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Abstract
This point-of-view presentation explores “stakeholders” and “opioid substitute treatment,” their dimensions, selected enabling necessary conditions to operate, or not, implications, and consequences from a range of selected perspectives.
THE AUTHORS
Stan-Shlomo Einstein, Ph.D., is a clinical and social psychologist, student, academician (emeritus), and researcher. He has been a journalist (newspaper and radio) and editor/author of 28 books. He has been the journal editor and founder of journals such as Substance Use and Misuse, Drug Forum, Social Pharmacology, Violence, Aggression and Terrorism; and Altered States of Consciousness. He has also been a consultant, lecturer, conference and training program organizer, and a volunteer. He has received several awards including the Pace Setter award, NIDA, and the Mayor of Jerusalem Outstanding Volunteer Award. His areas of interest include among other things the parameters of failure.
Notes
1 The reader is referred to Primo Levi for a stimulating consideration of this important concept. Levi, Primo. The Drowned and the Saved. Trans. Raymond Rosenthal. New York: Vintage International, 1988.
2 The following “Whiskey Speech” was delivered in the Mississippi House in 1952 by Noah S. “Soggy” Sweat, Jr., a multiple SH (former state legislator, lawyer, district attorney, circuit court judge, and college professor) when the House was debating legalizing liquor … which was illegal in Mississippi years after Prohibition had ended in the USA. The state collected what was called a “black market” tax on alcoholic beverages totaling millions of dollars. This speech has been considered as being a prize example of policy maker's “double talk”; another face of “drug”-related semantic surrealism
You have asked me how I feel about whiskey. All right, here is just how I stand on this question: If, when you say whiskey, you mean the devil's brew, the poison scourge, the bloody monster that defiles innocence, yea, literally takes the bread from the mouths of little children; if you mean the evil drink that topples the Christian man and woman from the pinnacles of righteous, gracious living into the bottomless pit of degradation and despair, shame and helplessness and hopelessness, then certainly I am against it with all my power.
But, if when you say whiskey, you mean the oil of conversation … the drink that enables a man to magnify his joy and his happiness and to forget, if only for a little while, life's great tragedies and heartbreaks and sorrows; if you mean that drink, the sale of which pours into our treasuries untold millions of dollars which are used to provide tender care for our little crippled children, our blind, our deaf, our dumb, our pitiful aged and infirm, to build highways, hospitals, and schools, then certainly I am in favor of it. This is my stand. I shall not retreat from it. I will not compromise
3 The interested reader is referred to Boots and Milford (Citation2007) which is one of the few community stakeholder studies in the literature.
4 intervention (n.) early 15c., “intercession, intercessory prayer,” from Middle French intervention or directly from Late Latin interventionem (nominative interventio) “an interposing,” noun of action from past participle stem of Latin intervenire” to come between, interrupt,” from inter- “between” (see inter-) + venire “come” (see venue). www.etymonline.com
5 This metric—which ranks journals by the average number of citations their articles attract in a set period, usually the preceding two years, was originally developed to help librarians make subscription decisions. It has become a proxy for the quality of research. Its built-in flaws include: being able to be skewed by just a few papers; failing to account for the differences between fields; its potential to be influenced by editors and authors; and its focus on what journal a study is published in rather than the content and quality of the study.
6 The reader interested in the history of treating narcotic-addicted drug users with addicting medicines in the USA and the UK is referred to Terry and Pellens (Citation1928), Berridge (Citation1980), and Musto, (Citation1987).
7 Slow Food is an international movement founded by Carlo Petrini in 1986, in Italy, as an alternative to “fast foods.” It began as an attempt by “stakeholders” to resist the opening of a McDonald's near the Spanish Steps in Rome. It currently has approximately 100,000 members in 150 countries. Many of its followers also seek an alternative to the pressures of the contemporary “fast life.”
8 The reader is referred to reviews about “crack babies” (Okie, Citation2009; Winerip, Citation2013) which summarizes the use and misuse of the original published data, of limited generalizability, in the prestigious New England Journal of Medicine by a range of health, media, politicians, and other professionals to shamelessly describe and prognosticate that which did not exist. The original study, Chasanoff, Burns, & Scholl (Citation1985), was based upon 23 premature babies born to cocaine and other drug-using mothers in the USA. These stakeholders had the power, an almost daily presence, position, status, and mass media-based technology to construct, transmit, and sustain, as a reality, an unchallenged, nonexisting medical, social, economic, political, etc., “problem.”
