In a recent post, I tried to unpack “drug policy” to look beyond legal/illegal and think through the kinds of things that drug policies determine and influence.
Historically, it seems that concerns about the harms associated with drugs have overshadowed the harm associated with policies that seek to prevent those harms.
It seems particularly important at this time to acknowledge the direct and indirect harms associated with drugs, and the direct and indirect harms associated with drug policies.
Several articles published within the last couple of weeks brought that post and the role of policy to mind.
Addicted to Cannabis?
The NY Times recently published an article on cannabis use and addiction. It raises questions about trends in use (also addressed in this recent article), the relationship between those trends its legal status, how differences in harms influence the ways drugs are thought about, and how problems are conceptualized by the public, journalists (the authors equate cannabis use disorder and addiction), and professionals.
Julian (who asked not to use his last name when talking about a sensitive medical condition) didn’t have much of a social life, so he started smoking by himself to pass the time. “Weed became my friend,” he said. “I would get off work and I would smoke because I was bored.”
Soon, Julian’s life began to revolve around cannabis. Smoking never interfered with his work, but it stopped him from doing just about everything else. “Typically, when you move to a new city, you establish new relationships, and I was doing none of that,” he said. “I was living almost like a recluse.”
…Despite the common misconception, people can become addicted to cannabis just as they can with other drugs, like alcohol or cocaine. As more states either decriminalize or legalize cannabis, more people are using it than ever before. According to the National Survey on Drug Use and Health, in 2021, approximately 19 percent of Americans 12 and older used cannabis, and nearly 6 percent of teens and adults qualified as having cannabis use disorder…
…The potential consequences of cannabis use disorder are not as severe as with other drugs like opiates, where overdose deaths are a dire concern. But cannabis addiction can cause “a dramatic decrease in quality of life,” said Dr. Christina Brezing, an assistant professor of psychiatry at Columbia University.
This Bridge Michigan story raises questions about policy influences price, how price influences use patterns, industry consolidation, and the creation of adjacent business sectors.
…as revenues rose for recreational use, the price of marijuana has plummeted. The average price of an ounce of recreational marijuana was $160.10 in February of last year compared with $86.00 this February.
Experts say one reason the price for marijuana is constantly decreasing is to encourage more consumers to buy it legally, rather than from illegal sellers.
“Even though prices are falling, there’s more people buying in the legal market [and] that’s what’s driving the increase in overall revenue,” said Beau Whitney chief economist for the National Cannabis Industry Association.
An oversupply
Others say oversupply is driving down the price of marijuana.
The Michigan cannabis industry started to become oversaturated with products about a year ago, causing prices to decrease, said Corbin Yaldoo, founder of Corbin Ventures, a commercial real estate development and investment firm in Bloomfield Hills that specializes in cannabis real estate.
“The larger operators have more capability of selling products at a cheaper price,” he said. Because larger operators are able to do this without taking a loss, they ultimately have control over the market.
“Michigan is in its consolidation stage right now, so larger operators are acquiring smaller operators or they’re merging together,” he said.
There isn’t anything that can be done immediately to help suffering businesses, but Yaldoo said lawmakers should limit how much cultivation space they allow growers.
The state currently has 753 active licenses for class c marijuana growers, who can possess up to 1,500 plants according to state law.
Changes in Alcohol Consumption Sharpen Health Inequalities
A recent Lancet article describes the consequences of changes in alcohol consumption patterns, the role the alcohol industry plays in the dominant public health narratives, and how those narratives obscure the inequities associated with those changes in consumption.
Alcohol-specific deaths (encompassing those deaths that are a direct consequence of alcohol, such as alcohol-related liver disease) in the UK have taken an extremely concerning turn, with the Office for National Statistics reporting 9641 such deaths in 2021—the highest on record and a 27·4% increase since 2019 (n=7565).1 This number of deaths reflects alcohol consumption trends since the pandemic, during which drinking patterns became more polarised, with people who were drinking lower amounts before the pandemic on average, drinking less, and people who were drinking higher amounts before the pandemic drinking more.2 This change represents a substantial sharpening of health inequalities, driven by changing consumption patterns of a harmful product.
Communications from the UK’s alcohol industry via their responsibility body, the Portman Group, present a different situation. In 2022, communications from the Portman Group published infographics that drew attention to declines in overall average alcohol consumption, emphasising that “the majority of UK drinkers consume alcohol responsibly”.3 The industry also explicitly links its activities to declines in average alcohol consumption. In an evidence submission to the Scottish government on minimum unit pricing,4 the Portman Group stated that it, along with others, has “played a role in supporting these falls in consumption and harm”, citing corporate social responsibility initiatives like the UK Responsibility Deal (which an independent evaluation found to not be effective5), funding DrinkAware (which independent research has shown communicates misinformation on alcohol-related harms6); and supporting community alcohol partnerships (for which there is little evidence of effectiveness).
The responsible drinking language used in these statements has been found to be overwhelmingly used by industry, rather than other stakeholders like government health departments or independent alcohol charities.8 Such language has been described9 as strategically ambiguous, designed to build positive impressions of an industry that appears to foster responsible use of its product, but with little evidence of effectiveness for responsible drinking campaigns. Crucially, talk of a responsible majority implies that people who drink large amounts of alcohol are somehow irresponsible, and that it is their apparent susceptibility which is to blame. This framing also implies that alcohol harm is a problem only for people drinking the most amount of alcohol, whereas the evidence is clear that alcohol causes substantial harm beyond this group.10
Across 32 months of implementation, we found a significant 13% reduction in deaths wholly attributable to alcohol consumption compared with our best estimate of what would have been expected had the legislation not been implemented. This is equivalent to avoiding 156 deaths per year, on average. There was a corresponding estimated reduction of 4% in hospitalisations for conditions wholly attributable to alcohol consumption, equivalent to avoiding 411 hospitalisations per year, on average. The use of a controlled interrupted time series study design allowed us to infer that the estimated impacts were plausible causal effects attributable to MUP legislation.
