Guest blog by Lorie Hammerstrom, SMART Recovery Lead Onsite Trainer

Substance misuse is not a new problem. Neither is being trapped in a cycle of a negative behavior(s) that have to be addressed in order to live a balanced and healthy life. Teens and young adults are no exception when it comes to battling addiction to substances or compulsive behaviors.  

SMART provides teens and young adults the self-empowering, no shame, no blame support they need and deserve. The stigma around addiction and the fear of being judged as powerless and labeled as an addict, alcoholic, etc., often prevents young adults from seeking help. 

Similarly, teens and young adults can feel overwhelmed at the thought of having to attend a recovery support group for “the rest of their life.” The fact that SMART supports participants attending only as long as it’s helpful is attractive. This means they can recover.   

The modern solution that has resonated with teens and young adults is SMART’s peer-support program. It uses a self-empowering approach to addiction recovery with a focus on what it means to people in recovery. Life experiences, points of reference, and ways of relating to others can be significantly different than in a situation where interaction takes place with others who may be 5, 10, even 20 years older. 

We’ve found that the approach that includes similar perspectives and our 4-Point Program® resonate with young adults by providing a relevant context. The 4-Point Program includes tools and exercises that help participants to: 

1. Build and Maintain Motivation
2. Cope with Urges
3. Manage Thoughts, Feelings, and Behaviors
4. Live a Balanced Life

Change can be difficult but is not impossible. In order to make changes a person needs motivation.  SMART Recovery tools and exercises can help focus and motivate. SMART’s tools also help to navigate through urges and build coping skills to avoid relapse.  

People often use drugs and alcohol to mask their feelings of low self-worth, negative thoughts, and unhelpful emotions. SMART Recovery helps teens and young people to change their self-talk and learn better ways of dealing with upsets. A balanced life is a life that makes one happy and fulfilled.  SMART Recovery teaches teens and young adults to set goals and find balance in life, clarifying goals and how to reach them.   

Other key points of the SMART Recovery program appeal to teens and young adults as well, including: 

• Religion-neutral 
• Tools for all stages of recovery  
• Topic-based meetings, which encourage discussion with peers 
• Run by qualified SMART facilitators  
• You can learn to maintain your sobriety by figuring out what’s important to you, setting goals, and finding healthy interests.  

If you are part of an organization that helps teens and young adults dealing with addiction in an educational or support setting, such as a high school, university, or recovery community organization, SMART will work with you to create a plan that meets your needs. Training options for SMART Meeting Facilitators include your choice of onsite group training (in-person or Zoom) or a convenient self-study online training option for individuals.  

Click here for information about in-person/group training.  

Click here to register for individual training. 

Let’s work together to benefit young lives! 

PLEASE NOTE BEFORE YOU COMMENT:

SMART Recovery welcomes comments on our blog posts—we enjoy hearing from you! In the interest of maintaining a respectful and safe community atmosphere, we ask that you adhere to the following guidelines when making or responding to others’ comments, regardless of your point of view. Thank you.

• Be kind in tone and intent.
• Be respectful in how you respond to opinions that are different than your own.
• Be brief and limit your comment to a maximum of 500 words.
• Be careful not to mention specific drug names.
• Be succinct in your descriptions, graphic details are not necessary.
• Be focused on the content of the blog post itself.

If you are interested in addiction recovery support, we encourage you to visit the SMART Recovery website.

IMPORTANT NOTE:

If you or someone you love is in great distress and considering self-harm, please call 911 for immediate help, or reach out to The National Suicide Prevention Hotline @800-273-8255, https://suicidepreventionlifeline.org/

We look forward to you joining the conversation!

*SMART Recovery reserves the right to not publish comments we consider outside our guidelines.*

This essay was also published by Scientific American on August 31, 2021.

The provisional drug overdose death statistics for 2020 confirmed the addiction field’s worst fears. More people died of overdoses in the United States last year than in any other one-year period in our history. More than 93,000 people died. The increase from the previous year was also more than we’ve ever seen—up 30 percent.

These data are telling us that something is wrong. In fact, they are shouting for change.

It is no longer a question of “doing more” to combat our nation’s drug problems. What we as a society are doing—putting people with drug addiction behind bars, underinvesting in prevention and compassionate medical care—is not working. Even as we work to create better scientific solutions to this crisis, it is beyond frustrating—it is tragic—to see the effective prevention and treatment tools we already have just not being used.

The benefits of providing effective substance use disorder treatments—especially medication for opioid use disorder—are well-known. Yet decades of prejudice against treating substance use disorders with medication has greatly limited their reach, partly accounting for why only 18% of people with opioid use disorder receive medications. Historical reluctance to provide these treatments and of insurers to cover them reflects the stigma that has long made people with addiction a low priority.

We must eliminate the attitudes and infrastructure barring treating people with substance use disorders. This means making it easier for clinicians to provide life-saving medications, expanding models of care like digital health technologies and mobile clinics that can reach people where they are, and ensuring that payers cover treatments that work.

The science of the matter is unequivocal: Addiction is a chronic and treatable medical condition, not a weakness of will or character or a form of social deviance. But stigma and longstanding prejudices—even within healthcare—lead decision-makers across healthcare, criminal justice, and other systems to punish people who use drugs rather than treat them. That approach may be simpler than asking us as a society to have compassion or care for people with a devastating, debilitating, often fatal disorder. But the risk of incarceration does not deter drug use, let alone address addiction; it perpetuates stigma, and disproportionately harms the most vulnerable communities.

