehab programs don't cure addiction, but they help people manage it.

Van Gogh, Wheat Fields with Cyprus

The reason America has turned its attention to the "opioid crisis" is that we are seeing more deaths and more deaths among white middle and upper class children. This is really an epiphenomenon.  Heroin addiction has always been out there and often among the affluent as well, but dead bodies have a certain insistence; you cannot cover up a death the way you can an admission to the hospital for drug detoxification. Fentanyl, a lethally potent opioid has caused the surge in deaths. That's what's new. The addiction problem is nothing new.

EMT's interviewed on NPR, who are on the front lines, complain they are called back six times to administer Narcan to the same addict who has overdoses yet again. Why are we doing this, they ask? What have we accomplished?

What irritates me is the unexamined assumptions I hear politicians and other pundits use:

1/ If we only cared more about these addicts, we would not see widespread addiction.
2/ If we only cared more about these addicts, we would not see all these overdose deaths.
3/ Caring more is expressed as spending more money on:
a/ Drug rehabilitation programs in and out of the hospital
b/ Hiring more people to be "drug rehabilitation certified" experts and advocates.
c/ Funding more programs in schools to "educate" kids not to use drugs or be attracted by the drug culture. Of course programs like "DARE" proved to be an utter failure and when it was examined for results it was such an abject bust, they discontinued it even in affluent counties which could afford it. The drug pundits say that's because it was only for grade school and middle and was not continued into high school. No, actually, that's because kids in an counter culture, bad boy mode are not going to be scolded into acquiescence by adults. 
d/ Putting Narcan rescue containers in ambulances, schools, airports, subways, you name it.
e/ Fund needle exchange programs so addicts can get clean needles



It is entirely understandable how  frantic parents become when they learn their kids are stealing opioids from them or from others and using them.
To say we are taking the wrong approach to managing drug addiction in this country is not to say we should do nothing, just give up on the addicted.



In the case of intravenous use, you get a whole separate set of diseases: heart valve infections, hepatitis C and HIV.  This could be addressed by a functioning health care system which included things like needle exchanges.



But this public health program has never been accepted as a public health problem. Big shots want to jail users and dealers alike.



Portugal has found a solution with measurable results. After legalizing the use and possession of drugs, HIV, hepatitis C and endocarditis rates, once the highest in Europe plummeted to the lowest by far. But that meant drug fiends, as they call themselves, were not jailed or scolded but simply treated in a national health care system.

But in our for profit, commercial health care system, what insurance company wants to take on the expense of drug addiction? Who will pay for these fiends?


There are some ugly truths out there. The fact is, most middle to upper class folk cannot even bring themselves to watch "The Wire" where these problems are most clearly delineated, much less to actually act to make our government develop humane and sensible and cost effective policies.

Doing the Opioid Crisis Rag

Heard a talk from a former New Hampshire House of Representatives Rep, a physician, about the opioid crisis and about all those deaths from Fentanyl in New Hampshire which earned us a shout out from President Swamp Boy about New Hampshire being a "drug infested den."

He showed a slide which showed that New Hampshire, second in the nation in drug deaths, is 49th in spending on drug rehab programs, the suggestion being that if we only weren't so cheap, and valued the lives of these people who are using opioids, we could save them. 

He did not have a slide which showed the expenditures of the other states on the X axis and drug deaths on the Y axis: In other words he did not know if the states which spent the most money on drug rehab programs had fewer deaths, and if this correlation exists is this because there are fewer drug deaths in richer states because when people are rich and have a lot to live for, they don't take drugs?

Of course, there are lots of stories of affluent white kids dying of drug overdoses, but the reasons for that are not well examined, as far as I can see.

A little defensive, are we?

The National Institutes of Health has a National Drug Abuse Institute and on this site they attempt to answer a Frequently Asked Question: Do drug rehab programs actually work?  Intelligently, the authors say, well it depends on what you mean by a program "working." They feature a graph showing that during the actual treatment program, those enrolled in drug rehab programs have fewer drug overdoses, but afterwards a sizable number return to drug use, in about the same proportions as people who are hospitalized for asthma continue to need treatment for asthma and people hospitalized for type 1 diabetes need ongoing treatment.
Oh, that's reassuring. 
Really, what they are saying is like alcoholism, heroin addiction is for life and you need constant attention.

