Austin Brown recently tweeted a link to an editorial from Drug and Alcohol Dependence which is, unfortunately, behind a paywall.

The editorial was written by Eric Strain, the outgoing Editor in Chief, reflecting on the research he’s observed in his 15 years as an editor. Coincidentally, it articulates the core message of my blogging over the last 15 years. [all emphasis mine]

He affirms the importance of overdose prevention, arguing it “is a medical, social, and moral tragedy, and there is a personal agony that a drug-related death evokes in family, friends and providers. In response to this sustained and unacceptably high number of overdose deaths, there has been a focus on a number of social and medical strategies to intervene and prevent these deaths. This is a highly worthy goal, and we should not in any way decrease our focus on that goal.“

While asserting the important of overdose prevention, he observes that the field “in both its research as well as treatment efforts is not giving due consideration to flourishing.”

He speaks to the shift in goals that is probably not visible to people outside of the field, “However, efforts to address this have resulted in a focus on decreasing overdose deaths as an endpoint… Not overdosing is an insufficient endpoint for treatment or for societal and medical interventions – it’s a starting point. We fool ourselves and do a disservice to patients if we allow this to be the measure that allows us to declare success.”

He notes the suffering that is too often invisible in academic discussions and can be obscured in statistical improvements in metrics like overdose rates: “Decreasing the percentage of deaths is a numerical goal that can be quantified and for which achievement can be celebrated when it is attained. A 100% decrease would be ideal, but goals of 30 or 40% decreases seem to be often proposed. And it is worrisome and problematic to think that decreasing the percentage of opioid overdose deaths will solve the problem of opioid use. For patients and their families, it will not.“

He comments on the ways we fail patients with low ambitions and the politics that limit the service array: “Our failure to forcefully advocate that patients need to flourish is tacitly acknowledged through interventions such as low threshold opioid programs, provision of naloxone with no follow up services, and buprenorphine providers who only offer a prescription for the medication. We have alarmingly high dropout rates from treatment with an OUD medication, fail to engage most high-risk patients in treatment, and fail to have broad use and agreement for treatments such as contingency management (CM) despite robust evidence that it doesn’t simply work, but that can be highly effective. Federal impediments further obstruct the use of CM despite its effectiveness.“

He also points to the irony that researchers and providers so often relentlessly pursue meaning and purpose in their own lives while neglecting meaning and purpose for these patients. He notes here that facilitating flourishing is hard work and not easily quantifiable.

Before closing the editorial, he offers readers the following questions to consider:

• “What do patients want, and what would it mean to them to flourish?”
• “Can contingency management be used to help patients flourish?”
• “How do the circumstances of different medications and their delivery enhance or impede a person from moving forward in their life?”
• “What factors (interpersonal, religious, vocational, educational) are most salient to patients with a SUD?”
• “Is flourishing best addressed individually, as a part of a family or community, or in group settings?”
• “How do we understand the biological and sociological mechanisms underlying flourishing, and why do some people flourish, and others do not?”
• “What is the relative role of religious engagement in helping a person with a SUD find meaning and purpose in their life?”
• “Is there a stage in the cycle of substance use when flourishing can take root (the AA concept of bottoming out)?”
• “Are there racial, gender, and other differences in particular themes of meaning and purpose?”

I’d never heard of Eric Strain, but I’ll follow him now. I’m grateful for his message. I couldn’t have said it better.

While there is much we do not know about addiction and recovery, there are things we know well but do not apply to our care system design. I am going to attempt to cover three of those in this blog posts because they interrelate. The first is that we have long term drug use patterns that tend to shift every decade or so. As this 2019 NBC article reports, there is a tendency towards “generational forgetting.” Essentially, when current drugs get bad press, the younger generation learns to not use that drug and drug use patterns shift, often to classes of drugs that were popular in a prior generation. They learn from seeing in the media that the current drug is dangerous and use more of another drug. These trends tend to move from opioids to stimulants and back a decade or so later. An observation is we tend to “tool up” for the current drug and focus on it and then get surprised when the patterns shift back. I don’t really like the analogy of a drug war, but using this tired analogy we are preparing for the last war, over and over again by focusing on single substance concerns, e.g. the Opioid Epidemic.

