Therapeutic nihilism

“None of them will ever get better”, the addiction doctor said to me of her patients, “As soon as you accept that, this job gets easier.”

This caution was given to me in a packed MAT (medication assisted treatment) clinic during my visit to a different city from the one I work in now. This was many years ago and I was attempting to get an understanding of how their services worked. I don’t know exactly what was going on for that doctor, but it wasn’t good. (I surmise burnout, systemic issues, lack of resources and little experience of seeing recovery happen).

Admittedly, a part of me recognised an echo of the sentiment. I’d worked for many years in inner-city general practice and back then, to be honest, I did not hold out as much hope as I might have for my patients who had serious substance-use disorders. After all, the evidence in front of my eyes suggested intractable problems. All of that changed when I began to connect with people in recovery and started to understand the factors that promote it.

Palliation or something better?

I don’t think my colleague’s perspective was (or is now) the predominant view, but by no means is it unique either. An addiction specialist has fairly recently urged us to accept that some ‘do not have the luxury of recovery’, seeing it as ‘a convenient concept, but an unobtainable reality for many people who use drugs’, who are really in ‘palliative care’. I struggle with this perspective. Some would say it’s realistic. I think it’s pessimistic.

Of course, there are people whose chances of resolving their problems and going on to achieve their goals remain low despite support, but who gets to choose who gets ‘palliation’ and who gets something better? We don’t start out with palliation as a goal of cancer treatment; why should addiction treatment be any different? If our treatment offer is focussed on palliation and only the few – the worthy and fortunate – get to go further, we are letting people down badly. Professor David Best has pointed out that this sort of therapeutic pessimism is a major barrier to the effective implementation of a recovery model.

My assessment in my visit to that MAT clinic was that I could not work in a service where views like that, for whatever reason, had become acceptable and explicit. However, rather than be defeated, I found instead that this provoked an energy within me to try to make a difference.  That one incident, perhaps more than anything else (save my own experience of treatment and recovery), drove me to set up the service I now work in.

The clinical fallacy

While therapeutic pessimism undoubtedly exists, I am buoyed up by my past experience of working in teams in community settings where expectation of what is possible is much higher. I can think of many colleagues who set the bar high every day in their work, even when they are working in demanding circumstances.

While despairing and cynical views are not the norm, it is apparent though, for whatever reason, that some working in the field don’t hold out as much hope as they might. I’ve heard enough reports from individuals who feel they were discouraged or blocked from moving on towards their goals to know that it happens too often. 

This nihilistic view of the potential of individuals to resolve their problems and move towards their goals can be explained to some degree by something Michael Gossop called ‘the clinical fallacy’.  This is the situation in which the clinician sees all of the challenging presentations and relapses, while the people who resolve their problems move out of treatment and are not seen again.

The clinician is confronted continually by their failures and denied the benefit of seeing their successes.

Michael Gossop, 2007

This may explain findings from elsewhere which show that we professionals working with people who have substance use disorders consistently underestimate what our clients/patients are capable of. This is important. The clients of clinicians who are more positive do better^[1] and conversely negative or ambivalent attitudes in professionals are linked to higher risk of relapse.

Professor Best, interviewed by William White in 2012, referred to work he’d done in the UK, scoping out the aspirations of addiction workers for their clients. He had asked them to estimate what percentage of the people; they were working with would eventually recover. The average answer was 7%. Evidence actually suggests that over time most individuals are likely to recover. However, if I believe your chances of recovery are only 7%, then I’m instantly holding you back because of my own beliefs and behaviours – conscious and unconscious. My bar is set way too low.

An Australian study found that practitioners there were more optimistic believing that a third of people with a lifetime substance dependence would eventually recover. But this is still an underestimate.

In general, it is fair to say that SUs [service users] look for tough criteria to define ‘being better’ – perhaps tougher than their practitioners.

Thurgood and colleagues, 2014

Raising the bar

Eric Strain picked up this theme of aiming too low in a recent editorial in the journal Alcohol and Drug Dependence when he wrote:

The substance abuse field in both its research as well as treatment efforts is not giving due consideration to flourishing. We need to renew our efforts to give meaning and purpose to the lives of patients.

Eric Strain,

Saving lives and reducing harms rightly need to be our first concerns, but is there a danger that we stop right there because we see the risks of our patients or clients going further as being too high? This week I was talking to an experienced addiction psychiatrist, now retired. He told me that early in his career he gave up trying to predict who was going to do well and who was not. He’d seen people, ostensibly with little going for them, get better from what looked like intractable problems. He’d seen others with a great deal of recovery capital die from addiction, despite the best efforts of family and professionals to support them. It’s hard to make predictions perhaps, but not too hard to hold out hope for everyone.

The necessity of hope

There are actually reasons to be more optimistic anyway. As I say, long term follow-up studies and retrospective studies of people in established recovery suggest that most people can expect long term resolution of their symptoms although this can take some years and several attempts during which we need to focus on keeping things as accessible, supported, and safe as possible, underpinned at all times by hope that things can and will get better.

So what of hope? Hope can be described as an emotion, a cognitive process or a positive anticipation which helps to motivate goal-oriented behaviour. However we define it, it is essential for recovery from substance use disorder, yet it features little in textbooks, guidelines and academic studies.

The patchy availability of hope in ourselves, our services and our service users does need to be addressed. Hope is a catalyst for moving forward. Academics have found that positive expectancies, like hope, predicted higher levels of resilience against post-traumatic stress symptoms. Other researchers have identified the critical role of hope in terms of survival. 

The inclusion of hope in clinical practice shows considerable promise. Individual, group, and family therapy interventions that incorporate hope theory have been found to reduce symptomology and mediate recovery from various psychological and psychosocial conditions

Gutierrez & colleagues, 2020

It is apparent that hope is a necessary ingredient, not only for patients/clients to progress, but for professionals too if we want to be effective in supporting individuals towards their aspirations. I’m not suggesting we come at this with an unrealistic Pollyanna bent. Without manageable caseloads, support from colleagues, good clinical supervision and adequate resources – including joined-up care – compassion fatigue can set in and the therapeutic relationship can suffer. Hope, though vital, can ebb away.

“We must address issues around staff burnout, which I suggest is related to repeated exposure to client relapses without parallel exposure to clients in long-term recovery.” David Best, 2012

Prof David Best

The introduction of hope

In that conversation with William White, David Best encourages us to ‘inspire belief’ through a variety of interventions::

“The interesting issue for me is much less about what particular therapies and modalities we offer and more about whether we can inspire belief that recovery is possible, establish a partnership between the client and the worker to facilitate that change, mobilise recovery supports within the client’s natural environment, and link the client to those community resources. 

We also need to locate recovery within a developmental perspective that recognises the lengthy (and non-linear) journey that most people experience in recovery. This means there are plenty of opportunities for a diverse array of interventions and also that people will evolve in their needs and their resources as the recovery journey progresses.’

Lived experience and hope

Structurally, the goal must be to create recovery-oriented systems of care, but within our existing services, there is a straightforward way to infuse hope. We can do that by embracing lived experience and introducing it into what are normally professional settings. Connecting those we work with to others in recovery stimulates aspiration. It’s true that some professionals are resistant to this concept, but people with lived experience can be involved in treatment settings, acting as role models and beacons of hope to everybody’s advantage – staff and patients. They can also bridge the gap between treatment and recovery communities.

In a local evaluation of a peer support model introduced into a harm reduction service, benefits to the service users were apparent, with greater levels of engagement and a high approval rating of the intervention. What was unexpected though was the benefit to members of the staff team. Because they normally worked with people at a much earlier stage on the recovery journey, the staff were not used to seeing people who had moved on from their problems. That experience of working alongside people who self-identified as being ‘in recovery’ changed the beliefs of the team, raising expectation and hope.

In a study^[2] published this month which looked at the feasibility, accessibility and acceptability of peer navigators in roles that aimed to reduce harm and promote recovery (wellbeing, quality of life and social functioning), the researchers added to the growing evidence base that peers with lived experience can positively influence not only the reduction of harm, but also improvements in quality of life through various mechanisms including role-modelling.