Evidence-based harm reduction, such as syringe services programs, also need to be a part of any solution to our drug crisis, as these have been shown to reduce HIV and hepatitis C transmission, and help link people to treatment for addiction and other conditions. While the federal government has embraced evidence-based harm-reduction programs, many communities continue to resist them, erroneously thinking they sanction or encourage drug use. Multiple independent studies have shown that they don’t. Researchers are also evaluating innovative but historically controversial strategies operating abroad like overdose prevention centers, where people can use substances under medical supervision and access other health services, to evaluate cost-effectiveness and ability to reduce deaths and improve health.

Part of the failure of the current approach to the drug crisis arises from the unrealistic expectation that people should—and can—just stop using drugs. Little concern is shown for people with addiction unless and until they are drug-free, but the reality is that difficulties and resumed use typically mark the recovery journey. Compassion, care, and support need to extend to those still using drugs and those who return to drug use, not just to those who can satisfy the stringent standards of abstinence. Everyone with a substance use disorder, regardless of whether they are currently using drugs, needs good healthcare and may also need help with housing, employment, and childcare needs.

To prevent young people from misusing drugs and to keep people from all ages from developing substance use disorders, our nation must address the social and economic stressors that increase the risk of drug use, such as poverty and housing instability, unsafe neighborhoods and schools, and other effects of a changing economy including social isolation and despair. Drug overdose deaths are one component of the “deaths of despair” that, along with suicide and alcohol-related illness, have caused life expectancy to decline in the U.S., even before the 1.5-year drop in 2020 caused largely by the COVID-19 pandemic.

On the ground, evidence-based interventions can make a big difference: Universal prevention programs as well as interventions targeted to the most at-risk families and youth not only reduce the risk of later drug taking and addiction but have radiating benefits on other aspects of mental and physical health.

This poses a question of collective willingness to invest in these measures. The long-term savings in healthcare and justice costs relative to the costs of prevention interventions can be substantial. But they are long-term investments with benefits that will take time to accrue, and the nature of our society is to look at short-term bottom lines and expect immediate results.

Radical change to save lives is long overdue. It is crucial that scientists help policymakers and other leaders rethink how we collectively address drugs and drug use, looking to the evidence base of what improves health and reduces harms across communities, and funding research to develop new prevention and treatment tools.

As a GP in inner-city Glasgow in the 1990s, I looked after patients with heroin addiction. I got to know many of them well, I knew their families, I immunised their children and, distressingly, I saw some of them die. Because of the nature of general practice, I saw the dreadful impact of those deaths on their families and on their communities. Sadly, I saw few recover – in the sense of resolving their problems and moving on to achieve their goals. There was very little choice around treatment – though some wanted to attend the addiction clinic, many did not.

In the 2000s, our practice started a methadone clinic. It was called ‘shared care’ because they also attended the specialist service. Things got better for many and there was more of a sense of ‘doing something’. Apart from community detox (which was not infrequently requested), methadone was really the only choice on the menu. I am ashamed to say that my expectations were low. There was a feeling of ‘this is as good as it gets’. The idea of our patients accessing residential rehab wasn’t really in our minds and would have seemed fantastical. 

Alcohol patients would sometimes be referred by us to a local inpatient unit, be detoxed and then come home with little, if any, community support. Return to drinking was the norm. Back in those days, I had never heard the term ‘mutual aid group’ and would not have rated such interventions in any case. I had two patients that I knew about who went to AA, so that did get on my radar, but back then it was generally a case of ‘doctor knows best’. 

I certainly didn’t rate lived experience and while I listened to my patients and treated them with compassion, I can’t say there was any great element of us making decisions together. Looking back, I can see that there was a problem with my approach: it turned out this doctor who was making recommendations for treatment didn’t know much at all about addiction. My learning about addiction came about dramatically when addiction happened to me, but that’s a different story.

Fast forward a couple of decades and treatment is much better. The evidence base has grown, waiting times are said to be reduced and there is more choice. For those with opioid use disorder, we have methadone and buprenorphine. A newer, long-acting preparation of buprenorphine looks like, for some, it gives several advantages over tablets. We have much more widespread distribution of naloxone and a greater public awareness of addiction as a health issue. Several newspapers now support progressive policies to tackle Scotland’s appalling drug deaths in a way that would have been unimaginable in the 1990s.  

The MAT (medicated assisted treatment) standards set a high standard for treatment access and for choice of medication and for how long to remain in treatment. Nowadays, the concept of partnership is embedded:

“Person centred care-planning that focuses on personal goals, with services working in genuine partnership with people, will result in more effective care and a better experience for people using services.”

MAT Standards, 2021

However, this issue of person-centred care with the patient as partner is an aspirational one that is hard to achieve. The MAT standards, not unreasonably given the evidence base, start from a position that choice is about which opioid to commence. The ability to choose something other than MAT in a way that identifies and manages risks, offers mitigations, and supports safer routes to reach one’s goals, is not outlined. While the principle is person-centred, the standards are fundamentally driven by public health concerns. Again, very reasonable given our public health crises in drug and alcohol deaths.