The second point is that drug use tends to occur with multiple substances. As this Feb 2020 American Journal on Public Health paper states, polysubstance is common in persons with opioid use disorders, viewing opioid trends in a “silo” ignores the fact not only that polysubstance use is ubiquitous among those with opioid use disorder but also that significant changes in polysubstance use should be monitored alongside opioid trends.” As noted by the Journal of the American Medical Association in this April 2020 paper, opioid overdoses with co-involvement with alcohol and benzodiazepines are “common and increasing – reaching 14.7% for alcohol and 21.0% for benzodiazepines in 2017.” Adding to this dynamic is the trend we are seeing in finding fentanyl mixed in with cocaine and methamphetamine, increasingly complicating these dynamics through overdosed on substances that users may not have been aware was in the drugs they used. The most common drugs associated with co-involved opioid overdoses were Benzodiazepine, Cocaine and Methamphetamine.

Finally, we are seeing a shift in drug use patterns that will require comprehensive interventions. Focusing only opioids through medications only without focusing on whole person care may be setting us up for additional loss of life. As noted in this Wall Street Journal article  effective strategies to move people into recovery “will require deeper change than just cracking down on one substance or another” and that “It’s unlikely it will respond to a specific drug or age category. It will need a much, much more comprehensive intervention.” Last week a Science Daily article noted that methamphetamine overdoses deaths were rising rapidly across all US racial and ethnic groups, with  American Indians and Alaska Natives having highest death rates overall.  This paper examining methamphetamine use in persons in Medication Assisted Treatment in Oregon noted that patients perceived methamphetamine as a safer alternative to heroin, for continued drug use. We are also seeing empirical evidence that methamphetamine use is undermining the efficacy of medication assisted treatment, and dramatically increase the dropout rates for person on MAT.

Efforts to address our addiction epidemic have been well meaning. The focus of simply getting people onto a medication to reduce opioid related deaths has been well intentioned as it addressed an immediate need. This is understandable as short term, immediate focus is how people and systems think in a crisis. The point is, we are not in a short-term crisis, we are in a long term and complex disaster. We need to get out of the crisis mode of thought and think long term and focus on developing a comprehensive care system centered on getting diverse communities into and sustaining their recovery over the long term in ways that addresses the challenges we face.

It will not be possible to do this with broad inclusion of communities in recovery, who have been largely absent from policy discussions about us or how to strengthen recovery efforts at the community level. Recovery management models must center on strengthening community and not on redesigning care models focused on narrow, transactional services provided in individual and groups as units. One of the keys to designing a care system to meet our needs is understanding that recovery is contagious as Bill White noted in this 2010 paper on recovery as a contagion – “recovery is contagious only through interpersonal connection—only in the context of community. For those still in the life to find hope and recovery, they must take the unlikely risk of leaving their cocooned world or we must risk going to get them.”

I have suggested “Guiding Principles for Consideration on Treatment & Recovery for the Biden Administration” the roots of these recommendations can be found in the works of the like of Bill White, Robert Dupont and a lot of dialogue across our community. Perhaps our greatest mistake in addressing addiction in the United States is not thinking big enough or realizing that recovery is the probable outcome if we design a care system around supporting the needs of our communities. We have not done so historically, and it is time.

There is an old proverb, “the best time to plant a tree is 20 years ago, the second-best time to plant a tree is today.” 

Let’s plant that tree!

Thinking a lot these days about alcohol, like all drugs it is neither good nor bad, but even among those who can moderate, there are always a cost. As behavioral neuroscientist Dr Judith Grisel notes, every time you use a drug there is a good feeling, but there is always a “payback” as the brain seeks homeostasis. Essentially you are borrowing good feelings from the future. Rewards beyond drugs work this way too, which is why you feel a little blue after a birthday or a big event in your life. Drugs give you that good feeling, but the more you use, the greater the future debt to be paid back. The COVID-19 pandemic is significantly adding to the already growing balance sheets in respect to alcohol use disorders for Millions of Americans.