Exploratory analyses indicated that the largest reductions were estimated in the 40% most socioeconomically deprived areas in Scotland, indicating that the implementation of MUP has had a positive impact in tackling deprivation-based health inequalities in alcohol health harms. The implementation of MUP legislation was associated with reductions in deaths wholly attributable to alcohol consumption for males and females. Furthermore, we found associated reductions in the age groups of 35–64 years and 65 years and older, but were unable to evaluate change in the 16–34 years age group due to the relatively small number of deaths for this group. The positive impact of MUP legislation by population subgroup was generally similar for hospitalisations, although to a lesser degree.
In this study, we assessed effects of outlet densities on six alcohol-related crimes during weekday, weeknight, weekend day and weekend night hours… we measured relationships between crime outcomes and outlet densities for different days and times. Strong evidence supported differences in DUI, assaults and robberies by day and time. DUIs and assaults occurred more often in areas with more bars or pubs on weekend nights. …Moderate evidence supported differences in IPV (interpersonal violence) by day and time.
This snippet from an email newsletter from the Detroit News raised questions about the influence of drug industries on public policy only tangentially related to drugs.
If you were going to the polls on this morning 110 years ago, you saw this in your Detroit News:
In the April 7, 1913 Detroit News, a short piece describes who can vote in that day’s election, in which women’s suffrage was on the ballot.
Women were voting, too, but only if they owned or shared property with their husbands. On April 7, 1913, full women’s suffrage was on the statewide ballot − and Michigan voters rejected it. (Influenced by a liquor lobby that feared Prohibition would follow, a reminder of the perpetual influence of money in politics.)
Drug policies shape the influence that drug manufacturers and purveyors have. Are they permitted to lobby? Are there any restrictions on their donations? Does tax revenue associated with their industry create incentives to protect them?
Too Few Options for Families Dealing with Addiction
…substance use disorders, if untreated, can lead to criminal behavior, debilitation and — all too often — death. The number of overdose deaths in the United States is higher than ever.
Ideally, people with addiction would seek care. But waiting for a person to choose treatment for a disease that affects rational thought can be catastrophic, now more than ever.
The writer goes on to discuss the policies and interventions that would help, he points to some gaps that make it difficult for patients and families to find and access quality treatment, and the absence of involuntary treatment processes to protect loved ones at high risk for death due to their addiction.
Updates
A couple more papers just came to my attention.
Alcohol Use Disorder Stigma and Responsibility
This Addiction article concludes that alcohol problems are more stigmatized than other mental health problems. This appears to be related to the perceived risk they pose to others and the responsibility ascribed to them.
This fits nicely with some of the references above. The study on alcohol outlet density demonstrates that there are real negative externalities associated with alcohol consumption, and the paper on changes in alcohol consumption patterns speaks to the influence of industry public education efforts emphasizing responsible consumption frame alcohol problems as a failure of personal responsibility.
Our systematic literature search identified 24 publications since 2010, analyzing aspects of stigma toward people with AUD and other mental disorders. The synthesis of findings revealed that stigmatizing beliefs and behaviors toward people with AUD were pervasive in the general population and usually more pronounced than toward persons with depression or schizophrenia. More specifically, people with AUD tend to be perceived as more dangerous and more responsible for their condition, as well as being faced with a greater desire for social distance and a higher degree of acceptance of structural discrimination than people with substance-unrelated disorders.
This Addiction paper looks at the prevalence of alcohol-related harms to others and their distribution among various groups.
Almost half (48.1%) of respondents in this Australia-wide survey reported experiencing one or more harms from others’ drinking in the last year, with 7.5% reporting that they had been negatively affected“a lot” by others’ drinking, and another 26.8% reporting they had been harmed “a little”. Analysing the likelihood of any harm from others’ drinking (including specific harms from known drinkers’ or strangers’ drinking), women, young people, Australian-born (vs. participants born in non-English-speaking countries) and occasionally reported HED (heavy episodic drinking) were more likely to report AHTO (alcohol’s harm to others).Women were more likely than men to be negatively affected both by the drinking of people they lived with and were related to, as well as by the drinking of strangers. In line with previous research, women and young people were at greater risk of AHTO.
More women than men have reported a range of harms from others’ drinking, including arms from intimate partners (24) and financial harm (26) from others’ drinking. This is consistent with previous findings from many countries, including the previous Australian survey (3, 27, 28). Young people are the group of adults that have consistently reported more harms from strangers’ drinking and from drinking of their friends and co-workers (3, 4, 27, 29). In our study, harm from strangers’ drinking was considerably lower for those aged 65 or more than for younger participants, and significantly higher for women aged 18-34 than for middle-aged women. Results in our study are broadly consistent with findings in previous studies that young people report more harms than older adults from strangers’ drinking and from drinking of their friends and co-workers(3, 4, 27, 29).
…women reported substantially more harm than men, particularly from people they knew but also from strangers. This suggests that attention needs tobe paid to reducing harm particularly to women (and particularly younger women) from others’ drinking. Data focusing on differences by this and other social inequalities can provide guidance and benchmarking for policy discussions and interventions.
“Let us use whatever power and influence we have, working with whatever resources are already available, mobilizing the people who are with us to work for what they care about.” – Margaret Wheatley
The title of this post is inspired by Margaret J. Wheatley, Who Do We Choose To Be?: Facing Reality, Claiming Leadership, Restoring Sanity (2017). The book came up last year in conversations I had with Phil Valentine of CCAR when we were talking about influential readings. He told me about it and suggested to me it was to be digested slowly. I am an avid reader and sat down to read it from cover to cover. The truth of his words became clear to me after a few pages. Wheatley talks about how all things – even societies, have life cycles and that ours was in a period where large scale change is not often viable. Our institutions have decayed in the current stage in our society that they are largely ineffective at broad systemic change.
