You’re Sick and You Almost Died, So Don’t Come to my Wedding
Jul09

You’re Sick and You Almost Died, So Don’t Come to my Wedding

The other day I heard from a friend about his son who has addiction. There was a recent overdose on opioids in which he almost died. Luckily there was someone with him to get him help, and he survived. He’s now in treatment and doing well. I was glad to hear he was doing well, but what really struck me in the conversation was that after word of his overdose had gotten around the extended family, my friend’s son was uninvited to his cousin’s wedding. You’re probably asking why, and I’d love to tell you. I don’t know why. My friend didn’t know why. Were they afraid he’d make a scene and stop breathing during the reception? Where they afraid he’d vomit on the wedding cake? Where they ashamed he was a person with addiction? I have no idea. But the first thought I had when I heard the story was the title of this article: “You’re sick and you almost died, so don’t come to my wedding.” That’s what overdose in someone with addiction means. It means they are ill, and now they almost died, if they’re lucky. Of course a lot, and increasingly so, aren’t so lucky and do die. Would we ever call up Aunt Sally during her breast cancer chemo and tell her not to come to the wedding? Would we call up cousin Sal and tell him that after his recent near death experience with diabetic ketoacidosis, we’d rather he stay home? No, we would not. In every other case, where a relative was potentially terminally ill, we’d welcome the chance for just one more family memory. Not so with addiction. I wrote recently about what people with addiction die of, the disease, ignorance, or cruelty. Too many have to live that way too. Hopefully, one day, we will be able to say that more and more people with addiction live with health and hope and love. Until then social isolation will continue to make the illness worse (the biology of this is described in my book) and we’ll continue to wonder why these addicts don’t just learn from their isolation. “After all, if we were snubbed, we’d change, right?” So we try to stem that ignorance every day. Just keep telling people you know the truth about addiction. It’s just an illness. It’s just biology. It’s just an act of nature. It just happens. If enough people understood, perhaps we could get to health, and hope and love.   Copyright 2016 Howard C Wetsman...

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Goodhart’s Law and Addiction
Jul07

Goodhart’s Law and Addiction

In a previous post I wrote about Goodhart’s Law in relation to prohibition. I want to give another example of Goodhart’s Law with addiction, this time with opioids. In a recent report making the national media rounds, Senators have written a letter to CMS, the government agency responsible for Medicaid and Medicare. The letter states that there is growing anecdotal evidence that surveys regarding pain scores are causing doctors to prescribe more opioids. Well, yeah, but this is Goodhart’s Law. “When a measure becomes a policy, it ceases to be a good measure.” CMS measured pain scores. They wanted to improve pain scores. So they instituted the policy that pain scores should go down. Pain scores ceased to be a good measure of quality of care, and instead became the driving force for increased prescription of opioids. By the way the same thing is happening with patient satisfaction scores and the intimidation of doctors who actually feel they’ll lose their jobs if opiate seeking patients write bad reviews of them. The real problem isn’t opioids or pain. The real problem here is the system’s response to the problem. Without ever trying to find the root cause of the problem, they just declared, “Solve the problem.” You just get another problem. I’ve written before about TOC and its usefulness in addiction here and here. This is another good example of where TOC could help. Instead of fixing what the problem looks like on the surface, we could use the TOC thinking processes to find the underlying common cause. We can then plan out how to affect the change and foresee the negative outcomes. Before implementing, we could address the negative outcomes and create an even better plan for change. But that, unfortunately, is not how large organizations like government work. And it is unfortunate, because where TOC is used we see remarkable change very quickly. I would like to see addiction go away tomorrow, and while even that isn’t possible with the TOC thinking processes, using them would make it happen a lot faster than it’s happening...