We know that alcohol use is way up as a result of COVID-19 as I noted in a CNN piece in the early days of the pandemic. The NIH has identified that alcohol related mortality doubled in the years preceding the pandemic, especially among women. Despite these dire statistics, we do not focus on alcohol use disorders in the same way we have opioids. Why not? Overdose deaths tend to be sudden, and alcohol related deaths either tend to be gradual or associated with other causations, such as car accidents, falls and drownings. I suspect it is also harder for us to talk about because it is so socially acceptable. As a society we still see those among us who are unable to moderate through a moral lens rather than based on what is actually occurring, a medical condition, typically with genetic components.

A just released Vital Strategies report, the Sobering Truth: Incentivizing Alcohol Death and Disability notes that government incentives to the alcohol industry is measured in the Billions. We using public monies to incentivize drinking even as we bury our family members from alcohol related disorders. This is obscene. The report notes that harmful alcohol consumption, such as binge drinking, affects a range of health, social and economic factors. It states that alcohol:

• Leads to one death every 10 seconds—3 million deaths per year globally;
• Is a leading risk factor for noncommunicable diseases (NCDs), including cancer, cardiovascular disease and liver diseases;
• Can worsen the course of infectious diseases, such as tuberculosis, HIV/AIDS, pneumonia and yes, COVID-19;
• Is the leading global risk factor for death and disability for people 15 to 49;
• Can exacerbate mental health conditions and contribute to violence in the form of homicides, suicides and domestic abuse;
• Caused approximately 370,000 deaths on the road globally in 2016.

The report goes on to question governmental incentivization of the alcohol industry and to urge governments, policymakers, and health advocates to actively monitor the alcohol industry’s interference in policy and to question the cost and benefits of these economic incentives. I find this particularly relevant as we are in the midst of a pandemic that is increasing problematic use of alcohol. We are setting ourselves up for additional waves of alcohol related mortality here in American and beyond.

It is a good report with much needed recommendations. We must go father. We do a terrible job at early intervention and follow through with alcohol related illness. I often here accounts of alcohol treatment needs being triaged behind opioid treatment needs because of the perception that alcohol use disorder are not as bad. Lack of referral from medical care systems is one of the factors resulting in the abysmal fact that in 2018, only one in every 13 people who need substance use treatment in America got it.  A 2017, American Journal of Medicine publication Treatment of Alcohol Use Disorder in Patients with Alcoholic Liver Disease noted that “despite evidence that outcomes improve with integration of psychosocial and medical care, there are almost no randomized studies for behavioral and/or pharmacologic treatments in patients with alcohol use disorder and alcoholic liver disease.”  As this recent Medscape article notes “many physicians believe no effective treatment is available for alcoholism; therefore, these physicians do not refer their patients for treatment.” This is most likely related to negative perceptions about people like me who have substance use disorders that seem unfortunately pervasive among medical care professionals. We do recover.

Solutions are complex. If they were simple, we would already have fixed them. We must address the underlying discriminatory practices that influence low identification rates for alcohol and other substance use disorders. We need to do some serious investment in our substance use treatment and recovery support service infrastructure and we need to invest in recovery oriented research. There is a train coming at us, we are on the tracks, what we need is the will to do something about it. “Those people” are our people. Let’s save some lives and more comprehensively address alcohol related disorders.

In the midst of winter here in Scotland when days are short, snow is on the ground and we’re in lockdown, it’s easy to get low. I’ve been thinking a lot recently about residential rehabilitation and where it fits into treatment options.

I think it’s true to say that rehab has felt a bit stuck in a kind of permafrost of neglect or obscurity. Rehab seems irrelevant to some and dangerous to others, yet those who have benefitted have often reported a transformative experience. Then there is the difficult fact that relatively little public funding supports the hundreds of people who go through rehab every year. The majority pay for their own treatment or are funded by insurance or charity. (For those not familiar with Scotland, almost all health interventions here are funded publicly). But there are glimmers of light, or, some might even say, beams of light, playing out now on our wintry shores and mountains.

It’s true that it’s only been a couple of months since our bleak drug-related deaths figures for 2019 were published, darkening the winter further, but this year the response has been different – after the outrage and sadness came listening and commitment to improve the situation – from the highest level in government. There have been brisk responses before admittedly – so what’s different this year?

As it turns out, quite a bit.