She suggests focusing locally and developing leaders to create space to support healthy community. I confess to not yet having finished her book. Having read books like Putnam’s Bowling Alone, The Fourth Turning by Strauss and Howe and Collapse: How Societies Choose to Fail or Succeed by Jared Diamond the topic is not new, but her focus (as far as I can see from about one halfway in) is to encourage leaders to develop and support community in ways that nurture people through difficult times. She calls these spaces “Islands of Sanity.” Quite a lot to digest. Truth be told and 15 months later I still have not finished this book even though it has had a great deal of influence on my thinking.
Many of us have experienced and are building such Islands of sanity in the recovery community. The Punta Gorda, Florida CCAR Multiple Pathways of Recovery Conference is such a gathering of people from around the nation to nurture recovery community. I have has similar experiences at the Mobilize Recovery convening in Las Vegas. The Association of Recovery Community Organizations through Faces & Voices of Recovery is another similar space. A theme of the conversations with people at these events is what do we do next to support additional recovery communities – I would call islands of healing around the nation. I think history has a few lessons for us on what works:
Communities can and do best self-define their own manners of healing. One of the well-known stories I have heard Don Coyhis, founder of White Bison and the Wellbriety Movement talk about is a conversation he had with federal grant officers when his organization was initially awarded funding to support recovery for indigenous peoples over twenty years ago. He was told he had to use evidence-based practices in the grant. He noted that the Native American community had several thousands of years of evidence of what worked to heal their communities. Much to their credit, they listened not just to Don, but to other recovery community organizations in including their own expertise in strengthening their own communities. In this way, these grants helped form these islands of healing across America through the SAMHSA the initial Recovery Community Support Project grants. These are community up, not government down solutions that can greatly benefit from the support of the government but must be led by the recovery community. Look at what was accomplished, the approach worked. CCAR and many other RCOs who formed at that time are evidence of this very dynamic.
If we want to build community-based services that meet the needs of our recovery community, we have to design funding around what works for these communities instead of trying to adapt healing processes to existing funding mechanisms. Recovery history shows us we tend to move away from community-oriented solutions as programming becomes institutionalized. We shift to fee for service funding models focused on individual units of care, following a clinical mentality. Instead of developing a deep understanding of what actually works, community-oriented programing is thus altered to meet existing funding mechanisms. These funding processes tend to favor large entities not grounded in recovery community. Community based recovery organizations try and use these funding mechanisms to serve their missions, but it often becomes a challenge as the focus becomes chasing these limited dollars and narrowing their missions to get paid for service units designed for clinical services.
There is great interest in the national recovery community to build additional communities of healing. Many of my conversations with leaders nationally end up focusing on what we can do to advance efforts to heal communities using a recovery community up model. As I have mentioned in prior articles, I see a lot of room for consensus, but that the development of such consensus involves deep conversations, inclusivity and a lot of active listening. Readers of this post inside of government seeking ways to address our burgeoning addiction epidemic would do well to follow the wisdom of leaders like Dr. H. Westley Clark and the first grant officer of the SAMHSA RCSP grants Cathy Nugent who worked to bring these communities together and to start building these bridges of healing communities by listening to their experiential evidence of what works and helping to support them instead of redefining them to fit into some other model.
There are many of us across the county invested in building a care and support system that actually meets the needs of our respective communities. When I see the depth of interest in this issue, it brings me hope. Our mutual well-being will be largely dependent on how we can help nurture each other’s islands and support new islands built by people focused on healing their own communities. In a post titled Creating a Broad & Inclusive Recovery Plank I suggested that developing broad goals is a good place to start strengthening such bridge building efforts.
Perhaps we should form a recovery island bridge building coalition of similar minded communities that want to understand and develop common ground in between our islands and build bridges that span our differences. Here are three points to start such a conversation:
Recovery communities are the experts on what is needed in their own communities. Recovery communities are diverse, and our efforts must be supported and funded equitably designed by us to serve our own communities.
Discrimination and stigma against us must end. Systems that tokenize us are perpetuating discrimination. It is not acceptable to tokenize our voices. There has to be an accounting for how this has happened historically to marginalize us in order for healing to occur and for our society to reap the full benefits that a recovery orientated model of care can offer.
How we do things matters. Our recovery communities are quite often vulnerable, and there are many groups, including some run by people in recovery that take advantage of our own people for material gain. We must establish a shared set of values and ethics and adhere to them to protect the most vulnerable among us.
So, to all the bridge builders of islands of recovery community – let’s find ways to develop consensus and understanding of each other and our experiential wisdom. If you disagree with my three points, I would love to hear yours, if those of us invested in bridge building listen to each other in this way, we will identify a common pathway forward!
It is true that when we come together, we are stronger. It is also true that the history shows us that we are most effective when we do so, even as there are so many forces that keep us arguing over small things. The truth is we do not need to have strong institutions to build consensus and community, we can do that with and for each other.
Please consider being a bridge builder between recovery communities, the island you strengthen may well be your own!
[Ed. note: Although Mooring Lines are not an “official” SR Tool, volunteer Stefan Neff and others have found them very useful in their recovery. This post represents Stefan’s views and analysis.]
I was recommended to use a process called Mooring Lines by a counsellor who said this tool is an important concept in addiction recovery. Also, the Substance Abuse and Mental Health Services Administration (SAMHSA) has recognized Mooring Lines as a helpful tool for individuals who are struggling with addiction.
What are Mooring Lines?
Mooring lines are metaphorical anchors that individuals can use to ground themselves when they are feeling overwhelmed or triggered by their addiction. They are a set of personal values, beliefs, and practices that provide stability and support during difficult times. Mooring lines are created by identifying the things that are most important to an individual and then creating a plan to prioritize and protect those things.
How Do Mooring Lines Work in Addiction Recovery?
Addiction recovery is a challenging process that requires individuals to make significant changes in their lives. These changes can be difficult to sustain without a solid support system in place. Mooring lines provide a framework for individuals to identify their values and beliefs and then use them as a foundation for their recovery.
