Guest blog by Ted Perkins, Facilitator and “Tips & Tools Guy”

Successful recovery from any addiction is a holistic process that  involves  not  just SMART  Recovery meetings, but also social support from friends and loved ones,  perhaps  professional  mental  health  support, and self-guided learning. A great way to learn about your addiction and  successful  recovery in general, is to read through SMART Recovery’s free on line resources and Toolboxexercises, watch our excellent YouTube videos, purchase our Handbook, and also read books.

Whereas in past decades the number of books available for purchase about addiction were less prevalent, today the publishing industry’s Addiction & Recovery genre is a thriving marketplace that features hundreds of helpful books to inform, entertain, motivate, and inspire anyone on their recovery journey.

Here is my list of the “Top-5 Books That Helped Me Recover” and a brief explanation of why I found the book useful and informative.

BRAIN BUGS: How the Brain’s Flaws Shape Our Lives by Dean Buonamano

Addiction happens in the external world of course, but it’s also manifested in our  brains.  Addiction  is a feedback loop that has gotten out of control. The more we  understand  the  way our own  brains can  sabotage our “common sense” or “willpower”, the more we may be able to push back and make better decisions.  This book analyzes many of the cognitive biases at work in our brains, and how so much of our decision making is guided by neurological algorithms that run without us even consciously knowing about them.

MEMOIRS OF AN ADDICTED BRAIN: A Neuroscientist Examines his Former Life on Drugs

by Marc Lewis, PhD.

Not only is this a page-turner, it’s a fantastic look at addiction told through the lens of someone who not only lived it, but then went on to study it. Lewis has been featured in several TedTalks, and I had the good fortune of interviewing him for a video I produced about addiction several years ago.  Part gritty memoir, part science paper, this book is a highly progressive, modern look at addiction not as a disease, but as a treatable behavioral disorder.

IN THE REALM OF HUNGRY GHOSTS by Gabor Mate, M.D.

Mate’s book is considered a must-read in many addiction and recovery communities. He addresses addiction by relating the experiences of several people whom he has treated throughout the years, both successfully and unsuccessfully. The book helps us realize that when it comes to recovery, no one size fits all, and while the mechanics of addiction are identical at a neurological level, each addiction is treatable in different ways.

THIS NAKED MIND by Annie Grace

Grace self-published her book as a way to help process her recovery from an alcohol addiction, never realizing that her manuscript would be picked up by a major publisher and turned into a best-seller. It’s easy to see why. Grace’s stories of her own relationship to alcohol are highly relatable, and the way she approached the solution to her addiction is inspirational. Fans of the book often say “that was me” as she describes her battle with booze.

THE HEART OF ADDICTION: A New Approach to Understanding and Managing Alcoholism and Other Addictive Behaviorsby Lance Dodes, M.D.

Why do people repeat behaviors that are clearly problematic? What is it about us humans that drives us towards 9uick rewards at the cost of long term conse9uences? Dodes explores these and many other topics from the point of view of both a clinician and a psychologist who helps us better understand the role that emotions play in addiction. He also successfully debunks several myths about addiction and argues for a more open-minded approach to treatment based on hard science, less stigma, and more progressive methodologies besides total abstinence or allowing people to hit rock bottom.

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

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

IMPORTANT NOTE:

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Katie Lain is the co-founder of Thrive Alcohol Recovery, an organization that uses the Sinclair Method to help treat alcohol use disorder (AUD).

Katie struggled a decade trying to get her drinking under control, but no programs or treatments worked. In searching the internet for answers, she found a TedX featuring Claudia Christian, How I Overcame Alcoholism, and thought what she was saying was too good to be true.

Developed by Dr. David Sinclair, the Sinclair Method works by taking naltrexone, an FDA approved medication, 1-2 hours before drinking, to block the pleasure receptors in your brain. With long-term, consistent use, it is medically proven effective at changing a person’s relationship with alcohol.