At a presentation on the MAT standards a couple of months back, intrigued by the notion of individual choice, I asked about exit routes from treatment, given that the standards emphasise that individuals should decide how long to stay in treatment. The answer was that individuals could ‘go back to their GP for prescribing’ when they wished to exit specialist services. I was disappointed by that answer. It wasn’t really what I had in mind and clearly wouldn’t remotely satisfy those who want to move to abstinent recovery.

In the work we’ve been doing on behalf of the Scottish Government in the Residential Rehabilitation Development Working Group it has become obvious that meaningful choice in treatment is limited in many parts of Scotland. This week a national newspaper drew attention to the plight of someone wanting to move on from MAT who was allegedly told there was no resource to do this. The Drugs Policy Minister stepped in to help. 

It is certainly true from the evidence our group heard that access to residential rehab is not available to all and where it is available, the route to get there can be difficult to navigate. In terms of barriers, funding challenges and pathways are major issues, (if you are well-off, no problem) but so too are culture, attitude and the beliefs of individuals who may influence access. 

It’s a fact that some people in MAT want to move onto abstinent recovery via residential treatment. However, residential treatment is mentioned only once in the MAT standards, and that’s to identify risk rather than advise on how such transitions can be managed safely as part of a comprehensive treatment system. Is there still an attitude of ‘professional knows best’ when it comes to treatment choices? 

Choice and partnership in decision making are topical subjects. In JAMA this month, Yaara Zisman Llani and colleagues write in favour of Shared Decision Making (SDM)^[1]. They outline the principles underpinning this approach:

• Eliminating power asymmetries between clinician and patient 
• Acknowledging that there are at least 2 expert participants: a patient having lived experience expertise, a clinician having professional expertise, and sometimes a family member
• Eliciting patient preferences for their involvement in the decision making (autonomously, conjointly with clinician input, letting clinician make decisions) and eliciting the patient’s specific values that could guide the decision (eg, reducing medication adverse effects)
• Discussing at least 2 treatment options (eg, taking, tapering, or stopping antipsychotic medications)
• Making a decision that aligns with the patient’s goals, preferences, and values that also makes clear the risks involved in particular decisions
• Accepting that the patient’s choice of treatment plan may differ from the clinician’s recommendation.

The article addresses these goals as applied to psychiatry settings, but they are valid in addiction treatment and support too. How prevalent are power imbalances and how much weight is given to lived/living experience expertise? According to this research, Shared Decision Making is not happening much. The authors say this relates to clinicians’ beliefs that their patients are impaired and that this can be a form of stigmatisation, resulting in discrimination and ‘paternalistic decision-making’.

Their solutions are to introduce training on Shared Decision Making and create a level playing field with clinician and patient bringing expertise to the encounter where decisions around treatment are to be made. I think we can add to that by ensuring that clinicians are informed about all treatment options and understand them. Of course, the same should be true for our patients; we have a duty to explain the range of options.

If I examine my own practice, I think I am better at this than I used to be, though still have much to learn and relearn. I am much more aware of the authority that is afforded to me in my role and while I hold my own experience, beliefs, and biases, I am more mindful of how I need to find a shared space with the patient, while still being honest about the risks and mitigations. I do see patients who are impaired – particularly around lack of insight – creating challenges around how to navigate joint decision-making.

Decisions about treatment for opioid use disorder are not simple, but the principles around the making of those decisions ought to be. What is often missing when options are being considered is the need to make the link between what the patient and their family wants from treatment and the outcomes with which that particular treatment is associated, including those around quality of life. For instance, how often does rehab come up in discussions about treatment options? I’ve heard so many reports now about a desire to explore it being raised by individuals and their families, only for this to be dismissed by professionals. While this option may not be right for an individual at that time for a variety of reasons, it should be part of the discussion.

Another gap is almost certainly around how we introduce and effectively connect our clients to mutual aid and LEROs. (This is a real issue: the evidence base is strong and growing yet, when surveyed, less than 1% of service users in one Scottish city had ‘ever’ been to a mutual aid meeting.)

I have been, and still am, a proponent and prescriber of MAT, but I’m also a proponent of choice in treatment. If those of us who work in substance use disorder treatment keep the evidence base close (and seek to expand it beyond prescribing), understand the options, know how to mitigate the risks, and have shared decision-making at the heart of all we do, then those seeking our support and their families can only benefit from increased choice through joint decision making.

Continue the discussion: @DocDavidM

^[1] Zisman-Ilani Y, Roth RM, Mistler LA. Time to Support Extensive Implementation of Shared Decision Making in Psychiatry. JAMA Psychiatry. 2021 Aug 18. doi: 10.1001/jamapsychiatry.2021.2247. Epub ahead of print. PMID: 34406346.

Monica Forbes is a person in long-term recovery, a nationally certified Peer Recovery Support Specialist, an Idaho certified Recovery Coach supervisor, and a certified SMART support group facilitator. She currently serves as the CEO of Recovery United, Inc., which operates and supports Recovery Community Centers, a Recovery Coach program, and the Peer Supports Academy.

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Video storytelling is a powerful tool in recovery, and we are proud to share our SMART Recovery content free-of-charge, available anywhere, on any device. Our videos hope to inform, entertain, and inspire anyone in the recovery community.

Subscribe to our YouTube channel and be notified every time we release a new video.