Mooring lines can be used in a variety of ways. For example, an individual might use their mooring lines to remind themselves of their commitment to sobriety when they are feeling tempted to use drugs or alcohol. They might also use their mooring lines to reconnect with their spiritual or religious beliefs, which can provide comfort and guidance during difficult times.
Benefits of Mooring Lines in Addiction Recovery
Mooring lines offer a number of benefits for individuals in addiction recovery. Here are just a few:
Increased Self-Awareness: Mooring lines require individuals to reflect on their values and beliefs, which can help them better understand themselves and their motivations.
Greater Resilience: Mooring lines provide a stable foundation for individuals to rely on during difficult times, which can help them weather the challenges of addiction recovery more successfully.
Improved Decision-Making: Mooring lines can help individuals make better choices by providing a clear set of priorities that guide their actions.
Increased Motivation: Mooring lines can provide individuals with a sense of purpose and direction, which can increase their motivation to stay sober and continue on the path of recovery.
Mooring lines are an effective tool for individuals in addiction recovery. By identifying their values and beliefs and creating a plan to prioritize and protect them, individuals can create a stable foundation for their recovery. Mooring lines can help individuals stay focused on their goals, make better decisions, and stay motivated during the recovery process.
Mooring lines Examples: Journaling, mindfulness/meditation, SMART meetings (therapy & case management appointments in some cases), recovery research (Sober Friends Club), exercise, diet, sleep and others.
Now make a list of your own mooring line that will help you stay grounded and connected to your recovery or sobriety path.
In 2005, concerned at the lack of choice in addiction treatment in Scotland and hearing frustrations from patients and families around lack of access to residential treatment, I sought support and funding to set up a drug and alcohol rehab service based on the therapeutic community (TC) model. This would be unique in Scotland as, based in the NHS, it would be free at the point of delivery, eliminating difficult funding pathways.
I proposed the service should serve a local population to keep people close to their families and allow them to develop local recovery supports and access intensive aftercare. It should develop close working relationships with other treatment and support options – this should be an ‘as-well-as’ service rather than an ‘instead-of’ service. There should be direct family support and detox offered as part of the deal. We would actively connect people to recovery resources in the community, offer them peer support and open avenues into education, training and employability.
Outcomes from rehab in Scotland (and even the UK) at the time were hard to find – but so were any treatment outcomes from services already in operation, so I built in that we should commission a robust evaluation. If this wasn’t going to work, we needed to know that – and if it helped people achieve their goals we wanted to get that message (and any other learning) out there.
This proposal and the evaluation were funded for a two-year pilot and in 2007 LEAP was born. A lot of people then came on board to help transform an idea into a reality. A little delegation of addiction doctors approached me as soon as the funding announcement was made. They were worried that by encouraging people to seek an abstinent recovery, we would end up putting them in grave danger. I pointed to the mitigations we would build in, we would ensure that potential risks were discussed and that consent would be fully informed. I’m not sure that I convinced them all, but in time some of these colleagues began to refer patients to us.
A very scrutinised service
So what of the analysis of the service?
Our initial evaluation was conducted rigorously by Figure 8 and the one-year 170+ page report shared with the commissioning ADPs and the Scottish Government shortly after a year of operation.
The two year report followed in 2010.
In 2014 we did a ‘Road Tour’, visiting Glasgow, Edinburgh and Dundee to disseminate the four year (as yet unpublished) outcomes.
The one-year outcomes were published in a peer-reviewed journal in 2017.
Our four-year outcomes have just been published in the British Journal of Psychiatry (Open) Journal this month.
After the initial baseline data collection, follow up was done by external researchers. Our family programme and recovery house have also undergone rigorous external evaluation.
So, in effect, quite a lot of scrutiny of what we’ve been doing – not to mention the data that has been reported regularly from the outset to the present day to the three Alcohol and Drug Partnerships that commission our service. What does all that data mean? Are there any key messages or things that are worth passing on?
The detail is in the published papers, but I think there are some valuable higher level lessons across the years that these reports and papers span. I want to share some of this because the learning has helped us, our patients and their families. It undoubtedly has wider implications.. What I’m sharing is based on research evidence, evaluation, plus a little bit of experiential learning too.
You can establish and run a rehab in an NHS setting
Not everyone thought that the NHS (in partnership) could run an effective rehab programme. The premise was simple: services to aid recovery from addiction should be available on the same basis as services for cancer, diabetes or broken bones – comprehensive and free at the point of delivery.
Until recently, to access rehab in Scotland you had to live in the right area, be wealthy or just lucky. Our initial evaluation gave us affirmation that an NHS service and its partners could deliver a service of high quality with good outcomes – joined up to other NHS services.
Lesson: there are advantages to embedding drug and alcohol rehab in the NHS as part of a recovery-oriented system of care.
Demand – if you build it, they will come
Lothian had few referrals to rehab per year prior to LEAP. It would have been easy to say ‘there’s no demand’, yet within a short space of time, a waiting list for rehab treatment developed which then doubled within a further year. Despite 16 new beds being available locally in Edinburgh for Lothian referrals, demand was quickly outstripping supply.
Lesson: when you value rehab and have straightforward pathways to it, referrals roll in.
Rehab associated with improvements in various life domains
We did find evidence that attending our programme was associated with improvements in a variety of outcome domains and that those who stayed longest/completed had the greatest gains. The two published papers capture this in detail.
Lesson: we can be optimistic that rehab is likely to help a significant number of people reach their goals.
Retention is important.
The best outcomes are for those who complete – our evaluations and our study have clearly demonstrated this. We adjusted our practice based on this finding to help the maximum number of people get to the end of the programme. Retention in the early days was around 55% (which was still better than the average for a 90 day programme in the UK), but we’ve increased this to around 65%.