SMART Recovery is a great compliment to the Sinclair Method because it teaches people tools, like the Hierarchy of Values (HOV) and Cost Benefit Analysis (CBA), to help them understand why they abused alcohol and how to now live life without it.

Check out this great interview by Luke Frazier, for our show Insiders+ Access, made possible in part by the generous support of SMART Insiders+ participants.

Watch on our YouTube channel

C3 Foundation

The Cure for Alcoholism by Roy Eskapa

For more information on how you can join the SMART Insiders+ Program, go to: www.smartrecovery.org/insiders

Listen as a Podcast:

Click here to find all of SMART Recovery’s podcasts

PLEASE NOTE BEFORE YOU COMMENT:

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

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

IMPORTANT NOTE:

If you or someone you love is in great distress and considering self-harm, please call 911 for immediate help, or reach out to 988 Suicide & Crisis Lifeline @ 988, https://988lifeline.org/

We look forward to you joining the conversation!

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

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A few years back in my first few months of working full time in addictions, I attended a seminar on mutual aid. Facilitated by an addiction psychiatrist, the meeting was packed with a variety of addiction treatment professionals.

The facilitator laid out the evidence base for mutual aid as it was at the time and discussed how assertively referring to mutual aid organisations could result in high take-up rates with benefits to patients. This was in the days when most groups were 12-step – SMART and other groups were still to be launched locally.

At the interactive part of the presentation the audience was asked ‘what objections might your patient have to attending mutual aid groups’? There were a variety of responses to this: people don’t like AA; many don’t want abstinence; people don’t like speaking groups; it makes people want to drink and use; they are too religious; everyone goes to the pub after an AA meeting; the groups are cult-like; it’s not safe for women etc.

As each objection came up the facilitator gave evidence from literature and from his experience to allay concerns in a robust manner. A curious thing began to happen, as he gave reasonable and, to my mind, fairly convincing reassurances to each objection, many of the participants began to double down, argue, find new objections and the heat in the room went up. Some got irritable and short.

I began to realise what was going on. The professionals were no longer relaying the concerns of their patients, they were relaying their own concerns, or to be frank, they were relaying their own prejudices. This of course, did not apply to some who hold open or positive views.

Some of the reasons for resistance to mutual aid have little to do with mutual aid, but to do with our own reasons for being in the caring professions. For some of us, the prospect of the client leaving our care and managing on their own is a bridge too far. When this is the case it is rarely in consciousness.

What else is going on when some of those who work with people with alcohol and other substance use disorders are antagonistic to mutual aid and lived experience organisations? In the last while I’ve heard a very senior medic dismiss lived experience as ‘fake news’ and assert that recovery communities are unlikely to prevent drug deaths. Recovery discrimination and stigma can be just as potent as addiction stigma.

On Twitter someone who is well respected and works in the field asserted, ‘the biggest risk to drug users is… recovery orgs… bound by a belief system handed down, full of holes, and not fit for now’. So not only not helping, but making things worse?

There are other less ostensibly antagonistic views out there which may be even more damaging. ‘It doesn’t suit everyone’ is often a starting point in discussions with colleagues about mutual aid (this happened in a meeting yesterday incidentally). This approach is a subtle way to remove any enthusiasm or motivation to get serious about connecting people to mutual aid. 

When patients have serious medical conditions that need intensive treatments like radiotherapy or IV antibiotics, we don’t initiate the conversation by saying ‘this doesn’t suit everyone’. If the evidence base is good that an intervention is more likely than not to provide benefits we usually come at it with a recommendation to try it, not to immediately stick a flag up that says ‘may not work’.

And does it work? Mutual aid, I mean. Well, yes.

A Cochrane review which examined evidence from 27 published studies involving 10,000 people found AA performed as well as established treatments like cognitive behavioural therapy (CBT) and motivational enhancement (and was free) but better than these when twelve-step facilitation was employed. Abstinence rates where people participated in AA were 42% one year later compared to 35% with other treatments including CBT. The time for confusion about the efficacy of mutual aid is over.