Changes afoot

In a significant move, Scotland’s first minister, Nicola Sturgeon, has appointed a new Minister for Drugs Policy who will lead on tackling our problems. In a speech yesterday, the Minister – Angela Constance MSP – pledged to ‘do more, do it better and do it faster’, in order to save lives.  

Ms. Constance said that she will continue to meet with those with lived experience, parents and other family members. She said she would build consensus both within and outwith the Parliament. I was happy to see that she will embrace both harm reduction and the promotion of routes to recovery, including residential rehabilitation. Polarisation has had its day. She rightly accepts that we need many solutions to our challenges.

The Minster also wants to ‘make sure that our own house is in order’. By this she means joining things up across different government departments – such as work on adverse childhood experiences (ACEs), mental health, homelessness, the justice system and tackling poverty and inequality. Over the years I’ve tried to do this on a much smaller scale locally, but multiple chains of command, clashing philosophies, competitive attitudes and differing priorities make joined-up work very difficult to operationalise.

Joined up for recovery

However, the vow to take this work forward is welcome news. Such coordinated approaches are essential for recovery-oriented systems of care (ROSCs) to work effectively. Remember, we’ve been trying to get ROSCs up and running for many years – the Essential Care report called for this as long ago as 2008. The development of ROSCs was a focus of the last, and the current, drug (and alcohol) policies. ROSCs were called for in the Independent Expert Review on Opioid Replacement Therapy in 2013. That report was stark:

The review found considerable variation in local delivery of even the core elements of recovery orientated systems of care (ROSCs). Many areas stated their plans were at very early stages of development. There was little evidence presented by some ADPs regarding a real impetus towards recovery. Stakeholder reports supported this view.

Independent Expert Review, 2013

Things may have come on a bit, but how much has really changed in the last 8 years? Our challenges have become all-too-familiar bedfellows.

The power of rehab

In her speech, Ms Constance acknowledged the urgent necessity to reduce harms now and cited ‘the power of residential rehabilitation’. I hope that’s a phrase we hear again and again. As a treatment option which is difficult (and in some areas impossible) to access, unless you are wealthy, this was gratifying to hear.

We need every treatment dish on the menu so that people can get the help that’s best for them and their families when they need it. Whether that’s access to safe injecting spaces, equipment for safer injecting, drug testing services or entry into medication assisted treatment programmes or residential rehab, all need clear access and easy-to-navigate links between services which, too often, seem to sit in silos.

We’ve actually started working on issues relating to rehab in Scotland already. The Residential Rehabilitation Working Group was set up last year by Joe Fitzpatrick, the then Public Health Minister. We published recommendations last month. You can read more about what we found here.

Commitment

Meantime, we have a profoundly exciting promise which does suggest the heralding of spring for residential rehab in Scotland. Ms. Constance said:

The First Minister will make a statement next week laying out how we will achieve a step change in the short, medium and longer term. That will include a commitment to increase the provision of residential rehabilitation and bring our bed numbers up to the European average.

Angela Constance MSP, January 2021

The way forward

Our group estimated that fewer than 5% of all treatment episodes in Scotland in 2019-20 were for residential treatment, compared to an average of 11% in Europe. This means we are setting an ambitious target. I’m a big fan of setting the bar high, but this means committing to a lot of hard work to sort out barriers to treatment. These include challenges around capacity, access and pathways, understanding the various models of treatment, setting standards, adequate duration of treatment, and of course, having sufficient and straightforward funding.

Then there is the difficult and somewhat perplexing issue of understanding and tackling the ambivalence, iciness, or even hostility that some professionals have towards rehab. This can result in a glacial rate of referrals from certain areas or teams.

The right to be involved in choosing what kind of treatment is right for you is set down in our drugs strategy, Rights, Respect and Recovery and this should apply as much to residential treatment as it does to other valid choices. Where attitudinal barriers exist, they need to be identified, discussions and education had, and channels opened up.

Finally, we need to address the dearth of evidence on outcomes from rehab. We only have one rehab study from Scotland  published in a peer-reviewed journal. That’s despite over a thousand people going through rehab in Scotland every year and rehabs being around for three decades or more. Who are these rehab graduates? What took them to rehab? Did they have prior episodes of treatment? What happens to them afterwards? What value does their recovery have to them, their families, their country and the recovery community? Does rehab have an effect on reducing alcohol and drug deaths?