This answer stinks strongly of self interest, the bias of a group of practitioners whose salaries depend on the notion that what they are offering is effective.

Of course, every time the deaths of young people are presented to politicians, they run for cover and talk about the government programs, the spending they are directing at the problem.  This is a shield for the politicians, but as far as I can see, there is precious little evidence these programs or expenditures actually prevent drug deaths in the medium to long run. 
It reminds me of the point in the diabetes lecture when the guy says, well, of course, you have to refer your patients to a registered dietitian and everyone in the audience is thinking--oh, good, now I can wash my hands of that obligation. But, of course, the nutritionists have nothing effective to offer: Well, count your carbs and eat what is pictured on this poster and you will notice absolutely no benefit at all. 

It may be dated, and it is focused on the inner city drug culture, but "The Wire" presents a detailed discussion and depiction, which if people actually watched the 5 seasons, would convince most of them what we are doing and calling "drug rehab" is insanity.

There was an old cynical jibe at the cancer hospitals: More people make a living off cancer than actually die of it.  When I listened to the programs mentioned tonight, involving certification of Drug Rehabilitation Coaches and in patient facilities and outpatient clinics, that came to mind. Lots of people cashing in on the efforts to treat drug addiction and drug deaths are benefiting. The patients, not so much.

Portugal has taken an radically different approach to drug deaths and drug disability: It decriminalized drug use and drug possession and treats addicts as patients.
They still prosecute drug dealers, oddly enough. Not sure how they do this.
But deaths from drug use related HIV, subacute bacterial endocarditis and hep C diagnoses have plummeted in Portugal. 
Until we actually want to face the uncomfortable truths in America about what drug use means, and how we should regard drug abusers, we likely will spend money foolishly, and we'll pat ourselves and our politicians on the back and ignore the real problems and their solutions and the deaths and associated diseases will continue.

Until liberal politicians take a hard look at reality, engage in tough minded analysis of what we call "drug rescue programs" they will continue to look like opportunists who always have an easy answer, and no credibility.

Justice Scalia and A Well Regulated Militia

If ever you need a good laugh, or if ever you need a good cry, or if ever you need something to get your blood boiling and your brain exploding, just to reassure yourself you are actually still alive and capable of outrage, or if you simply want to reassure yourself that mental masturbation was alive and well among the justices of the Supreme Court in June, 2008, go on line and read Justice Scalia's opinion which reversed centuries of Supreme Court precedent and delivered the right of any half witted citizen the right to buy, possess and use firearms in the comfort of his own home. Not just firearms, but specifically hand guns.

The case is "Heller v District of Columbia," and, to Scalia's credit, he begins with the "prefatory phrase" which he agrees is "unique" in the Constitution, in that it is the only place in either the Amendments (Bill of Rights) or the articles where the founders (of whom Scalia is enamored to the point of ancestor worship) actually explain why they are granting and defining a "right."

Scalia has a real problem here and over the next 10 pages or so he tries to wriggle out of his dilemma with allusions to what the country was like in those days when gods in powdered wigs roamed the land and wrote the Constitution, which, next to the Bible, is the holiest book on earth, handed down engraved originalist parchments, which may or may not have been in gold plates, buried and then rediscovered--I'm not sure, I may be mixing up the Bible with the Constitution or the Book of Mormon.

The problem, of course, is that the founding fathers did not always write with the precision and clarity of Madison, but sometimes more in the ornate and blurry style of Hamilton, who may have written like he was running out of time, which is to say, voluminously, but who often could have done us all a favor if he had taken time to edit.  But, in the case of the Second Amendment, they took care to say, okay, this might sound a little crazy, but since we have no standing army and the only way we have of defending our new nation is these local militias made up of men who have a flintlock above their mantle places, we have to assure that no government, like the King's government we knew in the early part of the 18th century, will come by and demand citizens hand over their guns.

After all, we need those militias, as long as they are "well regulated."  The founding fathers, note, did not shrink from that idea of "regulations."  (Donald Trump would not have done well as a founding father. )

Of course, for Justice Scalia, it's always a question of "What would Jesus do?"  or, in the secular case of the Constitution, "What would Jefferson and Madison have said?"