9 Another “reason” often given by, and for, a stakeholder's position is “common sense”. This phenomenon is not that common with regard to human judgment and decision-making. All-too- often it can be, and is, arbitrary, capricious, unreasonable, politically motivated, unsupported by generalizable evidence—credible scientific justification at that time—and is inadequately assessed in terms of immediate and longer term micro to macro consequences and implications. More “common” is a stakeholders’ dissembling of facts and figures! What, for example, are/can be the implications—and for whom—of making a medicinal (methadone, buprenorphine, morphine, pharmaceutical heroin, “medical marijuana,” “medicinal alcohol”) available and accessible, or not, as a therapeutic, by doctor's prescription or as an “over-the-counter” status? The relevant policy or law presumes decisions of expert regulatory agencies regarding the: (1) safety of the drug as well as (2) efficacy of the drug as an indicated treatment. What types of expertise are necessary to make assessable, repeatable, evidence-informed decisions—(or to maintain arbitrary ones)—about opioid substitute treatment policies for a relatively new socially constructed and medicalized “disease”? Or for diagnosing acute or chronic pathology? Health? Addiction? Dependency? Habituation? Risk taking? Risk management? Recovery? Relapse? Harm reduction? Treatment as a: philosophy, a value, a norm, an ethic, a human right, a process, an adjudicated opportunity, a punishment, etc.? Judgment? Decision-making? Compliance? Well-being? Quality of life? Conflict resolution? Change agents? Control agents? (ADD Specify: ). The types and qualities of “necessary expertise”, and the “experts” raises the challenging nonscientific issues of WHO gets the final say in such matters, and based on what? “Substitute treatment” has been, and continues to be, as well as not to be, many things to many people and systems.
10 US federal officials, systemic stakeholders, frustrated that people continued to consume a great deal of illegal alcohol even after it was banned, by the 18th Amendment to the Constitution, planned and implemented a different kind of Prohibition enforcement. Industrial alcohol manufactured in the United States, which were stolen and resold by bootleggers as drinkable spirits, was poisoned as a government policy. Why? To scare people into giving up illicit drinking. To “purge” alcoholism. An example of “for the common good.” By the end of Prohibition in 1933, the US federal poisoning program, by some estimates, had killed at least 10,000 people. This “chemist's war of Prohibition” is rarely noted or remembered. It is interesting to note that the law banned the manufacture, sale, or transportation of alcohol, and not its consumption. This gave rise to “medicinal alcohol,” maintained “sacramental alcohol” and even legally-defined alcohol to meet the interests of stakeholder farmers. The reader is referred to a brief description of the poisoner–stakeholder intervention “service”, by Dr. Deborah Blum in http://www.slate.com/ articles/health_and_science/medical_examiner/2010/02/the_chemists_ war.single.html Slate February 19, 2010, or in her book, Blum, D., 2010, The Poisoner's Handbook: Murder and the Birth of Forensic Medicine in Jazz Age. New York) New York: Penguin Press
11 Consider “guilt by urination” as an empowered stakeholders’ justified, socio-politico-theological-driven-ritual, to achieve absolution, cleansing, and purification.
12 The reader interested in exploring stakeholder “harm-production” during an era in which OST has been introduced as a harm-reducing process is referred to: Elovich, R. and Drucker, E., (2008), On drug treatment and social control: Russian narcology's great leap backwards. Harm Reduction Journal,5:23. http://www. harmreductionjournalcom/content/5/1/23
13 The reader is referred to Hills's criteria for causation as a helpful, critical review of the complexities of “cause and effect” relationships. These were developed in order to help assist researchers and clinicians determine if risk factors were causes of a particular disease or outcomes or were merely associated. The nine original criteria include: strength of association, consistency between studies, temporality, biological gradient, biological plausibility, coherence, specificity, experimental evidence, and analogy. (Hill, A. B. (1965). The environment and disease: associations or causation? Proceedings of the Royal Society of Medicine 58: 295–300.).