PLEASE NOTE BEFORE YOU COMMENT:

SMART Recovery welcomes comments on our blog posts—we enjoy hearing from you! In the interest of maintaining a respectful and safe community atmosphere, we ask that you adhere to the following guidelines when making or responding to others’ comments, regardless of your point of view. Thank you.

• Be kind in tone and intent.
• Be respectful in how you respond to opinions that are different than your own.
• Be brief and limit your comment to a maximum of 500 words.
• Be careful not to mention specific drug names.
• Be succinct in your descriptions, graphic details are not necessary.
• Be focused on the content of the blog post itself.

If you are interested in addiction recovery support, we encourage you to visit the SMART Recovery website.

IMPORTANT NOTE:

If you or someone you love is in great distress and considering self-harm, please call 911 for immediate help, or reach out to The National Suicide Prevention Hotline @ 800-273-8255, https://suicidepreventionlifeline.org/

We look forward to you joining the conversation!

*SMART Recovery reserves the right to not publish comments we consider outside our guidelines.*

Anne Devenport sought help for a loved one in SMART Recovery’s Family & Friends program and fell in love with the program herself. As a retired schoolteacher, she now facilitates online Family & Friends and ToolTime meetings!  Anne is paying it back for all SMART has done for her. 

Watch on our YouTube channel.

Learn more about becoming a SMART volunteer.

Subscribe to the SMART Recovery YouTube Channel

Video storytelling is a powerful tool in recovery, and we are proud to share our SMART Recovery content free-of-charge, available anywhere, on any device. Our videos hope to inform, entertain, and inspire anyone in the recovery community.

Subscribe to our YouTube channel and be notified every time we release a new video.

PLEASE NOTE BEFORE YOU COMMENT:

SMART Recovery welcomes comments on our blog posts—we enjoy hearing from you! In the interest of maintaining a respectful and safe community atmosphere, we ask that you adhere to the following guidelines when making or responding to others’ comments, regardless of your point of view. Thank you.

• Be kind in tone and intent.
• Be respectful in how you respond to opinions that are different than your own.
• Be brief and limit your comment to a maximum of 500 words.
• Be careful not to mention specific drug names.
• Be succinct in your descriptions, graphic details are not necessary.
• Be focused on the content of the blog post itself.

If you are interested in addiction recovery support, we encourage you to visit the SMART Recovery website.

IMPORTANT NOTE:

If you or someone you love is in great distress and considering self-harm, please call 911 for immediate help, or reach out to The National Suicide Prevention Hotline @800-273-8255, https://suicidepreventionlifeline.org/

We look forward to you joining the conversation!

*SMART Recovery reserves the right to not publish comments we consider outside our guidelines.*

Forward: I first met Dr. H. Westley Clark. MD, JD around the year 2000, when I heard him speak at an event in Philadelphia. He has had such a huge positive influence work to move our SUD care system towards a recovery focus. He is still very active in the field in his current position as the Dean’s Executive Professor of Public Health at Santa Clara University in Santa Clara California. At the time he spoke back in 2000, he was the Director of the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Service, where he led the agency’s national effort to provide effective and accessible treatment to all Americans with addictive disorders. His Curriculum Vitae is among the nation’s most impressive. I have listed a portion of his professional life accomplishments in the paragraphs below.

Beyond his extensive achievements, one are of common interest and collaboration has been around federal SUD privacy laws and the importance of those laws and the accompany regulations to assure that people like us who experience a substance use disorder can get help without fear of consequences. Over the years he took time to show and teach me some of the nuances of these laws and regulations. He helped author the law 42 U.S.C. § 290dd-2 that answered the first question I asked when I walked into a treatment center in 1986. I needed to know what happens to the information I had to share to get well because drug use is illegal. He made sure that information was protected. His work in this area assured that the question could be answered in a way that made me feel safe enough to talk with the people trying to help me. Over the years, he has served as a mentor to me in respect to substance use privacy laws and regulations, he is a huge resource on this and many other areas. His mentorship has helped many of us and extend these protections to ensure the next generation can also be assured that their privacy rights are also protected.

In the course of our interview, I asked Dr Clark why he cared about those of who experience substance use issues so much. He reminded me of the start of his career, working in the Haight Ashbury section of San Francisco with Dr David Smith in the mid-1980s, he talked about his work with Methadone and being the medical director of clinics in several areas of the country and all he has done in his 75 years. The truth is that many others see what he saw in respect to the consequences of addiction, and they move on to a less stigmatized issue. He did not. He saw us, he saw our plight and he saw our resiliency and potential and he dedicated his professional life to working on our issues. Issues which have always been so highly charged with stigma and discrimination. It was apparent to me that the idea of not helping simply never occurred to him. I told him that beyond all of his academic and other significant life achievements, one of the things that made him such an exceptional human being is he really saw us – people with substance use issues. He committed to working with us and helping us over the course of his entire career. Unfortunately, people who see us and engage with us from a perspective of positive regard and collaboration remains more of an exception than the rule. The kind of commitment he has to our community is exceptional and is to be honored and acknowledged. We could use many more people like Dr H. Westley Clark.

Prior to directing CSAT, Dr. Clark was the former chief of the Associated Substance Abuse Programs at the U.S. Department of Veterans Affairs Medical Center in San Francisco, California and a former associate clinical professor, Department of Psychiatry, University of California at San Francisco (UCSF). Dr. Clark served as a senior program consultant to the Robert Wood Johnson, Substance Abuse Policy Program, a co-investigator on a number of the NIDA funded research grants. He worked for Senator Edward Kennedy as a health counsel on the US Senate Committee of Labor and Human Resources. A more complete bio is here.