We have a really high threshold for discharging people and we have instituted measures associated with treatment completion. We’ve found that tailoring the programme, varying the length of it, using contingency management, peer support and a variety of procedures to manage challenging behaviour short of discharging people work well.
Lesson: we need to pull out all the stops to get people over the finish line (and the finish line is not the finish line in any case…)
Deaths
Deaths in this rehab population were not related in time to detox and were more likely to occur from respiratory disease (a quarter) and complications of alcohol dependence (a third) than be drug-related. That doesn’t mean we are complacent. We instituted measures like raising our methadone threshold (to avoid people detoxing too much in the community prior to admission), inpatient partial detox, naloxone distribution, overdose prevention training, rapid referral back into MAT where return to use occurs, offering inhouse re-titration onto OST to those leaving early etc.
Lessons: the risks associated with opioid detox can be mitigated in this setting. It’s important to look after general health.
The severity of dependence does not predict outcomes
The LEAP study cohort at intake was older than the average treatment seeking population (34 vs 27), had higher drug and alcohol use and more severe alcohol and drug problems as measured by the severity of dependence scale than in the Scottish DORIS cohort. However the severity of dependence did not seem to predict treatment outcomes.
Lesson: don’t deny a rehab place based on how severe someone’s dependence or problems are – you may be surprised.
Rehab can impact on injecting behaviour
In our study we divided our patient group into those who completed vs those who did not complete and compared the two groups. In those who completed there were significant reductions in injecting behaviour (though we need to be cautious as numbers were small).
Lesson: rehab is effective harm reduction
Rehab can generate significant cost savings
Although health economics is a notoriously difficult subject, our evaluators noted:
“This report suggests that the costs incurred in achieving recovery outcomes for LEAP graduates are more than offset by the savings across health and criminal justice domains by a factor of as much as 3.”
Lesson: rehab can make significant cost savings downstream and may be more cost effective than other treatment options in the long term.
Abstinence is associated with better outcomes.
Abstinence is not everybody’s goal, but in our patient group, those who achieved abstinence did best overall – something in keeping from research elsewhere. It’s been my experience as a professional that abstinence as a goal is not well received or supported in some circles, yet undoubtedly it is something some people coming for help want and something that significant numbers of people can achieve (More than 60% of those who completed treatment at LEAP reported abstinence at 4 years in our study).
Lesson: abstinence is a legitimate and achievable goal, associated with good outcomes.
Other lessons
There are other lessons we’ve learned: the recovery journey can be long and non-linear, so rehab makes best when it’s joined up to a robust system of care. The therapeutic community is a powerful force for change. There’s no need for a battle between harm reduction and abstinent recovery when the larger system you operate within offers both and referrals happen in each direction depending on need.
Hope matters – lived experience in the staff team and from peer volunteers really helps here.Harm reduction measures are simple to adopt into rehab settings. Effective and fast referral back into community treatment is important when people return to use. Intensive preparation and long-term aftercare are vital.
A multi-disciplinary team allows us to accept those with greater needs. Addressing mental health is critical to success. People have multiple co-morbidities. Polypharmacy can be effectively addressed in rehab. People are often able to go on to do longer term therapies for PTSD. People may need more than one rehab treatment episode, so ‘one shot and you’re out’ makes no sense. When patients benefit from rehab so do families, but families also have the right and opportunity to find their own recovery and support can be provided in-house by the service to achieve this.
Summary
Residential rehab should be part of a comprehensive care system – the time for saying ‘there’s no evidence that it works’ is over. Yes, it’s only a part of the recovery journey for some, not all, and yes, it’s not something everyone wants. But some people do want rehab and they ought to have a choice about it. It is possible to deliver rehab in an effective manner with good outcomes, including harm reduction outcomes for the people who go through it. Furthermore, as the evidence accumulates, it’s possible to improve the quality of the services we offer.
Rehab is effective and can be a powerful tool to help those with addictions reach their goals.
I’d like to thank all of those who gathered and examined evidence for our service – Figure 8, McMillan Rome and the authors of our two peer-reviewed papers, but particularly Dr Nina Mackenzie for her part in our four-year outcome paper. Thanks are also due to the amazing LEAP team and volunteers, NHS Lothian, our colleagues across statutory and third sector services, our partners (City of Edinburgh Council, Access to Industry, the Cyrenians, The Ritson Clinic, the Lothian Alcohol and Drug Partnerships and the Residential Referral Team) and, most of all, to our patients who have achieved remarkable outcomes through their determination to recover and via the hard work they put in.
The drunk driver crossed the line and changed Kristal Field’s life forever. She was seriously injured and her best friend was killed. She required opiates for pain relief and struggled for the next ten years, crossing her own line at some point from taking opiates for pain management into full-blown abuse. Kristal lost herself in a cycle of misusing opiates and her life became focused on feeding the addiction. It all came to an end with her 2013 arrest for possession of narcotics. That’s when the rebuild started.
Because it was her first arrest, Kristal was put through a diversionary program that included being sent to Narcotics Anonymous (NA) meetings. Nobody mentioned other options like SMART. Kristal says she had trouble with the idea of a “higher power” that is integral to 12-step recovery like NA, but she figured out how to stick around, “The way I chose to think about [higher power] is that it was the fellowship, it was the group, it was the sharing of information…hearing other people’s stories, that is so powerful in itself.” This strategy kept her life moving in a positive direction, even as she remained convinced that she did have power over some things and there were things she could control.
One example was her decision to pursue a college degree, and that led her directly to investigating SMART for a class assignment. It clicked, “I absolutely just loved everything about it…it resonated so much with me and was also in alignment with the things I was doing in school.” Kristal started attending meetings and found it personally valuable as she juggled working full-time, going to school, being a mom, and being in a relationship. She also attended Family & Friends meetings, which she credits as helping mitigate her household’s COVID pandemic stress.