John Kelly, a Professor of Addiction Psychiatry at Harvard University, one of the researchers who co-authored the Cochrane review, has just published a further paper on mutual help organisations,[1] in which he says, “AA and similar freely available community-based 12-step and non-12-step (eg, SMART Recovery) MHOs [mutual help organisations] may be the closest thing public health has to a “free lunch.”

AA is without doubt the most studied mutual aid group with many robust studies now published. Although the same quality of evidence is not available for other mutual aid groups, Kelly writes, “Emerging evidence from statistically controlled prospective observational studies do show positive salubrious relationships between NA participation and better opioid use disorder outcomes, particularly increased abstinence and enhanced adherence to medications for the treatment of opioid use disorder.”

He also reports, “NA mutual-help attendance was associated with twice the rate of abstinence independent of buprenorphine or methadone engagement more than 3 years after entering the trial. Professionally delivered behavioural treatment in that study, on the other hand, was not associated with opioid abstinence.” It is likely that non-12-step mutual aid confers benefits too.

The problem with this free lunch is lack of access. The table is set, the dishes are served, the plates are bountiful and healthy, but relatively few are turning up – though it does not have to be that way. In England, recognising the public health benefits of a free lunch, PHE published a suite of documents to improve uptake.

While we have acknowledgement of the value of mutual aid in policy documents here in Scotland, we still have a blind spot in terms of the emphasis we place on it. If you want evidence, look at the research output on mutual aid from the academic community in Scotland. (I’ll save you time, there is next to none). In Edinburgh in 2010, less than 1% of individuals attending treatment services had ever been to AA. For NA, it was less than half a percent. Think back to those professionals and their views on mutual aid at that seminar I attended. We ought not to be surprised.. I think things are better now than they were then, but not nearly as good as they might be.

Unless you have a drugs or alcohol worker or social or healthcare professional who is aware of the evidence base, who is not carrying conscious or unconscious bias against mutual aid and who knows how to get you to the free lunch then your chance of getting to lift your knife and fork and feast at the recovery table is limited. That’s not okay and it’s got to change.

Continue the discussion on Twitter @DocDavidM

[1] Kelly JF. The Protective Wall of Human Community: The New Evidence on the Clinical and Public Health Utility of Twelve-Step Mutual-Help Organizations and Related Treatments. Psychiatr Clin North Am. 2022 Sep;45(3):557-575. doi: 10.1016/j.psc.2022.05.007. Epub 2022 Aug 1. PMID: 36055739.

Reading about addiction and recovery can be overwhelming and confusing. Media reports and experts often make strongly worded statements that are contradicted by statements from other media sources and experts. Other times, they seem to negate or minimize the lived experience of people with drug or alcohol problems and their families.

For example, it’s very common for press releases, media reports and, occasionally, researchers to make statements about a study demonstrating the effectiveness of a particular intervention. Other times, we hear people say something like, “science shows that [insert intervention] works.”

However, when we look closely at the study, we may find that the outcomes don’t fit our idea of “effectiveness” or “works.” Further, the conditions and subjects don’t resemble the real world.

This isn’t confusing just for lay people, it’s confusing for professionals and policymakers too. And, to make matters worse, most of us are pretty reluctant to question statements presented as science or evidence-based.

For this reason, I’ve been working on a guide that will hopefully allow anyone to review a study and evaluate its relevance to its goals. This way you can make an informed evaluation rather than having to rely on the reporting of others, who may see things through their own bias or interests. The guide is based on the following questions.

  1. What is the treatment or intervention being studied?
  2. Who were the subjects?
  3. How long was the study?
  4. What outcomes did the study measure? (How did they define success?)
  5. What were the study methods?
  6. What were the actual findings and does the authors’ discussion accurately represent the findings?
  7. Were there any conflicts of interest (real or potential)?
  8. What questions does the study not answer?

1) What is the treatment or intervention being studied?