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A Study From PNAS
Jun12

A Study From PNAS

I just read a piece in Quartz, an international online news reporting service. The article is entitled “A new study of 250 million patients shows medicine is still full of guesswork” and reports on a study published in Proceedings of the National Academy of Sciences. The study makes some assumptions they don’t tell us about. What the study does is aggregate the medical data from 11 sources in 4 countries in a standard way. It’s a great Big Data project and may tell us much. This study of that data though is a study of treatment pathways, and they found interesting things comparing the treatment pathways of diabetes, hypertension and depression. Really the point of this study was to show that study of this issue in an international way is possible and I applaud them for that, but they draw conclusions that go way beyond the data. Here’s a quote from the article “The pathways revealed that the world is moving toward more consistent therapy over time across diseases and across locations, but significant heterogeneity remains among sources, pointing to challenges in generalizing clinical trial results.” They go on to point out that in the case of diabetes over 90% of people get the same first line medication, but that things aren’t “so good” in hypertension. The basic assumption in the study is that what should be happening is that everyone with one of the complex chronic illnesses, all three of which have multiple causes, should get the same first line treatment. And in fact the study shows that over time, more and more people with these three illnesses are being treated with the same first medication. The authors feel this shows an improvement of medical insight. I wonder how many of them have actually practiced medicine. When I read that 90% of people in four countries with adult onset diabetes were started on the same medication my first thought was, “Wow, which one? I bet they have a great marketing department.” It might seem like because Type II Diabetes is a single illness it should have a single treatment, but it doesn’t have a single cause. Illnesses for the most part are final common pathways of multiple pathways. We cannot assume that everyone with the same diagnosis needs the same treatment. What the study actually shows is that medicine is being practiced more and more by fiat of large organizations. Over time doctors are picking the treatment the insurance company wants you to start with, or the one with the best advertising, or the one the government endorses. This was not the case for thousands of years. Dr Osler...

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Modern Monetary Theory and Addiction

I was in a debate this morning on twitter about the validity of Modern Monetary Theory (MMT – not to be confused with Methadone Maintenance Therapy in this post), but ran into problems with the 140 character limit. For those of you who don’t know, MMT is a theory based on government’s monopoly of excreting fiat currency as a basis for an economy. Basically MMT says that money is what the government says it is. If the government wanted us to pay our taxes in chocolate, we’d use chocolate for money. But the government wants Federal Reserve Notes (or their bank deposit equivalents) and so that’s what we use as money. It’s a compelling theory that fits the facts of our lives today and has gotten a lot of followers lately. The point I was trying to make in my twitter debate was that the flaw of MMT, the thing that makes it not something to base long term predictions on, is its original assumption. That assumption, that money is money because the government says it is, might be true today in America, but it isn’t always true. In fact, it isn’t even true most of the time in most places in our history. The word money comes from Jupiter Moneta, a temple at the center of Rome which was used as a mint. The ancients saw money as part of the natural world. It was a gift of the gods like trees, rivers, and thunder. You could use it, you could modify it, but you could not have total dominion over it. And you certainly could never forget its natural power. Greek myths are replete with examples of mortals who, in their hubris, denied the power of nature. Man can control nature to an extent, but as soon as he thinks he has it licked it’s game over. Money is money because several billion interdependent economic actors all making decisions about what is best for them bring about its emergence. Money is an emergent property of a complex natural system. There have been many forms of money over many thousands of years, many governments that went along with them, and many governments that tried to deny money’s emergent nature. So my point about MMT was that money isn’t money because the government says it is, at least not always and in all circumstances, and when governments forget money’s natural force, it’s game over. So what does this have to do with addiction? Addiction is an illness, a natural phenomenon. It emerges from nature because of forces that aren’t in our control as individuals or as a professional field....

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The Big Short
Jun06

The Big Short

By now, most American’s have heard of the book, The Big Short by Michael Lewis, and the movie of the same name. (To short is to sell something you don’t own because you believe it will go down in price or value a great deal) Most people know that the book is about people who saw the collapse in the housing market before it happened and made money from it. That’s not really what the book’s about. The book is about how hubris and cluelessness of government officials and establishment organizations allowed imbalances to get so great that when they finally balanced (as imbalances always do) the entire financial system was at risk. The fact that individual traders saw the imbalances and acted on them should be no surprise. What is a surprise is that those very traders tried to tell people something was wrong. They went to the rating agencies and told them they were wrong; they went to the big banks and told them they were wrong; they went to the government and told them they were wrong. The reaction of all these people was that the traders didn’t know what they were talking about. “How could they know?” the establishment seemed to say. “The system had worked just fine all these years. Who are they to tell us that there are hidden costs that we don’t see?” Well history has decided who was right and who was wrong on that score, and it was an expensive lesson for all of us. The problem behind the Big Short was the assumption that housing in America could never go down across the country at the same time. It hadn’t happened for over 70 years, so it couldn’t happen, right? As long as it didn’t happen, even the crappiest sub-prime mortgage bond would be good. Turns out the assumption wasn’t true, the bonds were worthless, and the pyramid of derivatives built on them were as well. Is there a “big short” in addiction today? Is there a situation in which entrenched establishment groups or regulators are so sure they are right that they can’t see the hidden costs of their system? Is there a situation based on an assumption so old that no one today can question it? I think there is, and it’s also about 70 years old, but that’s long enough for generations of academics and clinicians to have been trained by people who were trained by people who were trained by people who assumed that this was the truth. The Big Short was a best selling book with hundreds of thousands of copies in print. There’s another bestseller that is...

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