Many participants also described less tangible but nevertheless important changes, including increased confidence and hope.

Parkes and colleagues, 2022

This was not all plain sailing, but staff noted how the peer navigators were able to spot things that staff didn’t, had tenacity with clients and could engage more ‘chaotic’ or ‘hard to reach’ clients.

What’s lovely about this open-access study is how easily the lessons can be adopted into practice. There are issues to be tackled and more work needs to be done on capturing outcomes, but this has the opportunity for us to tackle therapeutic nihilism within ourselves and within our services.

Recovery champions can convey the possibility that things can be different and offer living proof of that difference in their own lives.

Prof David Best

Generating hope

Peers with lived experience don’t just have the potential to introduce hope. Research also suggests that peer contact can help to reduce stigma. Visible recovery is generally inspiring, though some may be threatened by it. There is mostly a contagiousness about it which generates hope. I wonder if my colleague working in that challenging MAT clinic who came to believe that nobody would ever get better would have avoided therapeutic nihilism if she were buoyed up by working daily shoulder to shoulder with those with lived experience.

When we see burnout, despair and therapeutic nihilism we need a compassionate response, but more than this, we need to transform situations where hope has atrophied. Moving to peer support models in every treatment setting is surely an effective way to generate hope, not only in those who use our services, but also in ourselves.

Continue the discussion on Twitter @DocDavidM

^[1] Simpson. D., Rowan-Szal, G., Joe, G., Best, D., Day, E., & Campbell, A. (2009). Relating counsellor attributes to client engagement in England. Journal of Substance Abuse Treatment, 36, 313–320.

^[2] Parkes T, Matheson C, Carver H, Foster R, Budd J, Liddell D, Wallace J, Pauly B, Fotopoulou M, Burley A, Anderson I, Price T, Schofield J, MacLennan G. Assessing the feasibility, acceptability and accessibility of a peer-delivered intervention to reduce harm and improve the well-being of people who experience homelessness with problem substance use: the SHARPS study. Harm Reduct J. 2022 Feb 4;19(1):10.

The Recovery Research Institute recently posted a review of a study examining patient and physician definitions of success for opioid treatment beyond treatment retention.

The Study

The researchers conducted semi-structured qualitative interviews with prescribers and patients from 2 family medicine clinics. Interviews were conducted by phone and lasted 20-30 minutes.

Physicians

14 physicians

• All waivered to prescribe buprenorphine.
• Half were faculty and half were residents.
• The faculty had been waivered for an average of 5.7 years and the residents for an average of 1 year.
• All white, 8 female & 6 male.
• They were asked 2 questions in a semi-structured interview about treatment success:
  • What do you consider success in your patients receiving MAT?
  • In addition to retention in treatment, what else reflects patients doing well?

Patients

18 patients

• Average age was 38 years old.
• 14 white, 2 black, 1 American Indian, 3 Hispanic.
• 8 female, 10 male.
• All were long-term MAT patients, averaging 2.5 years at this clinic (range 1.5–4 years).
• They were asked 2 questions in a semi-structured interview about treatment success:
  • What progress have you made in your recovery by being part of our medication-assisted treatment program?
  • What does success mean to you with respect to your recovery?

Findings

7 themes

Seven themes emerged from the interviews:

1. Staying sober
2. Tapering off Buprenorphine
3. Taking Steps to Improve Physical and Mental Health
4. Improved Psychological Well-being
5. Improved Relationships
6. Improved Role Functioning (Setting and Meeting Goals)
7. Shift in Identity (Decreased Stigma and Shame)

Patient / Prescriber Misalignment?

Of the 7 themes identified, the physician and patient groups shared 5 of the 7 themes, but there were 2 that were only identified by the patient group. Those were themes 2 (tapering off buprenorphine) and 7 (shift in identity).

Regarding tapering off buprenorphine, the paper noted that “Only one physician noted that he hears this goal from many patients”. They did not quantify the number of patients identifying this theme but characterized it as “several”. Interestingly, their desire to taper off buprenorphine was not characterized in a way that communicated ambivalence about using the medication to stabilize and initiate their recovery. Comments included mention that it should happen “eventually” and after stabilization.

I find a couple of things striking here.

First, only one of these physicians (who have been waivered for an average of 5.7 years) reported hearing this goal from many patients. It’s easy to imagine physicians not seeing tapering as an indicator of success, but it’s striking that they report not hearing it from many patients, when the researchers found this sentiment to be prevalent among them. Over that average of 5.7 years, how many patients have these physicians treated? Are patients not communicating this to physicians? If not, why? Are physicians not hearing this from patients? If not, why?

Second, these were patients who’d been in the MAT program for an average of 2.5 years and their comments imply positive feelings about their treatment. I imagine a lot of people would frame this theme as a manifestation of stigma. That is possible, but it isn’t intimated in their responses. In fact, one of the comments in theme 7 (Shift in Identity) describes their treatment helping them feel more like a normal person and changing how they feel about their medication.

It’s interesting that I’m familiar with models of care that don’t involve agonist medications like buprenorphine, and there are millions of American receiving treatment with buprenorphine. What I haven’t seen are pathways for tapering stabilized patients off buprenorphine. One wonders if buprenorphine retention would improve if these patients’ preferences were integrated into treatment models. You could frame retention rates as patients voting with their feet about this preference and it’s important to note that these patient comments indicate that they are in no rush to taper, but would like to eventually. Of course, we also need to keep in mind that these are patients who have been retained for 1.5 to 4 years.

As the X waiver is eliminated, addressing this misalignment seems particularly important.

Image by Vectorportal.com

I recently listened to this interview with Maike Klein discussing her qualitative research on the experience of relapse in people with addiction who have experienced repeated relapses.

Here are a few take-aways:

• The experience of relapse is one of self-betrayal — one self being wholly committed to abstinence/recovery and a self at another point in time betraying that commitment.
• A demoralizing element is the loss of trust in self. Knowing that a future self will betray themselves. This is an experience of powerlessness.
• She distinguishes this from self-efficacy which she frames as confidence in oneself to navigate risk environments (external threats to their recovery). Self-mistrust frames the threat as oneself.
• She explored the impact of relapse on clinicians:
  • She speaks to trauma associated with witnessing relapses and deaths associated with relapses.
  • There is a parallel process between patients and therapists.
    • Therapists develop their own experience of self-mistrust and begin to question their own knowledge, skills, and capacities. (They internalize the relapse — I’m not up to the task.)
    • Therapists begin to distance themselves emotionally from clients and she describes and experience of clinician powerlessness and implies that the clinician begins to externalize the experience — this is what clients with addiction do… this is addiction.
    • This results in emotionally distant therapists. (And, eventually, an emotionally distant system of care.)
    • The therapeutic environment becomes untherapeutic.

Why this is noteworthy

We are in a moment where there is so much emphasis on the suffering in addiction as a product of external responses to addiction and relapse. Her work describes the internal consequences of relapse and drug use within addiction. External responses can influence that experience, ameliorating it or making it worse, but that internal suffering exists regardless of external responses.

Her exploration of the parallel process experienced by clinicians (intensified when deaths are experienced) powerfully describes the threats addiction professionals face to maintaining their own wellness, the challenges clinicians and systems face in trying to maintain a hopeful recovery-orientation, and the consequences when that parallel process is not addressed and managed.

Questions

• Is it possible that her description of that parallel process explains some of the current trends in drug policy discussions?
  • If so, how does it show up?
• Is it likely that the overdose crisis makes us uniquely vulnerable to playing out that parallel process?
• Does the overdose crisis amplify the consequences of failing to acknowledge and manage parallel process?

1. Hope matters in recovery

I’ve been musing a bit recently on the place of hope in addiction treatment and in recovery journeys. Researchers from the USA^[1] identified that hope, although recognised as essential for recovery, was not well researched in terms of how it helps recovery progress. They used validated tools (questionnaires) to assess hope and recovery in 412 people. They found that progressing in recovery reduced relapse risk and that hope had a positive mediating effect.

Behavioural change or life transformation?