• Who role did you have in helping ensure there was a Recovery Summit in 2001 in Saint Paul?

What we did preceded the recovery summit and starts with the Recovery Community Service Project, that was a priority of ours when I lead SAMHSA. This was an issue I cared a lot about and worked hard with others like Cathy Nugent to create. In the preceding years we started to become quite aware that we needed to have more than what could be offered in a traditional acute care treatment service model. The acute care model was just not cutting it. To do this, we needed to bring the resources of the recovery community into the picture. This has both service and broad advocacy dimensions. It was clear to us that we needed to invest more in long term support efforts and community strengthening efforts. So, we made it a priority.

I am sure that my experience working as a physician in the treatment space informed my own perspective. What do people do to support their recovery when the treatment center is closed? My office hours end at 5 PM, what do my patients have for support at 6 PM? What kind of support was available for families? What do people do on the weekends to support their healing?  

I had seen the power of recovery and what one person in recovery helping another had the potential to really change things if we funded it. With my work the Veterans groups I saw the value of one vet helping another vet. A similar model and advocacy dynamic has also unfolded in respect to HIV and the gay community organizing to help each other and to assert their basic rights. I realized that some of these very same dynamics could be leveraged to save a lot of lives in relation to substance use.

We also knew that public attitudes about addiction and recovery were not great. From a BIPOC perspective, we can say that there is a whole lot of hostility towards people experiencing addiction, with some groups experiencing more hostility that others. We have made some progress, but this is still the case today – there is a lot more to do to support recovery. At the time, we also knew that we needed to elevate voices of recovery and have the larger society see what people in recovery have to contribute, which is substantial. So we started the Recovery Community Support Project, which eventually became the Recovery Community Services Project because of some political considerations as federal administrations changed. We knew that starting the RCSP would mean that the Saint Paul Recovery Summit would be a natural outcome. It is a relatively small community; a lot of people were seeing the direction we needed to go and were willing to work together to make it happen. The work that SAMHSA did with its relatively modest levels of funding played a significant role in what transpired.

• What do you see that came out of your efforts at the time around the RCSP and the Recovery Summit?

We initiated a change in the sociological and philosophical view of addiction by emphasizing recovery! It is important to note that not all jurisdictions have or are necessarily supportive of recovery community organizations. We saw recovery as an organizing concept as I spoke about in this interview with Bill White back in 2007. This was true then and it is still true today. Changing these attitudes and making sure that recovery is seen as viable and supported is important for all of our communities. Our efforts at SAMHSA and what transpired at the recovery summit has served as a springboard to changing these attitudes and ensuring that recovery support and recovery community are prevalent across America. It is also important to note we achieved what we have with a relative meager amount of dollars, to accomplish more it has to be valued and it has to be funded. Take drug court funding as an example. They were getting 70 million when recovery was getting a fraction of that. Nothing against drug courts, it just shows the difference of priority, and we must value recovery and fund it in ways that get resources to our grassroot communities as this is where the work is being done!

We had people like Tom Kirk, Jr PhD, do tremendous things to build out recovery care systems. Although we lost Tom in 2020 he did so much to bring recovery efforts in communities to the forefront. Tom was the former Commissioner of the Connecticut Department of Mental Health & Addiction Services whose leadership transformed Connecticut’s mental health system and recovery efforts across the state. He was a pioneer in moving that system to a recovery-oriented system of care model and his influence was felt in the work we were doing. There were other people like Tom who were raising up the value of recovery and the power of recovery community in ways that helped, along with the writings of Bill White on recovery management to synthesize additional actions.

We also have not had benefactors like the large pharmaceutical companies funding MAT outreach efforts. What we have had instead is a motivated community that at the time was largely abstinence focused, but we helped widen that lens by emphasizing many pathways to recovery, which has led to a much broader sense of recovery as a result. Beyond that, we also stimulated the discussions that led to the creation of Faces & Voices of Recovery. If you think about it, a whole lot was accomplished with the meager resources available, and this is in part because what we were doing resonated with so many people in so many communities across America.

• What are you most proud of in respect to what was accomplished?

We grew something and allocating funds to recovery was a critical element. What was done helped stimulate a dialogue that has continued through present times. We helped show America that there were care models and supports that extended beyond the acute care models into our communities. Unless you were wealthy, short-term care is pretty much the only thing that was available before then, there were no community supports! The early efforts to bring recovery organizations together was mostly focused on abstinence-based models of recovery, but we were very cognizant that it was important to emphasize many pathways to recovery.

The work we did at SAMHSA went a long way to set the stage to change the dialogue by focusing on recovery. It was well worth the investment. What was very clear to me from my life experience as the medical director of programs in Michigan and Massachusetts and beyond is that we needed support for the holistic needs of all of these communities, including those using MAT pathways. My work in San Francisco helped prepare me for the opioid epidemic because we saw what happened there in that era, but we learned through things like the free clinic model to care for people as the focus of the work. We still somehow miss this as the core of what we need to focus on, even decades later.