The next powerful decision she made was to become a SMART meeting facilitator. As a self-identified introvert, Kristal says stepping into a facilitation role was definitely out of her comfort zone, but she did it anyway and was rewarded, “Going through the facilitator training was life-changing, it made so much sense and it really made it all come together for me in my own recovery.”
Now Kristal looks ahead and realizes that with her Human Services and Health Administration degrees, combined with her SMART Facilitator training, the sky is the limit. “My ultimate dream would be to open my own recovery house and if I could run SMART meetings all day every day that would be great!” She says watching participants grow, even through tough times, is rewarding. Kristal particularly relates to the women members of her group learning how to advocate for themselves and use SMART tools to develop the strength to do so. She sees it happen regularly.
Ultimately, Kristal just wants to see SMART grow as much as possible, and help individuals before it’s too late. She has lost friends to Opiate Use Disorder, but now she is part of the solution, “I may not be able to bring my friends back but I can still try and influence the ones who are still here.”
“The Chinese use two brush strokes to write the word ‘crisis.’ One brush stroke stands for danger; the other for opportunity. In a crisis, be aware of the danger–but recognize the opportunity.” ― John F. Kennedy
Societies, like people rise to challenges when faced and decay when hard tasks are avoided. Healing for people and societies are complex, multifaceted processes that take effort. Modern society is painful and isolative. Numbing strategies have isolated our community members and eroded social capital to the point we are in a crisis. We have created a negative feedback loop as people sooth the resultant pain on both the individual and community level which then fuels isolation, substance misuse and addiction. The pandemic made all of these dynamics worse, but we have the opportunity to revisit what we are doing to address some of the underlying dynamics related to substance use and alter our course. The recovery community can play a vital role in this revitalization if given the opportunity to do so.
Soothing the hurt of loneliness will not heal us
As this recent Harvard Report notes, America is experiencing an epidemic of loneliness. 36% of respondents reported feeling lonely “frequently” or “almost all the time or all the time.” A startling 61% of young people aged 18-25 and 51% of mothers with young children reported these miserable degrees of loneliness. Stats to pay attention to!
We must address the encroaching sense of loneliness across our society in ways beyond soothing these through gambling, social media, consumerism, alcohol, cannabis, and other drugs to numb the pain. We have a menu of drugs and distractions that provide fleeting respite from our underlying malaise but not much focus on changing our course.
Most of us have seen or heard about the 2015 Rat Park TED talk. It is quite persuasive. It contains a lot of truth. Our society magnifies sad, lonely rat like conditions for a majority of us. Taking a sad, isolated people and creating conditions to help them feel happy and connected would likely reduce the use of drugs and alcohol to cope with despair. Yet, we cannot delude ourselves into thinking that addressing these societal shortcomings will make addiction disappear. We like such simple solutions, if addiction was easy to solve, we would already have done so. But the dynamics of our rat park are quite real. Addressing these societal ills is a partial solution, not a panacea to addiction.
Society is about supporting its members across the long term. Addressing the dynamics in our society that erode our individual and collective sense of hope, purpose and connection. These challenges must be addressed as central facets of prevention and healing from what we are collectively experiencing as a people to preserve a functional society.
The Pandemic has potentiated societal dynamics of isolation and despair in ways it is clear we cannot sooth our way out of. We are also faced with opportunity to consider solutions to address the underlying dynamics that are eroding our society and impacting our health and wellbeing. The costs are not borne evenly. The Loneliness Epidemic Persists: A Post-Pandemic Look at the State of Loneliness among U.S. Adults explores the disparate impact that pandemic had on these challenges. Some notable findings they highlight:
People from underrepresented racial groups are more likely to be lonely. 75% of Hispanic adults and 68% of Black/African American adults are classified as lonely – at least 10 points higher than what is seen among the total adult population (58%). This is notably different than previous data which showed similar experiences of loneliness across racial and ethnic groups.
People with lower incomes are lonelier than those with higher incomes. Nearly two-thirds of adults (63%) earning less than $50,000 per year are classified as lonely. This is 10 points higher than those earning $50,000 or more. Relatedly, almost three in four people (72%) who receive health benefits through Medicaid are classified as lonely, which is substantially more than the 55% of adults covered by private, employer- or union-provided health insurance benefits.
Young adults are twice as likely to be lonely than seniors. 79% of adults aged 18 to 24 report feeling lonely compared to 41% of seniors aged 66 and older. This is consistent with earlier research.
Building Social and Recovery Capital
As previously noted, we must embrace recovery capital within our care system to save it. It should not be new information that successful treatment programs recognize the role of recovery capital and develop interventions that provide support via self-help groups, peer support, and families. We also know there are relationships between isolation and poor health in our broader healthcare system and that expanding social capital can also improve economic factors. It is a wonder that, given our current, broad societal challenges that developing connections within and across our communities is not a major policy focus here in the US. This is the crisis and opportunity we are presented with.
Where are the efforts to collectively address these challenges?
We should be seizing the opportunity hiding within the crisis to more effectively address our collective needs in a post pandemic era. There is an emerging effort to do so in the UK. This article, Post-COVID recovery and renewal through whole-of-society resilience in Cities in the Journal of Safety Science and Resilience explores one such effort. The authors note that the necessity of renewing approaches to building local resilience capabilities across the whole-of-society requires synchronization across and between formal and informal approaches – that is, “bottom-up” and governmental initiatives – to meet the diverse needs of communities.
This article examines the newly formed National Consortium for Societal Resilience (NCSR). It is comprised of business sector organizations large and small, charity organizations, governmental and academic entities. It is a broad-based coalition. The Consortium have identified the following founding principles to underpin this collective effort on whole-of-society resilience that resonate with many of us in the recovery community:
We must align behind a shared meaning of ‘whole-of-society resilience’.
We must exploit our synergies and the substantial opportunities from working collaboratively together.
We are working on an ambitious issue, so we need short-term (realistic) objectives and longer-term (ambitious) objectives.
We must be efficient in our work and facilitate researchers to provide its research capacity and support.