So he gets to arguing with Justices Stewart and Ginsburg over the meaning of to "keep and bear"  arms.  He digs out his 1773 edition of Samuel Johnson's dictionary (you cannot make this stuff up) and after several wearisome paragraphs he grapples with Justice Stevens' observation that James Madison, in his original draft of the Second Amendment adds a conscientious objector clause "but no person religiously scrupulous of bearing arms, shall be compelled to render military service in person."

Well, this is a problem for Justice Scalia because it reveals quite clearly what the founding fathers really were talking about--they were talking about arms as a part of an armed service, a regulated militia, not some nutcase who is stocking up his own arsenal hoping to arm all the Indians in a revolt against a whiskey tax.

But Scalia quickly dismisses all this evidence with a breezy well, this was a rough draft, and we can't be imputing motives or causes to rough drafts.

But the deed was done--this was all about military arms, military service not guns for personal use.

Scalia then entertains the folks with the observation that Catholics convicted of not attending service in the Church of England were penalized by losing their "rights to keep arms in their houses."  Scalia is never one to miss the opportunity to talk about Catholics or their history. 

The real question is, of course, do we want to live with what we regard as a living Constitution or with a secular Bible--if we prefer Bible, then we are in pursuit of knowing the mind of God, or in the case of the Constitution, the minds of gods.

It's entertaining, no doubt, for Scalia to skulk around looking for copies of a 1773 dictionary and to speculate about what Madison was really thinking, but the outcome of Scalia's prejudged decision, that he was determined to find a way to allow anyone who likes guns to own and use them, no matter what, is that we are left with a nation in which mass shootings by lunatics are visited upon people at concerts, movie theater goers, elementary school children, people on streets, people in churches and any place of congregation, all because we have some overstuffed Justice of the United States Supreme Court, who doesn't give a damn.

I suspect that when Roger Taney wrote his opinion in the Dred Scott case, he started, as Justice Scalia, with the end point, where he wanted to go--no slave can sue in the Supreme Court for his freedom--and he got there by similar exercises of thought contortion--oh, he cannot sue because animals cannot sue in the Supreme Court, nor can vegetables, only human beings, only men (and, on a generous day, perhaps women) may sue in the Supreme Court. This is called "standing." Slaves, dogs and pigs have no standing to sue in the Court.  Given that pretext, all the rest follows.

And now, given the faces on the current Court, that is where we remain.

A Well Regulated Militia

A well regulated militia being necessary to the security of a Free State, the right of the people to keep and bear arms shall not be infringed.

These guys look like what Mr. Madison and Jefferson had in mind.


But these guys are what the Supreme Court had in mind:

Nobody cares much about these guys.

Swamp Boy Strikes Again.

Swamp boy says the mayor of Puerto Rico is disrespecting him, but the problem really is the Puerto Ricans won't help themselves. 

Their electric grid is third world and they aren't real Americans. All they do is vote and serve in the military.

Some of them don't even respect the flag.

If the Dotard had a golf course down there, he'd have crews out there cleaning up right now.

There'd be so much winning.

And, oh yes, he hasn't forgotten how to fire people. 
Tom Price, who says he has always put the public first, who cares more about patients and other people than he cares about his own comfort was pushed out for flying in Gulf Stream luxury jets at taxpayer expense, $400,000 worth.

Got to give the Dotard credit, he acted fast. 

Betsy DeVos flies her own private airplanes. She is in no danger. She's going to make public schools private. Now that's real initiative. So much winning!

Swamp boy wants to play quarterback for the Redskins this Sunday. There'll be so much winning, Redskins fans will get bored.

But that name. Really a failing franchise name. New name:  Rednecks. Go with a winner. 
Hail to the Rednecks. 
Hail Victory.
Drain that old Swamp!
Fight for old D.C!
Run or pass and score. 
Return to burning coal once more!
Beat 'em Swamp 'em.
Touchdown! Let the points soar!
Hail to the Rednecks
Hail Victory.
Klan on the Rise Now!
Fight for Fantasy!


Here's an alternative fight song, from Randy Newman:
https://www.youtube.com/watch?v=j5mue4uDHNQ

I feel so much better.