A few days ago David McCartney posted an interesting piece titled “Choice in addiction treatment.”

That post got me recollecting about clinical practices in our outpatient methadone maintenance program that I thought I would briefly share – in case this historical information is somehow helpful or interesting to someone.

Our methadone maintenance program began operation in either 1968 or 1969. I was told a first-hand story of its founding, but don’t remember the year. (By the way, the first journal article describing methadone maintenance as a clinical practice was published in 1965, so those were some “early adopters” indeed).

When I began work in the 12 month residential drug-free therapeutic community in 1989, the methadone maintenance program was operated in the first few offices in the front of that residential program. And the two programs shared the same nursing and counseling staff. Believe it or not but when I started there the first nurse (RN) approved by the State to dispense methadone (who began work in 68/69), was still working in that program. And more amazingly, she continued to work there for at least my first decade working in that program.

Upon my arrival in 1989, our methadone maintenance program practices included:

• Patient limit of 50 total people on the program
• No minimum or maximum dose limit
• No minimum or maximum time on the program
• 7 day RN coverage on-site, 365 days per year, providing medication dispensing
• Phase system based on developmental milestones of improvement (stabilization, diminishment of clinically relevant problems, gains in practical life goals, sustainability of improved quality of life, etc.)
• Use of substances other than opioids was addressed according to clinical relevance (e.g. a moderate to severe problem in its own right; or use of a substance class that was not another use disorder, but represented a general relapse process; or seemingly no real relevance at all).

Later in my time there, our agency undertook a multi-year (1998-2007) change-project across the dozens of programs in our organization. That effort was called the Behavioral Health Recovery Management (BHRM) Project. We used the BHRM Principles to direct specific changes. At other times we would pick a Principle and use that Principle as a goal toward which we would make many changes at once or in a row.

During those years we made vast changes to policies and procedures at both the organizational and program levels. We went as far as wholesale elimination of the entire clinical guts of some programs and total replacement of their methods with new practices.

For the methadone maintenance program we adopted changes that included:

• Budgeting 10-15 blood draws per year. We did these to check the circulating methadone level both one hour before and four hours after, one dose. We used these levels to see if the patient’s body was metabolizing the medication properly (rather than us not believing the patient that their medication was not “holding” them).
• Viewing an addiction to another drug class (like alcohol, for example) as a co-occurring disorder. We would eventually refer the patient up to a short or long term residential level of care if necessary. But we would continue their methadone maintenance while they were there if they wanted to, and it was not clinically contra-indicated. In doing so we would hold their slot on the methadone program if they wanted to stay on the medication and continue in outpatient methadone maintenance after completing residential treatment.
• Adding a “Family Night With the Doc” quarterly. We had patients invite and bring their family members at least once, but it was optional after the first time. The night included elaborate snacks, beverages and desserts in a casual but organized format. The program physician would share some brief educational comments, take questions, and respond to any discussion topics raised by the family members and the patients in an open format.
• Having our patients continue to come to the very same group therapy for their entire first year off of methadone – if they chose to taper off the medication.
• Obtaining methadone dosing privileges at our County Jail. Our nurse would personally bring them an off-site dose each day, with the idea you would naturally stay on the program if you wanted to when released.
• Obtaining methadone dosing privileges inside all of our own drug-free short and long-term residential addiction treatment programs. Our nurse would personally bring them an off-site dose each day with the idea you would naturally stay on the program if you wanted to when you completed residential treatment
• Buying the starter kit, and providing free use of a large comfortable room in our program, during off-hours (no groups happening), for the patients to start and hold meetings of Methadone Anonymous. I personally worked with our patients on this idea for four years before the idea “took” and they started the meetings. I didn’t think it would take that long, but we just kept encouraging it. We knew that they needed to start and run it, as service, if they chose to. And that if we started it or controlled it that it wouldn’t work and wouldn’t last.
• Finding out which 12 step, faith-based, and other meetings in town (very specific days/times of certain meetings) were friendly toward the idea of methadone maintenance patients being “in recovery” and also allowing them to share – if they fit into the meeting and followed the guidance of the Chair. We tended to suggest they attend these meetings
• Finding out which 12 step, faith-based, and other meetings in town were openly hostile to that, and tended to suggest they avoid those meetings.
• Adding patient education and counseling that incorporated basic principles and practices from the Advocates for the Integration of Recovery and Methadone (AFIRM).

Some of our ideas and efforts made it into print. And so did some extensions of these efforts.

Suggested Reading

Hentoff, N. (1968). A Doctor Among the Addicts. Rand McNally & Co

Strain, E. C. & Stitzer, M. L. (Eds.). (1999). Methadone Treatment for Opioid Dependence.

We are pleased to announce the release of our newest Tips & Tools for Recovery that Works! video DIBs.

We all hold beliefs which guide our actions and influence our feelings. But some of these beliefs may be irrational. And many irrational beliefs may be actually harmful to our recovery.