The researchers suggest that professionals “Consider adopting a holistic approach to addiction recovery that includes factors associated with wellbeing and human flourishing, as opposed to focusing solely on the managing of behaviours. By helping individuals develop a sense of self efficacy (i.e. mastering my illness), clarifying their values, and fostering feelings of connection and belonging, treatment professionals help individuals reduce the likelihood of relapse.” 

They go on to stress how important these elements (self efficacy, values, connectedness) are to people who are new to recovery and how by highlighting these, professionals can strengthen their clients’ journeys toward recovery. Key to this is helping to frame recovery as a whole life transformation and not just a behavioural change. (My emphasis)

That feels like a quantum shift from how we come at things currently.

2. Abstinence goals may be more reliable than moderation goals

People asking for help for their drinking problems have a range of problem severities and a range of goals. Both things can be dynamic. Some folk want to reduce their drinking and others want to stop. Some, with severe physical or mental health consequences related to drinking will die if they continue to drink. When we research outcomes from treatment, we tend to look at outcomes that clinicians think are important and less at whether individuals reach their own goals.

In health terms, there’s a consensus emerging that no level of alcohol intake is completely safe, but for most modest drinkers, the risks are felt to be minimal. However, this is evidently not true for people with severe alcohol use disorders. Research has shown that the best treatment outcomes are achieved when people have set abstinence as an end goal, even if moderating drinking was the goal at the start of treatment. My experience from general practice for those with the most severe alcohol use disorders was that initially some – perhaps most – set moderation as a goal, but over a long period, even with maximum support, they moved towards believing abstinence would be safer.

For the kinds of patients I see seeking residential rehab who are at the far end of the severity scale, all have come to the conclusion that stopping drinking represents the best kind of reduction of harms. Many have tried to reduce or control their drinking over years and found that they could not do it in a sustained fashion.

In research^[2] from the United States involving 153 people with alcohol use disorder, researchers explored what was going on in terms of the drinking goals the subjects set themselves daily – whether these varied and whether they were able to reach them. They found that complete abstinence was the commonest goal and the one most likely to be reached compared to those aiming for moderation. Paradoxically, they also found that when a daily goal of not drinking couldn’t be reached, those individuals drank more than those setting moderation goals. Nevertheless, the researchers point out:

Abstinence-based daily goals appear to lead to the greatest reduction in at-risk drinking and quantity of alcohol consumption overall. 

Pavadano et al, 2022

They say their findings ‘support the clinical benefit of mapping daily goal setting and strategising for specific circumstances’. Of course, this is something mutual aid groups have been practising for decades.

3. Recovery – pulling is better than pushing

Recently I was asked whether getting bad test results (e.g. evidence of poor liver function from blood tests) could act as a motivator to help cut down drinking in someone with alcohol use disorder. I had to be honest and say that in the patient group I see, almost all of whom have biochemical evidence of livers under attack, this was not the case. I said that motivation for recovery generally has to come from hope that things can get better rather than fears that they will get worse. 

It was interesting then to have my own observations bolstered by qualitative research^[3] from Derby. David Patton, David Best and Lorna Brown explored the part the pains of recovery (push factors) and the gains of recovery (pull factors) play in recovery progress in 30 people with lived experience. Painful things identified included discovering unresolved trauma, difficult housing transitions, moving away from using friends, navigating a new self/world, hopelessness, family difficulties, relapse and stigma. 

Pull factors in early recovery related to making new friends in recovery and gaining tools for recovery – mostly in the settings of mutual aid groups. In sustained recovery those ‘pull factors’ were things like: exceeding expectation of what life might be like, supportive romantic relationships, social networks, stable housing, family reconciliation, finding purpose and making progress in employment.

The researchers found that ‘the pains of recovery rarely led to positive changes’ and that those changes were promoted instead by ‘pull factors’.

Their bottom line:

As recovery is neither a linear pathway nor a journey without residual challenges for many people, there is much to be learned about effective ongoing management strategies in preventing a return to problematic use that utilize a push and pull framework

This confirms my impression that when it come to positive change that carrots are generally better than sticks.

Continue the discussion on Twitter @DocDavidM

References

^[1] Gutierrez D, Dorais S, Goshorn JR. Recovery as Life Transformation: Examining the Relationships between Recovery, Hope, and Relapse. Substance Use & Misuse. 2020;55(12):1949-1957.

^[2] Hayley Treloar Padovano, Svetlana Levak, Nehal P. Vadhan, Alexis Kuerbis, Jon Morgenstern, The Role of Daily Goal Setting Among Individuals with Alcohol Use Disorder, Drug and Alcohol Dependence Reports, 2022,

^[3] David Patton, David Best & Lorna Brown (2022) Overcoming the pains of recovery: the management of negative recovery capital during addiction recovery pathways, Addiction Research & Theory,

I’ve often felt very confused about the direction of US drug policy debates have taken over the last decade.

I’ve worked in addictions and recovery since 1994 and have consistently sought to change social responses to alcohol and drug problems from punitive and stigmatizing to therapeutic and recovery-oriented. This happened to put me in alignment with the new recovery advocacy movement that emerged at the beginning of the millennium.

My views have not been static and have evolved as lessons have been learned and contexts have changed. However, in recent years this has placed me in a position where I feel placed in a conservative or traditionalist box. Those labels put it kindly, retrograde is probably pretty accurate.

The experience has been disorienting and confusing. My views had always been considered progressive on drug policy and those views are now categorized as regressive by significant and influential academic and advocacy segments of the field.

It’s become clearer in recent years that the change isn’t that the field has gotten more (left) progressive, the change is that the field has gotten increasingly libertarian.

Keith Humphreys describes how libertarianism, rather than liberalism, has shaped the conditions generating a lot of the recent concern in San Francisco.

What bedevils the city instead is its libertarian, individualistic culture. Since at least the 19th century, Americans have come to San Francisco to be free of traditional constraints back East, to reinvent themselves, to escape the small-mindedness of small towns and to find themselves. This culture underlies the city’s entrepreneurialism, artistic energy and tolerance for diversity in all forms.

But this has a downside when it comes to addiction, which thrives in such a cultural milieu. San Francisco has long been one of the booziest cities in the country as measured by metrics such as bars per capita or percentage of income spent on alcohol. The psychedelic drug revolution and much of the cannabis culture were born in the Bay Area. The “new” crisis around fentanyl is thus not as novel as portrayed: Heavy use of substances has always been part of how San Francisco defines freedom and the good life.

No, soft-on-crime liberalism isn’t fueling San Francisco’s drug crisis. Libertarianism is by Keith Humphreys

When we hear frustration with the status quo, that frustration is often directed at conservatism, traditionalism, moral panic, and entrenched commitment to the war on drugs. This framing, along with advocacy that emphasizes morality and compassion, obscures the libertarian foundations of this criticism and advocacy.

Is it possible that a major barrier to progress on alcohol and drug problems is entrenched libertarianism? Is it possible that this libertarian influence in drug policy discussion limits the imagination and the range of options deemed acceptable?

Humphreys offers three possible futures for San Francisco and links the status quo to the politics of COVID and gun policy.

Just as voters in some regions of the country decide that more COVID deaths are better than vaccine and mask mandates or that mass shootings are preferable to gun control, San Franciscans might decide that overdose deaths and open drug dealing are a reasonable cost to pay for their vision of freedom. 

No, soft-on-crime liberalism isn’t fueling San Francisco’s drug crisis. Libertarianism is by Keith Humphreys

While Vancouver and San Francisco get framed as exemplars of progressive drug policy, their policies may owe more to Milton Friedman than to progressive politics or ideology.

I suspect these libertarian and individualistic influences are more pervasive than might appear, showing up in ways that are large and small, subtle and obvious. Off the top of my head, here are a few examples:

Addiction isn’t a spectator sport, eventually the whole family gets to play

One of the things that still haunts me, years into recovery, is the memory of the impact of my addictive behaviour on others – particularly those I love but also my colleagues. There was plenty of suffering to go round, the debris spread far and wide. In some ways the cleaning up operation has never quite concluded.

This experience of ‘collateral damage’ is true for most of us who have experienced addiction, yet research is relatively restricted on the phenomenon, despite the fact that the impact on third parties may be as great (or greater) than the impact on the person with the substance use disorder. 