We need a new, ambitious, nationally consistent foundation on which to build whole-of-society resilience.
We will address significant resource gaps by producing materials and collateral which only contain the NCSR+’s neutral-branding and which can be adopted without charge, provided that NCSR+’s neutral-branding is retained equivalently alongside the user’s own branding.
We must accumulate diverse good practices from which to carefully select a starting portfolio to localize as no ‘one-size-fits-all’.
We must build the consortium into a national eco-system to coproduce approaches with the voices of our communities.
We must analyze the impact of our effort.
We must disseminate our learning to everyone via our events, website, outreach, and link.
NCSR holds out that we cannot be resilient on our own and they recognize that resilience must be developed from inside communities. This includes building on existing community structures and partnerships and establishing new ones. Shared understanding and joint working relationships will be key to creating an inclusive, supportive, and enabling environment for the co-production of whole-of-society local resilience capabilities. This is an approach which requires an adjustment of relationships on resilience between whole-of-society and resilience partnerships.
Even if the NCSR fails to fully achieve all of its goals, what it will likely succeed at simply by trying to do so is to strengthen social capital across the nation. It is the case that focusing on developing resiliency in diverse communities increases the kind of capital that we have been spending down rather than building up. We need to focus on rebuilding social capital here in America. How do we get a similar effort off the ground here in the US, or create more synergy around these types of efforts where they have already formed?
The challenges we are facing in reversing the alarming trends of isolation and despair run in close parallel to the kinds of things we are trying to do to strengthen recovery efforts in our communities. Recovery communities would make ideal partners in developing strategies similar to what the NCSR is being set up to address in the UK.
There are lessons here that resonates with many of us in recovery. Good things take hard work and collaboration. The more people come together, the more we see we have in common, the more we can accomplish together and the stronger we are individually and collectively. Effort yields some benefit no matter what other outcome is achieved. There is some irony in that we are learning that avoiding pain tends to only forestall and intensify how unpleasant it is once experienced. The other lesson is that no one group can address these issues alone. More evidence of opportunity posing as a crisis.
Let’s seize the opportunity to improve our society. It is an effort that will yield a vital bounty no matter what. The alternative is to sooth ourselves and our communities into further decay. It is not a tenable option.
It seems like more is being said about drug policy than ever before. I’ve been posting thoughts about drug policy here for years. However, as I read comments from others, I often wonder whether we’re talking about the same things. To be honest, I haven’t given a lot of thought to the conceptual boundaries of “drug policy” when I use the term.
As I contemplated the term, it occurred to me that I’d never seen anyone unpack all that the term could encompass. If you’ve seen something that does so, please share it in the comments.
Off the top of my head, here are some of the things that might fall under the umbrella of “drug policy.” Feel free to point out things I missed in the comments.
The criminal status of the substance
If possession and/or use is illegal:
Is it a felony, misdemeanor, or civil infraction?
What are the penalties and/or interventions?
If it’s legal:
Is it regulated? If so, how?
What’s the minimum age? What’s the penalty for selling to someone underage?
Are sales of it legal? If so, by who? The state?
If retail, do sellers need a license? Is there any management of outlet density?
Is there minimum unit pricing?
Are there any limits on quantities possessed?
Are content and potency regulated?
Are research and development regulated to manage innovation in drug creation, preparation, and consumption methods?
Is marketing regulated? Is targeting minors prohibited? Are billboards allowed?
Is there any effort to manage the influence of industry groups? (limiting size, restricting lobbying, etc.)
Where can it be consumed?
What’s the response to public intoxication?
Are hours/days of sales limited?
Is it medicalized?
Does it require a prescription?
Is it sold in pharmacies?
Are active ingredients subject to approval from a body like the FDA?
What’s the tax status?
How is tax revenue used?
Is the tax rate intended to impact consumption?
How is it taxed (weight/volume, potency, price, etc.)?
Is there any attention to tax revenue creating incentives for governments to protect the industry?
How do we manage crime that is related to substance use? (property crimes, impaired driving, interpersonal violence, etc.)
Is substance use considered in prosecution, sentencing, and monitoring?
Is coerced treatment an acceptable alternative to incarceration or other penalties?
Public health policy
Primary prevention – what interventions are used to prevent substance misuse?
Secondary prevention – what are the practices for screening and early intervention to identify and address misuse?
Tertiary prevention – what interventions are used to prevent the progression of established substance abuse before health consequences emerge?
Harm reduction – what interventions are used to reduce or prevent the negative effects of ongoing drug use?
How do we address the medical and mental health problems associated with substance use?
Research
How is it funded?
Who determines the research priorities?
Who determines what gets published?
How does research get translated into practice?
Treatment policy
What treatments are available?
What treatments are funded?
What treatments are prohibited?
What treatments are favored?
What endpoints are identified and prioritized?
What’s required of funders? Parity? Required covered services?
What’s required of treatment providers?
Are social determinants of health the responsibility of the treatment system, other systems, or the individual?
What’s it like to access treatment? What’s available on demand? What hoops need to be jumped through to access higher levels of care?
Policies related to the cultural status of the drug
What norms are communicated in schools and public education campaigns?
How is substance use thought of? (As a good thing, a neutral thing, an unavoidable and unfortunate part of human communities, a sin?)
How do we conceptualize misuse and addiction?
Is it an individual problem? A personal responsibility?
Is it an illness? Are some patterns an illness and others not?
How do we communicate that?
Where harm occurs, how do we think about the harms of use that may be experienced by children, other adults, or communities?
Who’s responsible for addressing these harms?
What strategies are used to mitigate these harms?
What’s the response to public intoxication or disruptive behavior related to drug consumption?
What goals, outcomes, and endpoints are selected for treatment and public health policies?
Where can it be consumed?
Where are outlets zoned, geographically? (Downtowns, neighborhoods, or more industrial areas?)
Do we create settings for communal substance use?
Are they commercial settings, like a bar, restaurant, or cigar bar?