Peer services in grassroots recovery community organizations are an integral element of a care system that meets people needs. We need to serve people with dignity and respect and offer assistance in ways that support their wellness, not just for a single substance or for an acute care episode but in ways that help them sustain growth in all life domaines over the longer term. Our efforts back then were fundamental to moving dialogue in the direction and to support these needs and beginning to value people who advocate for access to services that support their wellness in their communities.

• What did we miss if anything looking back at what you set out to accomplish?

I don’t think it is a fair question on some level. What was done was done by people operating on shoestring budgets. I don’t think we missed a thing. If we had more resources, we would have been able to accomplish more. We brought people together, we started recovery month, which is now celebrated around the country. We helped develop ways for people to talk about recovery and do outreach that had very positive ramifications. Recovery became visible and that began to change perceptions about what addiction looks like and more importantly, what recovery looks like.

There is certainly more work to be done. We need to have discussions about what happens when there is a resumption of use, how we connect families to support and a myriad of other things. We have to avoid the trap of focusing on a single facet of addiction. COVID-19 is a perfect example. People are under stress, their kids are under stress, their partners are under stress. They are worried about their economic situation, and they are more isolated from others than they were in pre-covid times. It is fair to say we will see increases in alcohol and other drug use and there will be consequences for using these drugs to cope that will last a long time. But we must stop making the mistake of focusing on the drug as the primary area of concern. Let’s focus on healing, let’s focus on the person, lets focus on their children and their family, lets focus on the community!  We cannot forget housing, employment, health and mental health; all of these contribute to the well being and dignity of a person.

We should ask how we can help people cope with what they are going through and meet them where they are with tools to help them heal in a more effective way. This is more than a harm reduction model; it is a recovery model. It is what we need to continue building out. But the lesson from what we did was not what we missed; the lesson is that we can accomplish so much more. We could expand recovery communities on the ground and connect them with the rest of our care system to support the needs of people in diverse communities across America. What can we do to help you cope and connect with support that work for you? This is a recovery orientation, and the recovery community has a tremendous amount to offer that would help us address these challenges, that is if we allocate funds and support the development of infrastructure inclusive of diverse recovery communities.

The historic recovery set aside effort underway in DC and ensuring that we have a permanent way to fund recovery support is a prime example of the ongoing nature of this work and our forward momentum. We do what we can do to make it happen on Monday and if on Tuesday we have not accomplished our goal it is what we work on when we get out of bed on Wednesday. We just simply keep at it. Perhaps this is what a summit now should focus on now, ensuring this agenda gets done and that people in recovery are at every table.  The “nothing about us without us” focus to ensure people in recovery are at the table in a meaningful way and not ever giving up until that is a reality. It looks like a worthy focus to me.

• What are you most concerned about in respect to the future?

We need to make sure resources get to the communities and not get preempted by other agendas. We are currently in a topography of change. So much is going on with syndemics, pandemics and epidemics. Unfortunately, much of the treatment system is rife with fraud and we must deal with that. Parity was codified into law, but enforcement policies are not being executed. There is great promise in harm reduction efforts but some of what is happening in that space is sensitive politically. Prevention is challenged to show outcomes on how it promotes lifestyles that reduce drug use and recovery efforts remain on a shoestring and at times are not being used in ways that are as helpful as they could be. There are plenty of challenges, but there have always been challenges. What we helped set up a is a community structure that can help us address these needs and move care and support in ways that work better and are run more effectively.

• What would you say to future generations of recovery advocates about what we did and what to be cautious of / your wishes for them moving forward?

We must ensure we have a robust recovery safety net for people who experience a substance use issue. We need to make sure we offer people social and psychological support that meets their needs no matter what community they live in. We need to watch out for opportunists who take advantage of vulnerable people. Opportunists have always been present in the background, and we need to keep an ever-watchful eye out for them. We must be cautious of the forces of greed, avarice, and fraud. A lot of people get taken advantage of when they are seen as the means to make a quick buck rather than a member of a community worthy of serving. People with addictions are seen as vulnerable and to be exploited and we need to be ever present in our guard against such things. The twelve step communities dealt with this in terms of thirteen steppers – people taking advantage of the vulnerable newcomer. We need to focus here and set up ways to ensure proper care and support that is ethically provided in a transparent way informed by the experts on recovery – people in recovery.

These trends are not new. I see groups like Faces & Voices doing constructive things to operationalize recovery support and to set up standards of conduct and ethical frameworks to operate from. These are important areas of focus, and I would tell them to pursue progress with an eye towards on ethics. To consider how they do things in ways that support the whole community and guard against those who take advantage of others for personal gain.

I think what we did back then makes evident now what could be accomplished if we more fully embrace a model of sustained recovery management that is developed for and by our grassroots recovery communities. Our work on the RCSP initiatives and what happened at that historic recovery summit in 2001 demonstrated that there are vast, untapped, and underutilized resources in our communities. It is something I have seen over the course of my own career, and I know that if future advocates work to bring these communities together in ways that validate the resiliency and power of recovery to change lives and communities, it will fundamentally change our care system and save millions of lives.

Dave Jansa is a SMART Facilitator in Sioux Falls, South Dakota, and someone with lived experience with the Family & Friends program.  He also serves on the board of Face it Together (FIT), whose mission is to solve the nation’s greatest health challenge drug and alcohol addiction. 