It was interesting then to read a study from Germany,^[1] published in the journal Addiction, which looked at the impact of addictive disorders on family members and how this affected their health and mood. Previous studies have shown that relatives can have increased problems with mental health, injuries, higher use of healthcare services and loss of productivity and that these negative consequences are improved by abstinence.

This was a big study involving almost 25,000 people living in Germany. The researchers wanted to get a feel for the proportion of family members impacted in the general population and how severe those impacts were. In this representative sample of people 15 and older, they found that almost 10% of individuals had a relative with an ongoing addictive disorder problem in the last year. A further 4.5% reported that they had a relative with a past dependency. They found that alcohol was by far the most common drug causing problems (80%), followed by cannabis (16%) and other illicit drugs (12%). 

Family members affected by addictive disorders had higher levels of depression (doubled) and lower levels of self-rated health. Family members also had higher rates of smoking and risky or binge drinking. There was the suggestion of some good news though relating to the impact of recovery from dependence:

Findings suggest a strong association between the recency of the addictive disorders and ill-health and depression and correspond to the results of analyses from the United States based on health insurance data, which suggest that the psychosocial burden on partners of males with an alcohol use disorder decreases after successful treatment.”

Bischof and colleagues, 2022

I fear we do not pay attention enough to this in our research and practice even though Government Policy in Scotland emphasises the needs and role of family when we consider how we deliver treatment. The recently published final report of the Drugs Deaths Task Force recommended the adoption of a whole family approach and that families should have their own specific support for wellbeing and psychological health.

When families are not considered as part of an evaluation of the impact of treatment, we are missing something very important. Recovery may or may not include abstinence, but measures of recovery progress ought to include the positive gains family members and loved ones make as the individual with a substance use disorder recovers. How well do the families of the people in alcohol and drug treatment in Scotland fare?

A few years ago when I was part of a group supporting the production of the Independent Expert Review of Opioid Replacement Therapies in Scotland, I had an opportunity to take evidence from family members of those with substance use disorders members attending a national conference. It was a bruising experience. Families were not happy with the care on offer at the time.

At the end of the session, although I had gathered a wealth of evidence for feedback, I was left feeling responsible for all of the sins of the treatment system. It was not easy to hear the experiences of people who felt they had let down. The message was clear, family members felt excluded from treatment decisions, did not generally support opioid substitution (though they liked buprenorphine more than methadone) and felt stigma stopped them coming forward.

“The needs of the relatives, friends, co-workers and communities affected by the drinking of people in their social networks are seldom voiced, counted or responded to.”

Brian Coon, writing on this blog last year, picked up some themes that are relevant to this. Commenting on a paper that showed improvements in those with alcohol use disorder who cut back on their drinking but continued to drink heavily – arguably a kind of recovery – he references Kelly and Bergman^[2] who point out that heavy drinking can continue to impact on families and that their needs have to be taken into account. 

Brian highlights the danger of separating research data from experience. If we are too narrow in our exploration we will not see other things that are important. We are not islands, we are connected into rich social networks, including our family members. Our behaviours affect others. A finely focussed microscope is a limited tool when the big picture is what matters.

Classifying someone as being in successful “recovery” due to the fact that they appear to be functioning but while engaging in very heavy drinking, ignores the potential collateral damage to close significant others (eg, children, partners), whose well-being can be severely impacted by the enduring unpredictability of heavy use. – John F Kelly, Brandon G Bergman

Of course, family members’ recovery ought not to be dependent on the recovery of their loved one. In the residential rehab service I work in, we have a family programme running alongside the patient programme. This is aimed at supporting the families of those we treat. While most people in the treatment programme will go on to complete it and most of those who complete it will find sustained recovery, we have the philosophy that the wellbeing of the family members is not contingent on how well their loved one does – that families can improve their emotional and physical health by mutual support and self-care regardless.

Families can also be supported through mutual aid groups like AlAnon and via local and national support groups. I think the therapeutic effect of family members coming together and supporting each other is very powerful – perhaps more so than one to one support.

In Scotland, the national organisation, Scottish Families Affected by Drugs and Alcohol captures this ethos in their impact report. I’ll finish with a quote from it because I can’t say it better than they do.

“Being able to enjoy a relaxed family meal, ignoring your phone for a while, giving yourself permission to go for a walk or meet a friend for a coffee, or joining a class or a group for the first time are all huge steps for family members. Their everyday lives have been wholly shaped and controlled by their loved one’s alcohol or drug use, often over many years.

Working with families to learn new ways to communicate and interact, be confident in setting boundaries, prioritise self-care, and understand more about substance use and recovery really does change lives and save lives.” 

Amen to that.

Continue the discussion: @DocDavidM

Picture credit: Oatawa istockphoto, under license

^[1] Bischof G, Bischof A, Velleman R, Orford J, Kuhnert R, Allen J, Borgward S, Rumpf HJ. Prevalence and self-rated health and depression of family members affected by addictive disorders: results of a nation-wide cross-sectional study. Addiction. 2022 May 31. doi: 10.1111/add.15960. Epub ahead of print. PMID: 35638375.

^[2] Kelly JF, Bergman BG. A Bridge Too Far: Individuals With Regular and Increasing Very Heavy Alcohol Consumption Cannot be Considered as Maintaining “Recovery” Due to Toxicity and Intoxication-related Risks. J Addict Med. 2020 Oct 14. doi: 10.1097/ADM.0000000000000759. Epub ahead of print. PMID: 33060467.

Elderly senior person or grandparent’s hands with red heart in support of nursing family caregiver for national hospice palliative care and family caregivers month concept

Enabling and caregiving both involve a strong desire to love, help and nurture another person. These desires are amplified, often with a sense urgency and desperation, for those with loved ones in active addiction.  The reality, however, is that many of the behaviors that seem “helpful” are actually quite the opposite. We can literally love others to death. Here we will differentiate between caregiving and enabling (which we can also refer to as “caretaking” or codependency), offering a more helpful approach to supporting your loved one in active addiction.

Caregiving is the act of giving care to another person who is incapable of giving it to themselves. For example, it is developmentally appropriate to tie a two-year old’s shoes (if they cannot). Enabling or caretaking, on the other hand, is taking away another person’s ability to do something for themselves. When we get into a dynamic of enabling, we rob the other person of any opportunity to learn and experience the growth necessary to function on their own. This creates a mutual dependence that leads to more frustration and resentment for both parties.

When it comes to addiction, enabling adds fuel to the disease’s fire. If you enable your loved one in active addiction, these behaviors prevents them from experiencing the natural consequences of their own behaviors. Examples of enabling in relation to the addiction process include: giving money to an addict; repairing common property the addict broke; lying to the addict’s employer to cover up absenteeism; fulfilling the addict’s commitments to others; screening phone calls and making excuses for the addict; speaking for the addict or bailing him or her out of jail. It isn’t that these behaviors are “bad” or “wrong”, but it is clear they aren’t working to keep your loved one safe and sober.

To stop enabling isn’t easy. For many, the fear of a loved one losing his or her job, going to jail or overdosing is too much to create any lasting behavioral change. You may have to weigh consequences of short-term pain versus long-term misery in each case. However, the most important thing to know is that you do not have to make any of these decisions alone. Like Alcoholics Anonymous and Narcotics Anonymous, Al-Anon and Nar-Anon provide space for those affected by the disease of addiction. Sponsors and other members of the community can help you navigate these challenging decisions, set boundaries that you are comfortable with and learn to enable your loved ones’ recovery instead of their addiction.

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About Fellowship Hall

For 50 years, Fellowship Hall has been saving lives. We are 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.

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“. . . the individual, family and community are not separate; they are one. To injure one is to injure all; to heal one is to heal all. – from The Red Road to Wellbriety, 2002” – as quoted by William White, Recovery Rising

Perhaps the most important insight in recent recovery history is that recovery community, through collaborative effort leads to restoration not only in individual lives but supports healing across entire communities, in all their diversity. Recovery capital is a function of self and community agency. We saw that insight take form twenty years ago, highlighted in the writings of Bill White, Don Coyhis and many others. Bill wrote about recovery rising and community as the primary change agent of healing. Don wrote about incorporating native community methods into healing processes. Not narrowly defined peer service, but the capacity of community to heal itself. It works across America in modestly supported pockets. Developing recovery capital is fundamentally about resourcing and supporting diverse communities to address their own needs. This meets a lot of resistance.  