It’s important to pay close attention to the intervention being studied. It is common for news reports about the study to describe it poorly. Further, it’s common for the study itself to obscure the details of the intervention.

Interventions might include:

It’s also important to know more about how the treatment was delivered:

Question 2: Who were the subjects?

There is a wide spectrum of alcohol and other drug problems, with addiction on the most severe end and misuse on the less severe end. Further, there can even be considerable variation within a category. Additionally, there can be significant differences in where the subjects are found as well as their life experience or current conditions.

3) How long was the study? 

Robert DuPont once observed, “The most striking thing about substance abuse treatment is the mismatch between the duration of treatment and the duration of the illness.” 1

Addiction is a chronic disease and recovery is a long-term process, but research is often limited to days and weeks.

The longer the study, the better. For example, Dennis, Foss, and Scott 2 found relapse rates of 64% for people between 1 and 12 months abstinent. Those relapse rates drop to 34% for people with between 1 and 3 years abstinent. 

Therefore, a study that reports on any outcome at less than one year may say very little about what can be expected long term.

Look for studies that report on outcomes after one year.

4) What outcomes did the study measure? (How did they define success?)

Outcomes measured in research do not necessarily correspond well with the outcomes patients are seeking.

Common outcomes include:

Less common outcomes include:

The implications for this are profound. For example, a study may investigate the effects of a treatment on people with opioid use disorders. If the study is only examining the impact of the treatment on illicit opioid use, the treatment could be described as effective when subjects sustain alcohol, cocaine, or prescription opioid problems. 

Consider the outcomes you want for yourself or your loved one. Then, determine whether the study’s outcomes match your desired outcomes.

5) What were the study methods?

There are many approaches used in SUD research and each approach offers advantages and disadvantages in different situations. Methods include experimental (including randomized control trials), qualitative, case studies, meta-analysis, and observational.

It’s often said that randomized controlled trials (RCTs) are the gold standard for research. It’s important to keep a few things in mind about them. First, they lend themselves to studying easily quantifiable outcomes, which means they tend to focus on relatively narrow outcomes in relatively narrow contexts. Second, they tend to be very expensive, which means that they often only get done with financial backing from large institutions (public or private). Third, in some cases, their use may be limited by ethical problems related to using placebos or blinded treatments. Finally, they tend to eclipse experiential and local knowledge. 

It’s also important to look at other factors, for example:

6) What were the actual findings and does the authors’ discussion accurately represent the findings?

This sounds very straightforward, but it often requires a lot of effort to answer this question. Outcomes are sometimes reported very clearly in raw numbers and percentages, other times they are reported in the form of statistical terms that can be a challenge to decipher. 

7) Were there any conflicts of interest (real or potential)?

A conflict of interest is a situation in which financial or other personal considerations have the potential to compromise or bias judgment and objectivity. It is worth noting that a conflict of interest exists whether or not decisions are affected by a personal interest.

Conflicts of interest can lead to more than unreliable information about particular treatments. For example, Stenius (2016) described alcohol and tobacco industry’s influence on the assumptions underlying policy decisions.

It is well documented how the tobacco industry for decades funded research aimed at producing uncertainty about the danger of smoking (e.g., Brandt, 2012). For alcohol, the transnational producers have invested resources in research that questions the relation between the total consumption and alcohol-related harms on a population level to prevent general regulations of the alcohol market (Adams, 2016).Stenius, Kerstin. (2016). Addiction journals and the management of conflicts of interest. The International Journal of Alcohol and Drug Research. 5. 9.

8) What questions does the study not answer?

No study can answer every question, nor should any study seek to every question. However, it can be helpful to stop and ask, what questions does the study not answer?  

There are two ways to group these questions.

First, there are questions that simply cannot be answered by the study. Considering what was asked, and not asked, provides context for the study.

Second, and maybe more important, is what questions does the study appear to have data for, but chose not to answer? For example, if a study looks at the impact of a treatment on drug use, as measured by urine drug screens, does it report on the number of subjects who were continuously abstinent?