In the podcast, Dave talks about:

• Resolving his struggles with addictive behaviors on his own and by observing what others were going through as guidance  
• Being curious and confused about his addiction experience and recovery transformation
• Face it Together being disturbing innovators
• The similarities between SMART and FIT and implementing SMART into their recovery options
• How using the Family & Friends program transformed the way he interacted with his son
• The needs of teens and young adults differs from adults in recovery
• The Community Reinforcement and Family Training (CRAFT) method
• FIT’s Recovery Capital Index
• How addiction affects everyone in the family
• Being part of the solution in people’s recovery
• Finding the diamond in the rough

Additional resources:

Click here to find all of SMART Recovery’s podcasts

PLEASE NOTE BEFORE YOU COMMENT:

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IMPORTANT NOTE:

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It seems to be human nature to go to extremes; especially when something shows promising results. Harm reduction has been shown to save lives and therefore should be celebrated and implemented. However, it seems that harm reduction has become the entire conversation about recovery; specifically, the support of Medication-Assisted Treatment (MAT). 

Alex Pentland, a professor studying human behaviour at MIT, said, “When we see people in our peer group play with an idea, our behaviour changes. That’s how culture is created.” In essence, we gravitate to the standards of those around us. This brings up some questions about recovery culture. What effect does harm reduction have on recovery culture? Obviously, it saves lives, and that’s essential for the recovery process, but are there other effects that we should be aware of?

In exploring some of these other effects, I came across Steven Scanlan, a Board-Certified Psychiatrist specialising in Addiction Medicine, who wrote an article in 2010, titled “Concerns Behind the Miracle,” in which he pointed out that implementing Suboxone (one of the medications used for Medication-Assisted Treatment in the Harm Reduction Model) for more than a month can lead to a “strong dependence.” Dr. Scanlan also mentions Suboxone’s potential to numb an individual’s feelings. These types of things need to be considered when implementing a treatment model such as medication-assisted treatment. If such adverse effects aren’t considered, it’s possible for a widespread model, such as MAT, to undermine the recovery culture: by not providing support for adequate feeling (a developmental task of recovery) and healing (many individuals with an addiction suffer from trauma; feeling is essential for healing trauma).  

Is it possible that while MAT, specifically Suboxone, has been shown to save lives in the short-term, it might have counterproductive results in the long-term? According to this recent research paper by Dr Katherine Herlinger & Professor Anne Lingford-Hughes, “More recently, a study of individuals prescribed long-term opioid agonist treatment reported enlargement of the right caudate nucleus, and reduced volume in the right amygdala, anterior cingulate cortex and orbitofrontal cortex. These changes were reportedly more pronounced in those with longer duration of OUD.”

The amygdala is our emotional processing centre and is responsible for regulating our emotional reactions. Reduced volume in the amygdala has been shown to affect one’s ability to control inhibitory (unwanted, or “goal-irrelevant”) actions. One thing I found appealing in the research paper by Herlinger & Lingford-Hughes is that there is “potential for structural changes to return to normal after a month of abstinence.” This is also highlighted in a different section of the research paper, “Of growing interest has been the effect of OST (opioid substitution therapy) on cognitive functioning.

One meta-analysis of methadone-maintained individuals reported neurocognitive deficits in working memory, attention, cognitive flexibility, and other areas compared with controls. In another study both methadone and buprenorphine users exhibited deficits in visuospatial working memory which were strongly correlated with higher mood and anxiety symptom scores. This highlights the potential need to pursue abstinence-based therapy in OUD.” What is so interesting about this is that I never hear about it in the mainstream discussion around opioid use disorder.

When I think about Alex Pentland’s point about how we mirror what we see, I become concerned that the loss of an abstinence-based culture may lead to fewer long-term benefits. So, how can we ensure that individuals on long-term MAT get the rich social connections and resources that an abstinence-based approach may provide?

I believe the answer lies in the practice of discernment. If there is no discernment, then everyone is a good or bad candidate for Harm Reduction, or MAT. This is a problem because treating everyone as such isn’t necessarily appropriate for their recovery, or congruent with their goals. An extreme example of this is at a clinic in Pennsylvania, where an individual sued the clinic’s owner, manager, and doctor for “keeping him reliant on Suboxone.” 

It’s important to acknowledge that MAT can help a significant number of people but it’s also important to acknowledge when it isn’t helpful (e.g., if an individual begins to misuse it). This boils down to providing individuals with the best path for their stated recovery goals. Can we say, in all honesty, we are providing individuals with the treatments and resources that will lead them to their desired outcomes? 

If we look at drug overdoses over time, we can see that drug overdose deaths have quadrupled since 1999, despite a small drop in 2017, according to the Center for Disease Control and Prevention. I think it’s important that we acknowledge it’s time to look at other evidence-based treatments, as opposed to solely MAT. Nutrition, or the lack thereof, is an often-overlooked aspect of addiction treatment and yet has been shown to be correlated with craving and the potential for relapse. 

I think it’s time we admit this (the harm reduction) initiative can be used as a stopgap while we look for ways to build recovery capital. Dr. Gabor Mate put it this way, “We can’t just hand out more and more medications. We have to look at the stresses that, on a social level, affect people.” Another way of saying this is in the words of Recovery Historian, William White: “Our focus should be not on what professionalised services we can offer members of this community, but on how we can support the development of resources within this community that diminishes its members’ needs for professionalised services.”