We need to examine these headwinds if we are to keep moving forward. It is critical to take a hard look at how the recovery community gets sidelined and coopted in subtle or not so subtle ways. Head winds that create barriers to self and community agentry must be fixed if we are to get more Americans into wellness. These forces often stem from homeostasis, even as the state of things is woefully inadequate to the tasks at hand.

If we can reach a point where our voices are included in matters about us, our communities are strengthened, and we have real equity in the systems that serve us, headwinds can become tailwinds. To change, people and systems alike must come to terms with the impact of stigma on our recovery community. We must acknowledge that stigma of addiction and the discounting of persons with lived experiences is commonplace across all of our institutions. Stigma in the SUD realm often plays out across four interrelated dynamics:

• Cultural appropriation – The inappropriate or unacknowledged adoption of an element or elements of one culture or identity by members of another culture or identity. This is particularly true in respect to marginalized groups, which include the recovery community. Recovery initiatives not grounded in recovery are titled and run as such; treatment organizations rebrand services as recovery oriented for funding. Projects to collect our stories by outsiders are funded. Foundational elements of the recovery movement get appropriated when they become valuable. This extends to the very notion of recovery and all of its facets.
• Colonization – The action or process of settling among and establishing control over an indigenous people (in this case the recovery community). Control over what happens in the environment is delegated by entities in power to groups outside of the indigenous community to sustain control. This serves to undermine and inhibit the capacity of the inhabitants of recovery community to manage their own healing.
• – Healing methods and those permitted to provide such services shift away from the very recovery community who developed them. Barriers are erected to keep the marginalized group out in ways that the dominant group does not want or to prevent any shift of power to the marginalized group. Services become harder to provide. These barriers have the most severe and disparate impact on persons who are members of other marginalized groups, like BIPOC recovery communities.
• Cooptation – People from outside of recovery community organizations are placed in power over the role and function of recovery community groups to maintain the status quo. This serves to keep the recovery communities from developing a greater degree of agency over their own healing.

These are serious concerns not often spoken about in open dialogue out of very real risks of retribution but commonly discussed behind closed doors within the recovery community. Over the years, I have spoken to people around the nation in the recovery community who talk about how these dynamics play out. They include:

• Events or services initiated by the recovery community get taken over by treatment agencies or the government. We end up fighting to retain even window dressing levels of inclusion in our own projects.
• Pedagogy developed by us and for us get taken away and end up under the control of our bureaucracies, who then place barriers for us to access these very same methods of instruction. The process of learning and service provision begins to replicate the very challenges that they were developed to navigate around.  
• Recovery communities are disparately resourced, instead academic, and large human service organizations get the lion share of resources. When funding is set up for us, recovery community groups are often pitted against each other for scraps. This creates further divisions that sustains an unhealthy homeostasis.
• Who has control over our stories matters! Our stories get clipped into other groups agendas. We get written out of our own history. Our stories must be handled in ethical ways. Communities who are written out of their own teachings cease to exist in a generation. Revisionist history replaces the authentic history.

Even the most well-intentioned policy makers often end up unintentionally reinforcing these dynamics. Stigma is that powerful and that entrenched. If you are in a position of authority over our communities and you see people asking a lot of hard questions or becoming upset by what you are doing, perhaps share some of the power and strive to understand it and seek remedy in collaborative ways to strengthen agentry. The more common reaction is to quash it. Shut it down and move the process forward to meet predetermined objectives.

Signs of affirming recovery community agentry:

• Systems that affirm our very right to define ourselves and keep in check ever-present tendencies to define and control us have a better opportunity to effectively strengthen recovery through collaborative action.
• Systems accountable to those of us they serve and open to this responsibility with a sensitivity to the most marginalized subgroups can augment our strengths, engender trust and lead to more effective outcomes.
• As Recovery Capital is a function of community and is not just and individual process, systems that ensure that resources get to the members of the community are telegraphing that they understand communities are best suited to affect their own healing. The opposite of paternalistic care, which is rooted in stigma.

Last year, I did a series of interviews with some of the pioneers of the New Advocacy Recovery Movement. One of the parts of the interview with Bev Haberle that resonated with me as fundamental in a recovery-oriented change processes is the centering of our efforts in community grounded ethics. During this interview with Bev, when I asked what she was most concerned about in respect to the future, she expressed a concern that we may end up falling backwards if not careful to pay attention to ethics grounded in the community served. She noted:

“I recall one of the Recovery Community Centers I was involved with and how much effort we put into building an authentic advisory group. People who served on this advisory group / vision team were charged with keeping us focused on the needs of the community and making sure everything we did was done with high ethical standards. They were charged with being stewards of quality recovery support services that meet the needs of the local Community being served. There was a lot of open discussion about what we were doing and we worked hard to make sure we stayed true to our community mission. They often spotted things the rest of us missed. People coming into our centers with what on the face of it looked like beneficial things but who had hidden agendas or self-dealing schemes. As a leader, I knew we needed them as our anchor to our mission.”

Well-functioning systems spend a lot of energy examining ethics and making sure that they run in adherence to good principles. Even the best-intentioned systems do unintentional harm, but the best of them actively work to minimize and fix those harms. In Pennsylvania, we have horrific examples of disparate treatment of the recovery community. It happens in other states as well. What harms one of us harms us all. I see recovering people leaving our field in droves because of the impact of moral injury, as I noted in this article in Treatment Magazine last May:  

“Being in recovery makes many of us “those people” who end up getting disparate care. Every time I see it, I recognize it could be me getting disparate care and insurmountable barriers to accessing help. I could have ended up in a body bag instead of having a life. Every single day this very long week, I have spent time on the phone with people describing care denials of life-sustaining medical interventions under the lens of seeing addiction as a moral failing by licensed medical professionals, persons in long-term recovery who are being denied employment for decades-old legal charges and more. It is a normal week. It also hurts my soul.”

Disparate treatment creates systemic wounds that require healing. Healthy systems welcome tough dialogues and seek healing solutions to these wounds, dysfunctional systems shut down those discussions as too difficult and end up causing even deeper scars. What harms one of us harms us all. What heals one of us heals us all. These are tough subjects, but the work to heal these wounds can shift our headwinds to tailwinds and help heal whole communities. Ignoring these wounds deepen these harms and prevent collective healing. What kind of system of care do we want? The one I want to create deals with the tough stuff head on. If this was an easy process, we would have fixed it decades ago, it remains the challenge before us.      

The question of how to describe and categorize addiction has been the subject of several of my recent posts. Some people scratch their heads about why I care so much about whether we think of it as a disease. Bill White summarized the stakes well here:

If AOD problems could be solved by physically unraveling the person-drug relationship, only physicians and nurses trained in the mechanics of detoxification would be needed to address these problems. If AOD problems were simply a symptom of untreated psychiatric illness, more psychiatrists, not addiction counselors would be needed. If these problems were only a reflection of grief, trauma, family disturbance, economic distress, or cultural oppression, we would need psychologists, social workers, vocational counselors, and social activists rather than addiction counselors. Historically, other professions conveyed to the addict that other problems were the source of addiction and their resolution was the pathway to recovery. Addiction counseling was built on the failure of this premise. 

White, W. (2004). The historical essence of addiction counseling. Counselor, 5(3), 43-48.

Whether we define alcoholism as a sin, a crime, a disease, a social problem, or a product of economic deprivation determines whether this society assigns that problem to the care of the priest, police officer, doctor, addiction counselor, social worker, urban planner, or community activist. The model chosen will determine the fate of untold numbers of alcoholics and addicts and untold numbers of social institutions and professional careers.

The existence of a “treatment industry” and its “ownership” of the problem of addiction should not be taken for granted. Sweeping shifts in values and changes in the alignment of major social institutions might pass ownership of this problem to another group.