14 Consider the following narrative, and caveat, shared by Scott Seely, a Microsoft executive who noted that de facto standards occur in many different industries. A long line of de facto standards cooperated to dictate why the NASA space shuttle engines are a certain size. The engines are crafted to be able to ride on trains from one side of the country to another. The width of train tracks is the same throughout the United States, and tunnels have certain minimum heights and widths. So, the engines have to fit through those tunnels while riding on a train car. Nobody got together to decide how wide the tracks would be. Instead, the first trains were created based on widths common in Europe.The distance between train tracks in Europe happens to be about the same width as the wooden rails that supported horse-drawn wagons in mines. No group got together to decide how far apart to place the wagon wheels or rails. The distance between wagon wheels is the same width as what the chariots’ were that the Romans used all over the Roman Empire, which at one time stretched into England. The width of those chariots was determined by the wheelbase used for chariots that had two horses, side by side. No group collaborated to decide how wide a horse's backside should be. We laid thousands of miles of track all over the United States (and other places on Earth), and the width of the track was based on a de facto standard—which ultimately dictated the size of NASA space shuttle engines—the width of a horse's backside! What have been, and are, the consensualized standards of opioid substitute treatment, and its associated policies and what are they based on?
15 The reader is reminded that with the advent of artificial science and its theoretical underpinnings (chaos, complexity, and uncertainty theories), it is now posited that much of human behavior is complex, dynamic, multidimensional, level/phase structured, nonlinear, law-driven, and bounded (culture, time, place, age, gender, ethnicity, etc.). Opioid substitution treatment, agenda and policy making, and drug use, misuse, etc., however they are defined and delineated, would be such behaviors/processes. This is not a semantic issue. There are two important issues to consider and which are derived from this: (1) Using linear models/tools to study nonlinear processes/phenomena can and do result in misleading conclusions and can therefore also result in inappropriate interventions; (2) the concepts prediction and control have different meanings and dimensions than they do in the more traditional linear “cause and effect” paradigms (Buscema, Citation1998).
16 This concept, created by a Yale psychologist (Keil, 2006) describes a process of “transmitting ” a superficial understanding of how complex systems, such as pharmacotherapeutic treatment with opioid drug users work. When one hears or reads this term, or its three letters (OST), by pro or con drug user treatment stakeholders, one feels that we understand IT. That is, until we are asked to explain how OST actually works; confronting us with how little we actually know.
17 This acronym has been attributed to Lockheed aircraft to lead engineer, Kelly Johnson which expresses that simplicity should be a key goal in design and unnecessary complexity should be avoided. This principle is said to have been exemplified by the story that Johnson gave a team of jet design engineers a handful of tools, with the challenge that the jet aircraft which they were designing must be repairable by an average mechanic in the field under combat conditions with only these tools. The KISS that OST stakeholder policy makers use, pro as well as con, all-too often, does not have the same intent. Wikepedia
18 Please refer to the list of selected terms at the end of this point-of-view; p. 29.
19 The interested reader is referred to Tilly (2006) Why: what happens when people give reasons … and why, which posits that commonly given reasons—the pros- and cons of stakeholders—can be usefully categorized into four overlapping categories: (1) conventionally accepted reasons in which there is no need for noting any “cause and effect” relationship; (2) stories which rework and simplify complex social events, processes, outcomes, and relationships, sensitive to who is “responsible” for … and which are effected by the type of relationship; (3) codes—which represent rules, legal judgments, secular or religious traditions, etc., and (4) technical accounts, often “evidenced” by “experts”—self identified or by others—in which “cause and effect” is a central theme. Convention and stories are “popular reasons”; codes and expertise are technically based; conventions and codes are “formula” -driven,; stories and expertise transmit “cause and effect” relationships. For example, setting a minimal age and demonstrated failure in previous treatments as regulatory criteria for methadone treatment (MMT) is a “nonevidence-informed tale meeting a stakeholders’ beliefs. Pushing for, or against, “harm reduction” as a unique drug user treatment ideology—in a world in which people and systems violate “the other” daily, and brush their teeth soon after waking up—in order to “promote” dental health can be a nosological issue when MMT patients can, and are, humiliated with “guilt by urination” and little interests in their dental condition as part of being a whole PERSON and not just being and related to as titrated MMT—SUD's. A series of letters combined, created, and driven by professionals which can't, and don't, represent real people—whatever their chemical solutions for the problems and issues of daily living.
20 Another example of semantic surrealism in the field of “drugs,” however defined, is their broad range of users as well as nonusers—both representing heterogeneous and not homogeneous populations of PEOPLE, and the many types of interventions. Consider: Active or inactive chemical “substances” are used or misused; living organisms are and can be abused.
