Research: Opportunity or Applied Science?

05/16/11

In a recent article in the Addiction Professional (e-newsletter online exclusive for 05/11/11), Editor, Gary A. Enos,  writes:

“A New York Citydrop-in center serving homeless young people is finding that the medication buprenorphine can be integrated successfully into a broad-based harm reduction strategy targeting injection drug users.

“TheLower East Sidelocation of the Streetwork Project has been working with the Suboxone formulation of buprenorphine for the past three years. Counseling and case management are the core services of the Streetwork Project, explains program director John Welch, and the site also houses a syringe exchange program.

“Because the Streetwork Project is not governed by an abstinence model but by a broader effort to improve social functioning and quality of life for a group of street-involved young people, treatment of opioid addiction is highly individualized to each client’s condition. Welch reports that he often hears very positive comments about buprenorphine from the clients who are taking it.

“Some say, ‘It’s like it was before I did heroin. I feel normal now,’” says Welch.”

—-quoted from—-Addiction Professional 05/11/11

Usually, programs such as this are funded for one to three years, and the research helps us to know what works.  What concerns me for this population is that we do a lot of research that only incidentally translates into standards of care.  I worry when tight times come, and something has to be trimmed from the budget: are folks in the program going to be faced with tough choices: ‘return to using what you did before you found this program, finance your own medication assisted therapy, or get straight?’  Each choice is fraught with its own difficulties, time-frame, and support needs–none of which can be jerry-rigged into place by a treatment system under duress.

As research targets, folks with the disease of addiction are easy prey.  In the popular view: “They put themselves into that shape; and they can’t expect the taxpayer to foot the bill forever, can they?”  Every addiction research document needs to begin with a careful explanation that addiction is an illness that happens to folks in the same way that the incidence of heart attack occurs: familial risk factors, system stress, inauspicious habits or practices layered into ineffective coping strategies, and opportunity, opportunity, opportunity.  None of these factors is entirely controlled by the affected individual. Recognition of the harmful effect at the nexus of these factors is the first thing an individual must learn—beyond the shadow of a doubt—before s/he may be expected to get better.  That may follow years of treatment.  The “bottom” need not be in the Bowery.

Unless this program (though wonderful and aimed in the right direction) does a bang-up job of saying why it is both therapeutically and fiscally correct to put buprenorphine into future budgets dealing with homeless “individuals with more stable mental health profiles and those with less polydrug use … the best candidates for buprenorphine”—I am afraid it is just one more experiment in the right thing to do!   There is a point when the right thing to do becomes a moral obligation.  Right now, when the death rate in all age cohorts is at an all time high due to drug- and addiction-related causes—failure to operationalize an opportunity to save lives is irresponsible and immoral.  We are past the point when we “don’t know what to do.”   We are daily discovering serendipitous pieces of information that may be worked into standards of practice so that at-risk populations may be positively affected, and lives saved.

One that immediately comes to mind is the fact that the Center for Disease Control has concluded that there is no such thing as safe use of concomitantly prescribed opiates and benzodiazepines.  This fact is emphasized daily by burgeoning death rates–many from opiates in deadly combination.  Where is the public outrage?   Where are the strong black box warnings about such concomitant use?  Why do doctors still write such scripts, and/or pharmacists fill them?  Is the drug using population simply a research opportunity for corporate America?  Our drug using culture creates the inflation that we are seeing in addiction incidence.  Until we, all of us, change the social ethic from benign observation to concerned intervention—we must accept responsibility for creating the social and cultural downspin—the death dance—that a drugged culture creates for us.     Peace!  Jim

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