White, W. L. (1998). Slaying the Dragon: The History of Addiction Treatment and Recovery in America, page 338

I’ll acknowledge that hustles like patient brokering, cash MAT clinics, drug screen scams, and over-priced residential with little continuing care make it difficult to root for the survival of the “treatment industry” but White’s words capture the risks of transferring responsibility to other groups.

What’s made addiction counseling unique has been the emphasis on recovery as the endpoint. More specifically, a model of recovery that results in people with addiction becoming “better than well.”

An essential step in transferring responsibility from one group to another is redefining the problem.

Some efforts to define addiction as something other than a disease argue that it’s not a disease but, more often, arguments against the disease model are more about achieving particular goals (protecting liberties, assigning personal responsibility, advancing particular drug policy goals, advancing social justice, emphasizing particular interventions, stigma reduction, etc.) rather than questioning whether it’s actually a disease.

Recently, the American Journal of Public Health published an article titled The Harms of Constructing Addiction as a Chronic, Relapsing Brain Disease. I appreciated the clarity of its arguments.

The article opens with the following paragraph:

As an international network of historians and social scientists who study approaches to the management of drugs across time and place, we have noticed the effort to redefine addiction as a chronic, relapsing brain disease (CRBD). The CRBD model is promoted as a route to destigmatize addiction and to empower individuals to access treatment that works within that model’s terms.¹ CRBD usefully recognizes that brain-based neural adaptations place individual brains in chronic states of readiness to relapse. But brains are housed inside of people. Substance use is biological, social, and political; our concepts and approaches to complex questions surrounding substance use must be, too.^2,3 By overlooking the sociopolitical dynamics and inequalities bound up with substance use, the CRBD model can paradoxically further marginalize people who use drugs by positing them as neurobiologically incapable of agency or choice. We are concerned that the CRBD model paints drug users as individuals whose exclusion from social, economic, and political participation is justified by their biological flaws and damaged brains.

Anne K. Lie, et al. “The Harms of Constructing Addiction as a Chronic, Relapsing Brain Disease”, American Journal of Public Health 112, no. S2 (April 1, 2022): pp. S104-S108.

Note that the authors respond to an argument for what the disease model can accomplish — it “is promoted as a route to destigmatize addiction and to empower individuals to access treatment” — rather than to the argument that it is properly classified as a disease.

All illnesses occur within people and have biological, social, and political contexts. The past couple of years have reinforced that those contexts have important implications, even with something as seemingly straightforward as a respiratory illness caused by a virus. That COVID is associated with social, economic, and political disruption, conflict, and suffering shouldn’t and wouldn’t lead us to questions about whether COVID is properly framed as a disease.

Choosing between the CRBD model and addressing the sociopolitical dynamics and inequalities seems like a false choice. Why does it have to be either/or? Cant it, shouldn’t it, be both/and?

No responsible advocate of the chronic relapsing brain disease (CRBD) model would argue that people with addiction are incapable of agency or choice. Addiction is a disorder involving choice, but it is typically characterized as impaired choice or intermittent loss of choice, rather than a complete or consistent loss of choice. One might compare this to serious mental illness with intermittent fluctuations in impairment. These fluctuations in impairment may range from no impairment to severe impairment, depending on the individual and the current state of their illness.

It’s also important to note the authors’ switch from discussing the CRBD model in the context of people with addiction to people who use substances. The CRBD model should never be applied to people without addiction.

The article proceeds with a brief examination and critique of the CRBD model. The authors note that advocates of the CRBD model voiced hope that the model would produce a sharp break from the moral models that had dominated responses to addiction.

The supposedly new CRBD model recycles disease concepts that have mixed medical and moral concerns since the 18th century.⁹ Disease models have been used to support a range of policy approaches from strict prohibition, to compulsory treatment or “civil commitment,” to medical maintenance, to incarceration. In them, addiction has been both criminalized and medicalized; addicts were labeled as sick individuals yet also punished for bad behavior as deviants….

Despite the hopes placed on the new CRBD model, this heritage has not been erased by redefining addiction as a chronic disease located in the brain.¹¹ On the contrary, the brutal social inequalities of US responses to drug-related harms have persisted or even worsened.

Anne K. Lie, et al. “The Harms of Constructing Addiction as a Chronic, Relapsing Brain Disease”, American Journal of Public Health 112, no. S2 (April 1, 2022): pp. S104-S108.

Note that this is not actually criticism of the CRBD. Rather, it’s criticism of the fact that the CRBD has not delivered the change in policy and attitudes that many people hoped for.

Framing Addiction as a Chronic, Relapsing Brain Disease

The article continues with the suggestion that the CRBD may have accelerated these harms in ways that include criminalization, incarceration, and a molecular orientation that opened the door for the opioid crisis with the false belief that Oxycontin’s extended-release formulation might make it safer.

I’m not a believer that the CRBD necessarily leads to less stigma and better policy, and I won’t suggest that the CRBD is responsible for any changes in policy. However, the argument that the CRBD model is associated with incarceration is undermined by trends in incarceration for drug crimes. Even if the CRBD model could deliver significant policy and cultural change, that would take time — years, probably many years. The chart below shows a leveling off and eventual decline of people incarcerated for drug crimes during the period discussed. It’s still too many people incarcerated and those people are disproportionately African American but, if we want to assert an association between the CRBD and incarceration rates, the association would be a downward trend in drug crime incarcerations.

The Oxycontin argument would be a lot stronger if there wasn’t a long history of pharmaceutical advertising that misrepresented the safety profile of medications, often misrepresenting science to obscure the risks.

So… the criticism is not about the scientific or medical truth of the model, rather it’s about insufficient political and social progress.

This section ends with a strong point:

Expanding access to addiction medications without inclusive social policies and harm reduction has not been enough to prevent or stem America’s opioid crisis.

Anne K. Lie, et al. “The Harms of Constructing Addiction as a Chronic, Relapsing Brain Disease”, American Journal of Public Health 112, no. S2 (April 1, 2022): pp. S104-S108.

Calling something a brain disease does not and should not narrow our attention to pills and procedures. Behavioral, psychological, and social interventions ought to be particularly important with a brain disease, particularly since a brain disease is likely to affect those domains and those domains are largely experienced in the brain.

Alternate Frame: Harm Reduction and Social Justice

The authors offer harm reduction and social justice as an alternative frame:

There are other ways of framing and responding to substance use. The most promising of these is harm reduction, a 50-year-old social movement mounted against repressive drug policies. Rather than centering on the brain and embracing abstinence as a goal, harm reduction prioritizes the health and social inclusion of people who use drugs.

Anne K. Lie, et al. “The Harms of Constructing Addiction as a Chronic, Relapsing Brain Disease”, American Journal of Public Health 112, no. S2 (April 1, 2022): pp. S104-S108.

Note that the authors are not really speaking to causes or treatments and there’s no reason the recognition of a condition as a disease should omit social inclusion. For example, serious mental illnesses are recognized as diseases and social inclusion should be considered an essential element of effective treatment and policy.

So, what is the concern?

Consumers resist the coercive and often punitive ways in which medications for addiction have been deployed. Harm reduction links the biological to the social without prioritizing one over the other.

Anne K. Lie, et al. “The Harms of Constructing Addiction as a Chronic, Relapsing Brain Disease”, American Journal of Public Health 112, no. S2 (April 1, 2022): pp. S104-S108.

So, a concern is coercion. Calling something a brain disease does not necessitate coercion (think Parkinson’s), but it can open the door. In the medical world, that door might be opened through the legal designation of a guardian. With mental illness, involuntary treatment may be sought for patients that pose a risk to themselves or others. In the cases of guardianship and court-ordered treatment for a mental health crisis, there are processes designed to protect the rights of the individual, including time limitations on any court order resulting from the process.

In the case of addiction, involvement with the criminal justice system often leads to coerced treatment. And, there has been far too little systemic ambivalence about individual rights when it comes to coerced treatment (and incarceration) for addiction. Importantly, there’s also been too little concern about systemic injustices, like the disproportionate numbers of African Americans charged and convicted of drug crimes.

Addiction is also unusual among diseases in an important way. As Keith Humphreys pointed out, “To use a term from economics, addictions have high negative externalities that most medical disorders simply do not, and that changes how perfectly decent and reasonable people respond to them.”