Are they medicalized settings, like drug consumption rooms?
If the substance is medicalized:
Is there consideration of how that, at the individual level, changes object attachment?
If there isn’t gatekeeping by a prescriber and pharmacy, how does medicalization change the threshold for initiation?
Mark Kleiman was a thoughtful contributor to discussions on drug policy, with some of the most comprehensive and nuanced takes that I’ve encountered. In the paragraphs below, I think he does a good job managing expectations and explaining our obligations to do better. (Note: He published this when terms like substance abuse and substance abuser were the norm.)
Any set of policies will therefore leave us with some level of substance abuse—with attendant costs to the abusers themselves, their families, their neighbors, their co-workers and the public—and some level of damage from illicit markets and law enforcement efforts. Thus the “drug problem” cannot be abolished either by “winning the war on drugs” or by “ending prohibition.” In practice the choice among policies is a choice of which set of problems we want to have.
But the absence of a silver bullet to slay the drug werewolf does not mean we are helpless. Though perfection is beyond reach, improvement is not. Policies that pursued sensible ends with cost-effective means could vastly shrink the extent of drug abuse, the damage of that abuse, and the fiscal and human costs of enforcement efforts. More prudent policies would leave us with much less drug abuse, much less crime, and many fewer people in prison than we have today.
There are a lot of problems in addiction treatment, but 12-step hegemony is not the problem that advocates and media coverage would lead one to believe. (Keep in mind that 12-step facilitation is an evidence-based treatment.)
It’s worth asking why this is so frequently misrepresented.
Happiness can feel elusive, determined by what’s happening (or not happening) right now. Joy, on the other hand, is a sense of contentment one feels regardless of the current situation. It is not altered by external factors. You don’t have to wait until the trouble is over to be filled with joy. You may be wondering, “How can I be full of joy when things aren’t going well in my life?” Well, it takes a lot of effort, but the answer is simple. Are you ready? Experiencing a joy-filled life, no matter the circumstance, depends on where you choose to focus your attention. Here is a short list of things to focus on that can help bring more joy to your life:
Accept that the past is the past.
Understand that you cannot change things that happened in the past, but you can focus on the future and do what you can to make a positive impact on today and tomorrow. Joy comes in knowing that it’s not too late to turn things around. With every new day, you have the opportunity to make a better choice, to right a wrong or to encourage yourself and others to keep pushing.
Know that trouble does not always last.
Joy comes in knowing that whatever situation you are dealing with right now; it will not last forever. While going through a challenge in life, things can seem very dark. You can’t always see the light at the end of the tunnel. But, instead of focusing on the problem, focus your attention on solutions like working the 12 Steps, going to AA or NA meetings, and staying in contact with your support network.
See the good.
This is an old cliché, but it it’s true — “Things could always be worse.” Make the decision to focus on the good in every situation. It’s the old glass-half-full attitude that brings an unbridled sense of joy. Focus on the good things you have, not what you don’t have. Be grateful for what you can do, don’t harbor regret for what you cannot do.
Focusing your mind on the right thoughts can help you maintain a sense of joyfulness regardless of what is happening around you. When we realize that our perspective can shift our enjoyment of life and that at the end of the day, we are in charge of our feelings and our destiny, it becomes much easier to start finding joy in everyday life.
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.
Yesterday, I attended a memorial service for a former co-worker of many years. We worked together at Dawn Farm, an addiction treatment and recovery support program, where one of Robin’s roles was to teach GED classes. She was kind, warm, patient, and never harbored any doubt about our clients’ capacity to learn, grow, recover, and improve their lives. Everyone deserves someone like her in their life.
While we remembered her, some of us tried to estimate all of the people who obtained their GED with her help and encouragement. It was definitely in the hundreds.
For many of them, it was a milestone that enhanced their self-esteem, expanded their options, increased confidence in their ability to grow and recover, their expectations of themselves, and their range of possibilities. Many of them continued their education at the local community college and transferred to a university to obtain a bachelor’s or graduate degree. Of those, many played important roles in forming and sustaining collegiate recovery programs. These were not people who entered treatment with lots of recovery capital. Most of them were publicly funded, many were court-involved, and all of them had multiple prior treatment episodes. By almost any standard most of them would be considered to have high severity, high chronicity, and high complexity cases of SUD. Some of them started in low-threshold services and inched their way into the full continuum of care, while others jumped straight into high intensity services.
These conversations about her work and its place in treatment and recovery prompted me to reflect on some of the schisms in the field today.
As a starting point, I assume nearly everyone engaged in discussions about addiction and recovery has good motives. We may have different assumptions about the nature of the problem, the possibilities, or the best solutions. We may be focused on different harms, risks, and goals. Whatever the case, I assume most people want to improve the circumstances of people affected by addiction.
I think a lot of people would look at Robin’s students and assume that they are likely to spend the rest of their life struggling, and the most compassionate and pragmatic response is to seek to reduce the difficulty of their struggle. Programs that take that approach are important, we need services that meet people where they are.
Robin and Dawn Farm aren’t blind to the absence of recovery capital. However, they felt a responsibility to build recovery capital in tangible ways that addressed short and long-term needs, including long-term treatment, co-occurring disorder care, recovery-informed primary care, family support, treatments for trauma, employment support, recovery housing, social support, and, of course, GED classes.
There ought to be programs whose primary goals are to reduce suffering and harm. (To be sure, some of Robin’s students participated in some of those programs before they came to Dawn Farm and met her, and others may have struggled after their time with her and used those programs later.) While programs focused on reducing harms may feel more urgent, programs focused on building recovery capital and facilitating flourishing are just as essential to a just and equitable system. Those needs should not be pitted against each other.
I’m very concerned that the medicalization of the field will progressively eliminate roles like Robin’s–framing things like education and GEDs as extra-therapeutic issues that are the responsibility of some other system.
I can only hope there are many more Robins out there in agencies and systems that value their work.