  1. DuPont R. (March, 2018). Interview with Brian Coon. Interview presented at the NC Recovery Alliance Summit, Durham, NC.
  2. Dennis, M. L., Foss, M. A., & Scott, C. K. (2007). An Eight-Year Perspective on the Relationship Between the Duration of Abstinence and Other Aspects of Recovery. Evaluation Review, 31(6), 585–612.

 

You’ve probably heard “90 meetings in 90 days” before, somewhere during your recovery journey – 90 in 90 is a major method of maintaining recovery once you’re out of treatment and back in the real world. Although it may not seem easy to make room for meetings in your schedule, there are many benefits to consistently attending meetings throughout your recovery.  Here are a few reasons to encourage you to stay the course:

It’s not unusual to outgrow some of the relationships you had when you were using.  You may find that most of the people around you are your recovery friends who understand your challenges.  Attending meetings will give you an opportunity to build new friendships with those who share goals similar to yours.

Cravings are normal.  Everyone who has engaged in addictive behavior in the past will experience uncomfortable cravings during recovery.  The good news: cravings will subside if you work your plan. Recovery meetings can help you learn new coping strategies in a supportive environment, while you determine what works best for you.

With so many distractions, it can be difficult to see a Higher Power at work in your life each day. Hearing your friends share their personal miracles at meetings, it becomes easier to see the ways your Higher Power is at work in everyday life. You’ll get to a point where you’ll begin sharing your own stories, showcasing how your Higher Power is guiding you on your recovery journey.

There is a long list of to-dos when it comes to living a life in recovery. It can be overwhelming but having a community to help hold you accountable is important.  Connecting with your peers at meetings allows you to have people who can check in with you and help you stay on course. Support from others in recovery is essential – your recovery network can provide insight and understanding that friends and family might not be able to give you.

In active addiction, it’s not uncommon to isolate yourself from friends and family. But in recovery, you come to know that you are not alone.  Meetings can give you a sense of belonging and an opportunity to stay connected to a vital support community.

Attending meetings can help you prevent the occurrence of a relapse, see the miracles in your life and provide you with the opportunity to give to and receive from others. Meetings also provide a consistent schedule and continually reinforce the building of strong habits – you’re more likely to stick with your meetings once they’re an ingrained part of your daily routine, and the same goes for your recovery. Be encouraged to find your closest meeting and get involved. It can make all the difference.

 

***

For more information, resources, and encouragement, “like” the Fellowship Hall Facebook page and follow us on Instagram at @FellowshipHallNC.

 

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.

Demonstrated solutions to alcohol and drug problems will do more to reduce the stigma attached to these conditions than will endless debates about the source of such problems.

White, W. (2000). Toward a new recovery advocacy movement.

(Photo credit: beware of pity by shawnzrossi)

…I do want to suggest that something got lost along the road to professionalization. What got lost was a relationship between two people that transcended the roles of counselor and client. What got lost was our deep involvement in the community and in local communities of recovery. What got lost was our recognition of the power of community to heal and sustain people. John McKnight in his recent book, The Careless Society: Community and Its Counterfeits, argues that compassion shifted from a cultural value to a job description as paid helping roles replaced functions of families, extended families, neighbors, co-workers and friends. He argues that we don’t need more agencies or larger agencies, but that we desperately need more community. In medicalizing alcohol and other drug problems in hopes we could escape its social stigma and moral censure, we turned our backs on the power of community and created an ever-growing distance between ourselves and those we are pledged to serve. Perhaps it is time we went back and discovered what was of value along that road we didn’t take.

White, W. (2003). The road not taken: The lost roots of addiction counseling. Counselor, 4(2), 22-23.

(Photo credit: “a fork in the road” by pipiwildhead is licensed under CC BY-NC-ND 2.0.)