To illuminate those high negative externalities, Humphreys poses the following questions:

If you had a financial manager who would have access to all your accounts and personal information, would you consider that person developing a heroin addiction of any more consequence than him/her developing type 2 diabetes? If you were enrolling your child in a preschool, would you react in the same way if informed that the teacher was prone to methamphetamine binges as you would to learning that the teacher was prone to asthma attacks? If asked by a non-expert from outside our field, how would you explain why millions of people have chosen to attend self-help groups and treatment programs focused on recovering from having had an ‘‘alcoholic’’ parent, but there is no demand for recovery programs focused on adult children of hypertensive patients?

Humphreys K. (2017). How to Deliver a More Persuasive Message Regarding Addiction as a Medical Disorder. Journal of addiction medicine, 11(3), 174–175.

Acknowledging that there has been insufficient concern for individual rights, I suppose at least 4 considerations are important regarding coerced treatment.

1. Do the circumstances merit limiting the liberties of the person (through court supervision, incarceration, or coerced treatment)? Is this a circumstance where others were harmed or at serious risk of harm? If we removed the substance from the situation, would this still be a matter for the criminal justice (or child protection) system?
2. Treatment for what? What is the person’s substance use problem and is the treatment appropriate for that problem? Are we talking about someone with a mild, moderate, or severe problem? Are we talking about someone with a pattern of impaired control?
3. Coerced treatment is often an alternative to incarceration. This is a good thing. However, we should be mindful that this option doesn’t lower the bar for limiting the rights of a person.
4. What systemic factors are likely to influence who ends up in this system and how their case is handled? Are we acknowledging and addressing those? If forces external to this system are a problem, how can that be mitigated within this system?

I’m ambivalent about the development of processes for addiction that would mirror the mental health processes. Having worked in both systems, I know it would require a lot of work to protect the rights of people with addiction and an enormous amount of work to develop systems of care that can meet the need effectively.

As for the role of the CRBD model in this area, I do see the risk and I do sometimes hear the CRBD model deployed to defend coerced treatment. At the same time, the period of time the authors point to has been characterized by efforts to reduce incarceration and offer treatment as an alternative — on the grounds that addiction is an illness.

I think the CRBD model offers a valuable test for public policy — parity. Would we, should we, treat a cardiac or diabetes patient this way? The high negative externalities identified by Humpreys do present a challenge for parity tests using other chronic diseases, but he offers another frame. He’s talking about it in the context of public education, but it’s relevant for thinking about policy as well.

A better analogy than asthma, type II diabetes, and hypertension we could employ for addiction might be to liken it to chronic infectious illnesses (eg, HIV/AIDS). We accept that for infectious illnesses, some fear of people who have the disease is rational; indeed health professionals exhort people to engage in behavior designed to protect themselves from infected individuals (eg, insisting that a sexual partner with a sexually transmitted disease wear a condom, not personally cleaning the body of someone who died from Ebola). Further, we accept that there is a legitimate role for law enforcement— Typhoid Mary was prevented from continuing to infect people by police (Marinelli et al., 2013), not doctors. Analogizing addictions to infectious diseases has all the virtues of analogizing it to diseases with low externalities (eg, asthma) and also has the unique advantage of better matching the public’s experience of the disorder (and it is them and not ourselves whom we need to persuade).

Humphreys K. (2017). How to Deliver a More Persuasive Message Regarding Addiction as a Medical Disorder. Journal of addiction medicine, 11(3), 174–175.

Of course, this imagery will evoke strong negative reactions from many, but it also provides the potential to narrow the focus for coercive interventions to those where there is actual harm or serious risk to others.

Uneven Progress: Harm Reduction in Europe

Next, the authors provide a little background on harm reduction in Europe that they summarize as follows:

Harm reduction initiatives across Europe and the United Kingdom were introduced as part of publicly funded institutions that often coexist with repressive drug policy systems—something shown with unusual starkness in the French example. The UK example indicates how harm reduction measures do not always center on social justice for people who use drugs but are instead introduced to protect the majority population. The Norwegian example points toward how restrictive access to harm reduction services can facilitate paternalism and reduce agency of people who use drugs.

Anne K. Lie, et al. “The Harms of Constructing Addiction as a Chronic, Relapsing Brain Disease”, American Journal of Public Health 112, no. S2 (April 1, 2022): pp. S104-S108.

Conclusion: Human Rights as an Expanded Harm Reduction Frame

…The human rights frame counters some of the CRBD model’s limitations, including the centering on brain disease pathology and insistence on judging each individual as either a patient or a criminal.

People who use drugs are themselves developing community-based harm reduction approaches that resist both criminalization and medicalization on the ground that both have been used to control drug users. Harm reduction critiques hierarchical forms of clinical and neuroscientific expertise and instead supports people who use drugs in recognizing their expertise in managing their own practices and bodies, supporting their agency, and widening their options. Abstinence can be considered part of this approach, but only if chosen by people who use drugs themselves.³¹ When abstinence is imposed by external forces (medical practitioners, family, law enforcement, or other stakeholders), abstinence itself becomes a risk for overdose death. 

Anne K. Lie, et al. “The Harms of Constructing Addiction as a Chronic, Relapsing Brain Disease”, American Journal of Public Health 112, no. S2 (April 1, 2022): pp. S104-S108.

This illuminates another objection, that the disease label situates the person with addiction as a patient. (As opposed to a criminal.) It’s also important to note that the authors switched from addiction to “people who use drugs.” This switch is important because using drugs isn’t a disease but may be a symptom of the disease of addiction, just as coughing isn’t tuberculosis. To be sure, most people who use drugs do not have the disease of addiction. Differentiating between people with addiction and other people who use drugs is critically important in many ways, but particularly important when discussing the disease model, its conceptual boundaries, and its utility.

The framework of disease is helpful because it helps us draw a boundary to determine who has the disease and who does not, it can help us understand some of the processes involved and their consequences, it can help us identify treatments, and help us identify treatments, behaviors, and interventions that are contraindicated.

The authors seem to be very focused on protecting the right to choose to use drugs. For the minority of users with addiction, a critical element to understand is impaired control, meaning that drug use is not always freely chosen. (One might even say that, at times, the illness coerces the sufferer to use drugs. This is part of what’s so excruciating for people with addiction and their loved ones.) This is one of the reasons that, for this most severe form of drug problems affecting a minority of users, abstinence is indicated.

People with bipolar or schizophrenia have the right to refuse treatment in most circumstances. However, when their illness results in high negative externalities, they may be coerced into treatment via a process that includes several safeguards to protect their liberties.

So… this critique never seems to make a case that addiction is not a disease. Rather, it argues that the CRBD model has not delivered the change some people promised and they proposed a model centered on the social and political change. I don’t see where an emphasis on social justice requires the abandonment of the disease model. In fact, where high negative externalities are present, the disease model becomes a mitigating consideration, resulting in more just social responses.

I believe it’s true that addiction is a disease and the authors never really made an argument that it isn’t. Should that truth be sacrificed or obscured in pursuit of justice? I don’t think it’s a good idea. It’s the kind of thing that contributes to the current epistemic crisis and it isn’t necessary. Any model can be harmful if it’s misused or implemented in a reductive way that results in the neglect of important considerations. The CRBD is no different.

I recently stumbled on this educational page about stigma from the National Harm Reduction Coalition.

It’s well done and illuminates the assumptions and goals for their stigma reduction efforts. They frame responding to drug use as a choice between liberation and stigma, with harm reduction as the path to liberation.

While it may work for many (maybe most) people who use drugs, I’m concerned that it doesn’t work well for people with addiction and might require some modification if it’s intended to be helpful to this minority of people who use drugs.

They define stigma as follows:

Stigma is a social process linked to power and control, which leads to creating stereotypes and assigning labels to those that are considered to deviate from the norm or to behave “badly.” Stigma creates the social conditions that make people who use drugs believe they are not deserving of being treated with dignity and respect, perpetuating feelings of fear and isolation.