21 The following tale, associated with a 7th century Caliph, “catches” the potential strength of available and accessible mediation. The 18th Camel, There was a father who left 17 camels as the inheritance for his three sons.When the father passed away, his sons opened up the Will. The Will of the father stated that the eldest son should get half of 17 camels while the middle son should be given 1/3rd (one-third). The youngest son should be given 1/9th (one-ninth) of the 17 camels. Since it was not possible to divide 17 into half, or 17 by 3, or 17 by 9, the three sons started to fight with each other. So, the three sons decided to go to a wise man. The wise man listened patiently about the Will. The wise man, after giving this thought, brought one camel of his own and added the same to 17, increasing the total to 18 camels. Reading the Will again he gave half of the 18 camels (9) to the eldest son; 1/3 (6) to the middle son, and 1/9 (2) to the youngest son. All of this added up to 17 camels, leaving one camel, which the wise man took away. The challenge for effective policy negotiation, mediation, and problem solving is to find the “18th camel,” i. e., the common ground. A necessary condition to reach a viable solution is to believe that there is a solution. If we think that there is no solution, we won't be able to reach any. The reader is referred to http://www.ted.com/talks/william_ury.html for a helpful presentation of this by the Harvard anthropologist Dr. William Ury.
22 Consider the following definition, noted by the American science writer, Robert A. Heinlein, of a specialist or expert the next time you come across the term addiction “expert” or “specialist”: “A human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly. Specialization is for insects.”
23 MAT, medically assisted treatment; OST, opioid substitute treatment; ORT—opiate replacement therapy
24 The “backfire effect” is a term coined by Brendan Nyhan and Jason Reifler to describe how some individuals when confronted with evidence that conflicts with their beliefs come to hold their original position even more strongly.
25 Treatment engagement, or therapeutic alliance, is generally defined in behavioral terms as the intensity and duration of treatment participation. Additional critical dimensions include the quality of the relationship as well as a commitment to agreed upon goals via a mutual involvement with the “other”, over time. Consider that, rarely, if ever is the “change agent's” and treatment SH's engagement or therapeutic alliance considered or researched. I would greatly appreciate having references sent to me about research in this area;[email protected]
26 A traditional review of the literature, of policies, etc., will note, in variations: “found,” “discovered,” “documented,” etc. Rarely is the reader, listener, viewer presented with some type of Resource Table which would enable him or her to determine the generalizability of what is being presented, including its limitation and a range of critical unresolved issues. Consider the following potential “template” for exploring the effects of MMT “take-home” policies, for example: Author, Yr, Country, Hypothesis, Critical concepts, Underpinnings (theory-based, evidence-based, etc.) Type Population, Number, Control Group(s), Data Sources (Instruments Used) Type Data Collected, By Whom, Where, Type Data Analysis, Findings, Implications, Ethical issues, Study's Limitations, Critical Unresolved Issues.
27 This points up a stakeholder-related paradox. A drug user who is part of a legal, legitimate treatment is covered by the Americans with Disabilities Act (ADA) originally made into law in 1990 and then revised in 2009. This act states that no public agency, etc., can discriminate against someone for getting treatment for addiction among other things. While alcoholism and drug addiction are both disabilities under the ADA, they are, in some respects, treated differently. An alcoholic is protected by the ADA as having a disability. A drug addict is protected provided they are not currently using illegal drugs. But also consider that “persons addicted to drugs, but who are no longer using drugs illegally and are receiving treatment for drug addiction or who have been rehabilitated successfully, are protected by the ADA from discrimination on the basis of past drug addiction.” A shading of stakeholder, semantic surrealism.
28 The reader who is interested in looking “at things sideways,” from a totally “alien” perspective is referred to Viktor Shklovsky's concept of “disfamiliarization” as a useful option for relooking at the known. www.vahidnab.com/defam.htm. John Ruskin, the British artist, suggested toward the end of his first volume of Modern Artists in 1843 to young artists that they go into nature: “rejecting nothing, selecting nothing and scorning nothing.” A useful and apropos guideline for getting to know the “nature” of any drug user, as a person, as well as nonuser, and for the initial setting of the essential dimensions of an effective drug user's treatment agendas, goals, and policies. Frank Sinatra, singing Neville Powell's and Horace Hinds’ “Getting to Know You” can be background enhancement as one considers what needs to be considered.
29 This form of naltrexone, approved by the FDA in 2010 for the prevention of relapse to opioid dependence (a process no longer considered in the new DSM-V, 2013), following opioid detoxification, is injected intramuscularly once a month. It had been approved by the FDA only for the treatment of alcohol dependence in 2006. Dr.Nora Volkow, Director of the National Institute on Drug Abuse (NIDA), and a major drug user treatment stakeholder, has noted that the obvious advantages of Vivitrol are that the drug user does not have to be motivated to be active in a treatment process and program, and the ever-present “trigger” effects of “craving” and the much-expected relapse to drug use. The drug user treatment agent also does not have to be “motivated” given that WE only need to intramuscularly “see” THEM once a month.