September is National Recovery Month, but many advocates point out we can certainly recognize recovery year-round, including Keegan Wicks. He is the National Advocacy and Outreach Manager for Faces & Voices of Recovery. He works to ensure that the recovery spectrum of services is available and funded for anyone who needs them.

In this podcast, Keegan talks about:

Additional resources:

Click here to find all of SMART Recovery’s podcasts

PLEASE NOTE BEFORE YOU COMMENT:

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

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

IMPORTANT NOTE:

If you or someone you love is in great distress and considering self-harm, please call 911 for immediate help, or reach out to 988 Suicide & Crisis Lifeline @ 988, https://988lifeline.org/

We look forward to you joining the conversation!

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

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Eve Tushnet, from a list of 5 things the disease model gets wrong about addiction:

It isn’t mercy. If someone genuinely did not choose to do wrong then compassion for that person isn’t mercy—it’s justice. And conversely, if you can only have compassion on someone if you believe she did not choose her misdeeds, then you’ve defined mercy out of existence. You’re not forgiving—you’re saying there was never anything to forgive.

Eve Tushnet in 5 Things the Disease Model Gets Wrong About Addiction

(Photo by Miguel u00c1. Padriu00f1u00e1n on Pexels.com)

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For most of my career, I’ve been responsible for managing treatment programs. I believed strongly in those programs. At one of those programs, we developed a continuum of care that provided treatment and substantial, structural recovery support for more than 2 years for people with high severity, high chronicity, and high complexity cases of addiction. We devoted lots of time and energy to monitoring outcomes, patient retention, assuring quality, staff development, and integrating best practices. This program helped people whose lives had been destroyed by addiction become better than well and pursue lives full of connection, service, and personal accomplishments.

Over that time, I’ve been a vocal treatment advocate. That’s how this blog started. However, I’ve needed to be reminded over and over again that a lot of treatment isn’t worthy of that advocacy. Too many treatment programs market hope and recovery but provide care of inadequate quality, duration, and intensity. (Things like cost and credentials are often not good indicators of adequate care.) Some do it for profit, others aren’t knowledgeable or competent, and many are just following the status quo.

As the opioid crisis turned into an overdose crisis (with fentanyl as an accelerant) inadequate care became increasingly dangerous for patients, and it became increasingly important for providers to challenge inadequate and questionable care. It’s also become increasingly important for providers (and advocates) to ruthlessly interrogate their own models of care and be honest about their limitations.

I don’t believe any provider can be all things to all patients, particularly since patients come to treatment with different goals, needs, resources, preferences, etc. However, all providers can be transparent about the pros and cons of their treatment model AND the pros and cons of services/treatments they don’t offer. I’ve become convinced that this is the only path forward for ethical treatment providers — to develop rigorous models of informed consent that are repeated throughout the treatment episode and offer information and active linkage to any reasonable treatment option not offered by that provider. That informed consent is not a one-time event is critical — patients’ goals, preferences, needs, and resources change over time, particularly as they experience successes and setbacks that prompt reflection and re-evaluation of their options. Given the risks, tradeoffs, and individual factors, it’s the responsibility of the treatment provider to make sure the patient is informed and given the opportunity to choose the treatment approach that best aligns with their goals, needs, and preferences.

All of this has been a long introduction to a recently released study that’s been used to advocate for telehealth treatment services.

First, I want to make it clear that I harbor no skepticism about the importance of telehealth services as part of an effective system of care. With the explosion of telehealth during the pandemic, I’ve seen the benefits of telehealth in the engagement and retention of patients who might never try in-person services or stay engaged with in-person services for reasons as varied as transportation, scheduling, temperament, and medical or psychiatric comorbidities.

The study looked at medication retention and medically treated overdoses before and during the pandemic, with the before-pandemic group representing office-based care and the during-pandemic group representing telehealth care. They found good news and bad news

The good news was that shifting to telehealth did not adversely impact either of these outcomes.

The bad news was that I found the outcomes to be very disappointing.