National Harm Reduction Coalition

I’d emphasize isolation from their definition. To me, that is the essence of stigmatization. I see it as an evolutionary reaction to perceived threats, seeking to isolate the perceived threat from the rest of the community. That threat could be a disease, a behavior, or anything that might appear to be a threat to the health, function, structure, status, or social order of the community. (It’s important to recognize that something doesn’t need to be an actual threat and that evolution would favor the over-identification of threats. Further, many false positives will probably be aligned with the prevailing social structures, and ones that are not will often have post-hoc explanations that are aligned with those structures.)

In their framework, the goal for people who use drugs is liberation, which is described as such:

Liberation is the act of setting someone free from imprisonment, slavery or oppression.

In the context of drug use and sex work, liberation is about freedom from thoughts or behavior — ”the way it’s supposed to be” — and how we are conditioned to perpetuate harms to others.

National Harm Reduction Coalition

The first statement emphasizes freedom — freedom from external forces infringing on liberty and dignity. The second statement adds freedom from harmful traditions and orthodoxies.

This strikes me as a place where it’s important to distinguish between people with addiction and other people who use drugs.

The elements above may provide a pathway to liberation from social responses to a freely chosen behavior. And, for most people who use drugs, it is freely chosen behavior.

The illness of addiction, however, is characterized by impaired control over use. Further, the experience of impaired control over drug use is an experience of oppression. This illness and impaired control constitutes a barrier to a life organized around the person’s goals, values, and priorities. These barriers extend into all areas of life — the relational, occupational, emotional, moral, civic, and spiritual selves.

Where the illness of addiction is present, freedom from external oppression cannot deliver liberation, though it may remove some barriers to liberation and recovery.

So, how might this change the tree of stigma?

My previous posts on recovery-oriented harm reduction shed some light on my ideas. However, reviewing the tree of stigma got me thinking that, while I differentiated drug use in addiction from other drug use, I didn’t speak explicitly enough to drug use by people without addiction.

Most drug use is not addiction. There is a broad spectrum of alcohol and other drug use. Addiction is at the extreme of the problematic end of that spectrum. We should not presume that the principles that apply to the problem of addiction are applicable to other AOD use.

ROHR is committed to improving the wellbeing of all people who use drugs. ROHR services are not contingent on current AOD use, recovery status, motivation, or goals. Further, their dignity, respect, and concern for their rights are not contingent on any of these factors.

Addiction is an illness. The defining characteristic of the disease of addiction is impaired control related to their substance use. We should not presume that the principles that apply to other people who use drugs will be applicable to people with addiction.

Drug use in addiction is not freely chosen. Because the disease of addiction affects the ability to choose, drug use by people with addiction should not be viewed as a lifestyle choice or manifestation of free will to be protected. It is not a expression of personal liberty, it is a symptom of an illness and indicates compromised personal agency.

An emphasis on client choice—no coercion. While addiction indicates an impaired ability to make choices about AOD use, service providers should not engage in coercive tactics to engage clients in services. Service engagement should be voluntary. Where other systems (legal, professional, child protection, etc.) use coercive pressure, service providers should be cautious that they do not participate in the disenfranchisement or stigmatization of people with addiction. Some might wonder whether ROHR is appropriate for people who use drugs and recovery is not an appropriate endpoint. (Because it isn’t indicated and/or wanted.) Its goal is to assure that hope and a visible pathway to full and stable recovery is available to all for whom it is indicated, but never to impose it.

For those with addiction, full recovery is the ideal outcome. People with addiction, the systems that work with them, and the people around them often begin to lower expectations for recovery. In some cases, this professional despair emerges in the context of inadequate resources. In others, it stems from working in systems that never offer an opportunity to witness recovery. Whatever the reason, maintaining a vision of full recovery (complete and enduring cessation of all AOD-related problems and the movement toward global health) as the ideal outcome is critical. Just as we would for any other treatable chronic illness.

The concept of recovery can be inclusive — it can include partial, serial, etc. While my ROHR writing has argued for a distinction between recovery and harm reduction, Bill White has described paths that can be considered precursors (precovery) to full recovery.

Recovery is possible for any person with addiction. ROHR refuses cultural, institutional, or professional pressures to treat any sub-population as incapable of recovery. ROHR recognizes the humbling experiential wisdom that many recovering people once had an abysmal clinical prognosis.

All services for people with addiction should communicate hope for recovery. ROHR recognizes that hope-based interventions are essential for enhancing motivation to recover and for developing community-based recovery capital. Practitioners can maintain a nonjudgmental and warm approach with active AOD use while also conveying hope for recovery. All ROHR services should inventory the signals they send to individuals and the community. As Scott Kellogg says, “at some point, you need to help build a life after you’ve saved one.”

Incremental and radical change should be supported and affirmed. As the concepts of gradualism and precovery indicate, recovery often begins with small incremental steps. These steps should not be dismissed or judged as inadequate. They should be supported and celebrated as personal accomplishments and they should not be treated as a clinical endpoint. Likewise, radical change should not be dismissed as unrealistic or unsustainable pathology.

ROHR looks beyond the individual and public health when attempting to reduce harm. ROHR wrestles with whether public health is being protected at the expense of people with addiction, whether harm is being sustained to families and communities, and whether an intervention has implications for recovery landscapes. It recognizes that the interests of people with addiction and other people who use drugs will diverge in many cases. ROHR maintains deliberate awareness of this reality and refuses to sacrifice one group for the other.

ROHR should aggressively address counter-transference. ROHR recognizes a history of providers imposing their own recovery path on clients while others enjoy vicarious nonconformity or transgression through clients. Substance use workers of all orientations are vulnerable to savior and martyr complexes. These tendencies should be openly discussed and addressed during training and ongoing supervision.

ROHR refuses to allow recovery and HR to be framed as counterforces to each other. While recognizing that most people who use drugs do not need or want recovery, for those with addiction, ROHR seeks to be a bridge to recovery and lower thresholds to recovery and avoids positioning itself as a counterforce to recovery. Recognizing that addiction/recovery has become a front in culture wars, ROHR seeks to address barriers while also being sensitive to the barriers that can be created in this context. When ROHR seeks to question the status quo, it is especially wary of attempts to differentiate from recovery that deploy strawmen, recognizing that this rhetoric is harmful to recovering communities and, therefore, to their clients’ chances of achieving stable recovery.

ROHR recognizes harm reduction can be an appropriate end for many people who use drugs, but is better pursued as a means to an end for people with addiction. ROHR views harm reduction as strategies, interventions, and ideas to reduce harm. As such, it is wary of models that frame harm reduction as an end unto itself for people with addiction. Back to Scott Kellogg’s point, “at some point, you need to help build a life after you’ve saved one.” The end we seek is recovery, or restoration, or flourishing, whatever is most appropriate for the individual or group. ROHR maintains awareness of tendencies to view harm reduction as “the thing” rather than “the thing that gets us to the thing.”

None of this is intended to suggest that anything here is bad or wrong. In the absence of addiction, this model makes a lot of sense. For most people who use drugs, it makes a lot of sense.

Historically, we failed to do a good job distinguishing between addiction and other drug use, erring on the side of categorizing far too much drug use as addictive. Appropriately, people have sought to correct this problem via professional, academic, and cultural change. (I’ve previously shared concerns about the DSM 5’s effect on the differentiation of addiction from other drug problems.) Unfortunately, this correction has resulted in the erasure of the distinction in many spaces.

This has been a good thing for people who had previously been miscategorized. They are more likely to be left alone and, where appropriate, get help that doesn’t presume addiction is the problem.

However, I’m increasingly concerned about the needs of people with addiction having their needs understood, respected, and responded to appropriately.

As the spectrum of drug use is increasingly being professionally, academically, and culturally understood as a manifestation of liberty and free choice, people with impaired control are likely to be misunderstood and stigmatized.

There’s no inherent incompatibility, but there is some tension. The needs and interests of people without addiction who use drugs, people with addiction who use drugs, people in recovery from addiction, the loved ones of those three groups, and the communities/communities of those three groups are not always aligned.

Recognizing these misaligned needs/interests is essential to developing models, systems, and policies that consider and respond to the needs of everyone. This would be important if these were stable and discrete categories, but the need seems even more important when we consider that people may move through these categories and may be in more than one category at the same time.