30 “The man of system, on the contrary, is apt to be very wise in his own conceit; and is often so enamored with the supposed beauty of his own ideal plan of government, that he cannot suffer the smallest deviation from any part of it. He goes on to establish it completely and in all its parts, without any regard either to the great interests, or to the strong prejudices which may oppose it. He seems to imagine that he can arrange the different members of a great society with as much ease as the hand arranges the different pieces upon a chessboard. He does not consider that the pieces upon the chessboard have no other principle of motion besides that which the hand impresses upon them; but that, in the great chessboard of human society, every single piece has a principle of motion of its own, altogether different from that which the legislature might choose to impress upon it. If those two principles coincide and act in the same direction, the game of human society will go on easily and harmoniously, and is very likely to be happy and successful. If they are opposite or different, the game will go on miserably, and the society must be at all times in the highest degree.” Adam Smith “Theory of Moral Sentiments” (1759) VI.II.42
31 As I complete revising this presentation, I read that the Chinese government is creating a policy-driven mega-event. Its outcomes will surely be associated with the “law of unintended consequences” in terms of immediate and future social disorders including drug use(r's) and their treatment, including OST, mental health, suicide, etc. China has an estimated 12 million drug users (Swanstram, & He, 2006). Over the next 12 years—until 2025—it will be urbanizing 250 million of its rural population; almost 19% of its current total population (Johnson, 2013). So as to avoid the effects of “numerical illiteracy,” in which numbers lose meaning and impact (Paulos, Citation1988), consider the implications of changing the lifestyles and life space of the total populations of 26 of the world's largest populations over the next 12 years: Athens, Barcelona, Madrid, Berlin, London, Paris, Moscow, Rome, Tokyo, Buenos Aires, Istanbul, Cape Town, Manila, Mexico City, Sao Paolo, Sydney, Toronto, Montreal, Boston, Chicago, Dallas, Miami, Los Angeles, New York, Philadelphia, and Seattle in terms of effects upon individuals and systems.
32 In a visit, during January 2013, to San Patrigagno, a large drug user therapeutic community in Rimini, Italy, in which 1,300 people lived, worked, “mutually aided” one another, and in which smoking was not permitted, I experienced a half a glass of wine being offered to each community member, as part of lunch and dinner, if s/he chose to include this with their meal. When in “Rome do as the Romans do”…so I “Rome'd” it…enjoying the taste of the wines which this TC makes from its own grapes as one of its sources of support. www.sanpatrignano.org
33 A treatment site's dimensions—its “social climate” and “personality”—includes a number of critical dimensions which are associated with planned change-treatment. These include, among others: (1) Relationship dimension, enabled or not; (2) Personal development dimension, (3) Maintenance and change dimensions, which can facilitate a person's capacity for effective responsiveness to the “demands” of spontaneous and/or planned change; (4) Emotional catalyzer dimensions; (5) Information catalyzer/processing dimensions; (6) Environmental perceptions, attitudes, and values dimensions—the extent to which an affective bond, between people and place or setting, is “demanded,” facilitated inhibited, and/or prevented; (7) Problem-solving/ adaptational dimensions, and (8) Dimension definer—sets and defines boundaries: who and what is in↔ out; permitted↔ forbidden; included↔ excluded; role status increaser, modifier, diminisher, reinforcer; permitable closeness↔ distance, availability↔ unavailability, accessibility↔ inaccessibility (Bachelard, Citation1964; Tuan, Citation1974). As OST SH's have pro-ed and con-ed, about doses of the medicinal “natural” or man-made addicting narcotic, age-constraints, urine, hair, or saliva drug use testing, “take-home” privileges, and even making, or not, injection rooms available with THEIR drugs and OUR equipment, the actual treatment environment dimensions have not been a policy issue—locked safes for security excluded. Nor has this been a research issue.
34 The reader is referred to Musto (Citation1987) and Terry and Pellens (Citation1928) for a description of the range of stakeholders which enabled initiating and operating morphine maintenance of drug users in 43 clinics in the USA and the stakeholders who succeeded in closing them. The story about the Shreveport Clinic, in New Orleans, 1919–1923, is a well-documented account.