Retention rates for buprenorphine (defined as use over 80% of days) over 6 months were 31% for the office-based group and 33% for the telehealth group.

Retention rates for extended-release naltrexone (defined as use over 80% of days) over 6 months were 8% for the office-based group and 12% for the telehealth group.

18% of each group experienced a medically treated overdose during the study period.

The subjects were all Medicare patients. They had to meet age or disability requirements to enroll. However, the retention rate is no inconsistent with what I’ve seen in other studies with other populations.

I imagine most patients and families are looking for treatments that offer better than a 1 in 5 chance of an overdose, and 2 in 3 chance (or 9 in 10 for extended-release naltrexone) of discontinuing treatment within 6 months.

Are those outcomes explained to patients? Are they offered other options?

This criticism isn’t about the treatment being offered (in this case, medication) or the method of delivery (telehealth or in-person). My criticism is about the system of care that doesn’t offer treatment and recovery support of adequate duration, intensity, quality, and scope. (Which is the norm whether you’re entering residential, outpatient, or office-based MOUD.) And further, it’s representative of an evidence-base that tends to speak only to outcomes like medication retention and overdose.

In his call for recovery-oriented methadone maintenance, Bill White described the difference between remission and recovery:

Recovery from opioid addiction is also more than remission, with remission defined as the sustained cessation or deceleration of opioid and other drug use/problems to a subclinical level—no longer meeting diagnostic criteria for opioid dependence or another substance use disorder. Remission is about the subtraction of pathology; recovery is ultimately about the achievement of global (physical, emotional, relational, spiritual) health, social functioning, and quality of life in the community.

White, W. & Torres, L. (2010). Recovery-oriented methadone maintenance.
Chicago, IL: Great Lakes Addiction Technology Transfer Center.

Studies like the one mentioned above don’t even speak to remission.

22 years ago, in response to systems of care that were failing to meet the needs of people with addiction, their families, and their communities, Bill called for a new recovery movement:

The treatment movement that grew out of it focused on creating, professionalizing and legitimizing medically- and psychologically-oriented care of the alcoholic and the addict. While each of these movements can claim successes, the dissipation of the first movement and a backlash against the second has left a vacuum that begs to be filled. It is time for a recovery movement. The central message of this new movement is not that “alcoholism is a disease” or that “treatment works” but rather that permanent recovery from alcohol and other drug-related problems is not only possible but a reality in the lives of hundreds of thousands of individuals and families.

White, W. (2000). Toward a new recovery advocacy movement.

Two decades later, as we confront new system failures, and a new wave of treatments and research that intimate pessimism that full, permanent recovery is possible, it seems like a good time to revisit Bill’s early work on Recovery Management.

As he launched Recovery Management he described 10 areas of vulnerability with the dominant acute care model. A lot has changed, but many problems remain, and some new problems have emerged. Revisiting those 10 areas might be a good place to start to evaluate the current problems and opportunities.

  1. Attraction
  2. Access & Engagement Access & Engagement
  3. Assessment & Assessment & TxPlanning Planning
  4. Service Elements Service Elements
  5. Composition of Service Team Composition of Service Team
  6. Locus of Service Delivery
  7. Service Dose and Duration Service Dose and Duration
  8. Frequency of Discharge, Relapse, Readmission
  9. Failure to Manage Addiction/Tx/Recovery Careers
  10. Timing of Recovery Stability

References

Czeisler MÉ. A Case for Permanent Adoption of Expanded Telehealth Services and Prescribing Flexibilities for Opioid Use Disorder: Insights From Pandemic-Prompted Emergency Authorities. JAMA Psychiatry. Published online August 31, 2022. doi:10.1001/jamapsychiatry.2022.2032

White, W. (2000). Toward a new recovery advocacy movement.

White, W. (2002). A brief primer on recovery management.

White, W. & Torres, L. (2010). Recovery-oriented methadone maintenance. Chicago, IL: Great Lakes Addiction Technology Transfer Center.

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