Having this dialogue is important, especially when we are the ones responsible for giving the most reliable and honest information to individuals seeking our support. If an individual wants to pursue abstinence or doesn’t want to risk side effects, I would like to be able to offer them the tools and support necessary to do so. Conversely, if an individual doesn’t want abstinence but does want to improve their life, I also want to offer them relevant tools and resources. This type of integration requires a restructuring of priorities: from the necessity of surviving to growing. It’s about coming back to the power of recovery communities and the individuals who make them: what do they want to achieve and are we offering what we know to be the best way to help them do that?

Dylan Lundgren is a TEDx Speaker and Addiction Recovery Advocate.

Commentary – David McCartney

Dylan Lundgren gives us much to consider in his guest blog. He posits that there may be potential unintended consequences, cultural and practical, of shifting emphasis and goals from recovery to harm reduction and he is concerned that we do not always discuss the whole picture when we prescribe MAT. I think there is some truth in this – I don’t recall having many, if any, conversations about possible cognition, bone metabolism and immune system side effects from methadone, but while these seem trivial compared to the (potential) ‘side effect’ of death from untreated opiate use disorder, patients do have the right to have a better understanding of all the risks and how they might be mitigated, albeit balanced against the benefits.

The question of what treatment helps an individual to achieve what goal and with what degree of safety is pertinent. I work with those seeking abstinent recovery, but there are risks here too which need to be understood and conveyed. Research has arguably focused too much on reduction of harms at the expense of whether individuals and their families achieve their goals and flourish, but it may also be true that we do not accurately communicate risks to individuals pursuing abstinence.

The suppression of feelings by opioids is one of the reasons people use them. In clinical practice we sometimes see negative emotions related to past trauma surfacing during detox. At times, this is so overwhelming that it becomes intolerable, and we will discuss with the patient re-titration back onto an opioid. Buprenorphine, in my experience, is much less sedating than methadone and may better allow psychological therapy work to be undertaken to help support the individual and address the trauma. (As therapists tell us, it’s important to be able to feel uncomfortable feelings in a way that is sustainable and doesn’t lead to unhealthy coping mechanisms)

As I’ve written before, I believe we need to create a recovery culture in harm reduction services and a harm-reduction culture in recovery-oriented services. The key to this is to have people with lived experience engaged in both.

Finally, the aim of relying less on professionalised services through the development of lived experience/recovery community resources seems to me to be a sound one. Addiction is disempowering; relying on professional services can also feel that way. Mutual aid and LEROs (lived experience recovery organisations) allow people to take control of their own destiny, plus or minus professional support. Who can argue with that?

6 Strategies to Avoid Relapse Triggers

Protecting your recovery at all costs must be emphasized at every stage of recovery.  Because relapse starts well before a person picks up a drink or a drug, it is essential to understand what your relapse triggers are. You may ask, “What the heck is a trigger?”  A trigger can be described as a person, place, thing, feeling, or situation that leads to a thought that taking a drink or using a drug would be a good idea.

It the responsibility of the person in recovery to identify and know their own triggers.  A trigger prompts a thought, which if romanced, can become a craving.  A craving can become a relapse if action is not taking to deal with it. Smash that thought, play the tape to the end, and remember the pain you felt in active addiction.  Remember the H.A.L.T concept.  When you become restless, irritable, and discontent, ask yourself, “Am I hungry, angry, lonely, or tired?”  If so, these feelings could increase the risk of relapse.  Only you have the power to address these feelings with the recovery tools you now possess.

As it relates to personal relationships, we encourage people new to recovery to avoid triggers by focusing on developing healthy communication skills first.  It is helpful to learn to be emotionally intimate with peers before diving headfirst into a relationship rooted in physical attraction.  In early recovery, the newcomer is still developing healthy emotional coping skills.  Romantic relationships can distract a person and keep them from focusing on sobriety, which often leads to a quick relapse.  The newcomer is an infant in emotional sobriety, most have used alcohol or drugs to cope with emotions.

Living in recovery will give you a life worth living.  Here are six steps to help you deal with relapse triggers:

1. Be aware of complacency, euphoric recall, and forgetting the pain that addiction has caused.
2. Be conscious not to drift away from recovery. Regular AA and NA attendance is extremely important. It’s an easy and common mistake for people to reduce meeting attendance, stop calling a sponsor, or just stop going to AA/NA altogether!
3. Talk about feelings openly in meetings and with a sponsor.  Most people will never heal what they do not feel.
4. Remember, the brain chemistry has been changed.  You WILL be triggered at some point in time but don’ allow a trigger to be romanced into a craving.
5. Remember to assess your motives for being around certain people or going certain places.
6. Think before you drink or use.  The time to call that sponsor is before, not after!

Even with the best-laid plans to avoid relapse triggers and prevent relapse, the risk is always there. If you get caught off guard and slip-up, it does not mean that you are a failure and doomed to addiction forever. Recovery is still possible, but the sooner you act after a relapse the better.

Joe Peascoe, MS, CRC, LCAS, LPC-A

About Fellowship Hall

Fellowship Hall is a 99-bed, private, not-for-profit alcohol and drug treatment center located on 120 tranquil acres in Greensboro, N.C. We provide treatment and evidence-based programs built upon the Twelve-Step model of recovery. We have been accredited by The Joint Commission since 1974 as a specialty hospital and are a member of the National Association of Addiction Treatment Providers. We are committed to providing exceptional, compassionate care to every individual we serve.