Aren’t these interesting questions? Why the frigidity?

Can it ever be valid for someone to say ‘there’s no evidence that rehab works’ when the issue is nobody is interested in gathering and looking at the evidence? I don’t think anyone is claiming rehab is the answer to Scotland’s drug and alcohol harms and deaths. It should, however, be another valid option on the menu of treatment choices and currently in many places, it is not.

Hope

Once we’ve identified them, barriers and challenges can be overcome. With the right will, leadership and resources, there are things we can do quickly and there are things that need a bit more groundwork and planning, but which will thaw us out of winter and into spring. 

There’s a warmth in the wind. It’s feeling good.

Follow me on Twitter @DocDavidM

Negative Space and Art

In visual art, the area outside or around the main object is called “negative space”.

For example, if one draws a deer and places the deer on an abstract background, the abstract background is termed “negative space”.

In art, negative space is important.

What should the negative space be made of? And how should the negative space be made? How should the negative space be made to seem?

Sometimes, making the right choices in the design and use of negative space makes all the difference in how the actual “subject” of the art is perceived.

The main object may be interpreted one way with one contextual frame or appear very differently with another. In that way, the negative space may be more critical than the way the artist renders the main object or main subject of the work itself.

These are important considerations. After all, different people may have different subjective interpretations of the negative space. And thus, people will have different interpretations of the object itself, if only due to their differences in their way of experiencing the very same negative space.

Negative Space and Human Interaction

Relating and interacting with another person generally has an object or a topic.

That subject or topic sits in 1) the negative space we create, 2) the negative space the other person creates, and 3) the negative space that the two people co-create together.

Think of the zone of interaction between two people as a certain kind of negative space – the kind created by those three sources.

But stop to consider that negative spaces are also evaluated. And as in art, the perception and evaluation of the negative space changes the evaluation of the main topic, object, or focal point of the interaction.

• What does the other person we are with apprehend about our main subject – based on our intentional forming and handling of the negative space?

Endeavoring toward a more intentional rendering of our context, rather than our content, might be helpful in our interactions. Can we make the aesthetic evaluation of the negative space (in our daily interactions, and the counseling we provide), part of our recipe or menu of considerations in creating, forming, and holding negative space?

• Whose evaluation of negative space is included or excluded, and why?

Negative Space and Addiction Counseling

In the science and art of addiction counseling, what is the negative space?

Is it the room? Is it the silence? Is it the unthought-known below our conscious mental operation? Or some combination of these?

In the practice and art of addiction counseling, what negative space do we create? What look and feel do we give the negative space that we bring about?

• I wonder what an art therapist would say to improve my office. Or to improve my silence? Or to improve my holding of negative space?

What about the person undergoing addiction counseling? How do we apprehend and interpret the negative space that person provides? And how do they interpret ours? Are we each holding the best possible negative space for the sake of the process?

Negative Space, Addiction Illness, Addiction Recovery

Likewise, the one we assist and support, both forms and holds negative space during their illness, during their treatment or care, and during their recovery.

Someone experiencing addiction illness could form negative space during, and merely by, periods of abstinence – not just of use.

• While their substance use is stopped or temporarily controlled, what environment are they rendering?
• What quality of space do they live and bring to others?

While they partake of addiction counseling how does the person served form, have, and hold negative space?

• Concerning the rendering of negative space, do we assist the person we serve with its concrete and aesthetic formation?
• Recovery concerns more than only the object of self.  Recovery also concerns the creation and management of negative space.
• What do we model with our behavior, and teach with our words, and our silence, concerning the formation of intentional and high-quality negative space? 

Negative Space as Cause and Effect

It is axiomatic that “Creativity is close to spirituality.” In that sense, what kind of negative space do we create, co-create, and hold?  What quality of negative space do we first render and then bring to others?  Is the negative space in the lives of those we touch improved by the impartation from the negative space we bring?  In what ways, and to what degree?    

What would an art therapist say about the outcomes found in the aesthetic dimension of the negative space in the lives of those we serve?

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