The SMART Recovery tool DIBs stands for disputing irrational beliefs. It’s a system for breaking down why a belief may be irrational and then applying a systematic approach to come up with a more rational belief to help us along in recovery.

Watch on our YouTube channel.

Subscribe to the SMART Recovery YouTube Channel

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

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

PLEASE NOTE BEFORE YOU COMMENT:

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

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

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

IMPORTANT NOTE:

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

We look forward to you joining the conversation!

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

Leading the Future of Recovery

Saturday, October 23, 2021

SMART Recovery is a global movement of self-empowering addiction recovery mutual support meetings. We, along with many others, are truly leading the future of recovery and we want you to join us in our mission.

Join us at the 2021 SMART Recovery National Conference to hear from members of the SMART Recovery community, addiction recovery experts, and industry leaders. Learn about the current state of addiction recovery, what the future landscape looks like, and how SMART intends to be involved in the solution.

Conference Details:

• Time: 9:00 a.m. — 5:00 p.m. ET
• Location: This is a hybrid conference, with most attendees participating via livestream. Limited in-person tickets are available. The event is being held at the DoubleTree by Hilton in Laurel, MD.
• Cost: General Attendees: $50, Treatment Professionals (6 CEU credits): $90
• Register by Text: TEXT 2021SMARTCON to 41444
• Register Online: www.smartrecovery.org/2021conference

Conference agenda, speakers, sponsorship opportunities, and more can be found at www.smartrecovery.org/2021conference.

Contact conference@smartrecovery.org for more details.

Thank you to our sponsors

Level One

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PLEASE NOTE BEFORE YOU COMMENT:

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

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

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

IMPORTANT NOTE:

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

We look forward to you joining the conversation!

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

The other day, as I was going through social media, I saw a friend talking about being in a store when an alarm went off when what he had purchased set off an anti-theft device. He spoke about what a great feeling it was to stop and wait for a clerk to deal with the situation and how it differed from his active addiction experience. He noted it was far different because he shoplifted while in the grips of his addiction when he engaged in illegal conduct to support his use. He was not glorifying it, and the focus of what he said was about how positive recovery is for him because he no longer does those things. Someone told him on his thread that talking about his consequences in that way was wrong.

I am seeing this form of social media censoring occurring more frequently as tribalism seems to be taking over social discourse in our society, not just in the addiction and recovery realm. But it is particularly dangerous for the recovery community, who have long benefited from open discourse with a focus on broad consensus building. Ours is a community with many strong opinions. We achieve great things when we find and work on areas of common concern. The dangers of homogenizing our stories was a topic last year in this paper on the topic of recovery storytelling. It was an honor to work with Bill White and Danielle Tarino on a paper focused on opening up dialogue on personal privacy and public recovery advocacy focused on the ethics of sharing our stories and their value to the new recovery advocacy movement.     

What caught my eye in reading the post, was that the individual was being chastised by another person for talking about addiction in ways told that person’s uncomfortable individual truth, even as they were emphasizing the benefits of recovery. The sense is that even acknowledging things within the common knowledge of our society like criminal behavior in active use might reinforce stigmatized attitudes about people who experience an addiction. This moves us towards an unrealistic, homogenized version of addiction and recovery that is not actually reflective of what a severe substance use condition looks like. The unvarnished truth is that addiction often leads people to do things outside of their own codes of conduct, even illegal and dangerous things. It was true for me; it is true for the vast majority of us with severe substance use disorders. There is a long list of things that I did while addicted that I would not do now with a fully functioning brain.

Addiction is a condition of the brain, particularly the areas of the brain associated with executive function. The reasoning areas. Addiction also impacts the limbic system, the area of the brain that deals with base functions, the four Fs of evolutionary drive. For me, it was like the area of the brain in charge of reasoning between right and wrong was the quietest of whispers and the base function area of the brain that wanted the numbing sensation of the drug was shouting in my ear to do whatever it took to use drugs and ignore everything else between myself and the drug. As my brain healed, this reversed, and the executive function regions became much louder, the limbic system a quiet whisper. I have spoken about this dynamic with many persons who have experienced addiction over the years and in general that seem to understand this as similar to their own experience. It is common for those of us with severe forms of addiction. It is frightening to know from a lived experience what happens to volition in the grips of addiction, trust me on this.

What bothered me most about reading the exchange is that there is an increasing tendency to admonish anyone who acknowledges the things that we all commonly know about addiction. That drug use can lead to addiction and by extension, as addiction takes hold in the brain, it can cause people to do things that they would not otherwise do. I stay in recovery for two fundamental reasons. The first of which is that I can live the life I want free of drugs and alcohol. Moderation is not a choice for a person like me with a severe form of the condition. My life is much better this way! The second reason is that I am reasonably sure from what I can see in the literature and from experiences I see around me that for a person with a severe substance use disorder like me, use leads down a path where my very ability to act on my own volition become uncertain as addiction hijacks the brain. I have a responsibility to myself and others around me not to allow that to happen. Like thousands of others with severe substance use conditions, I don’t use drugs, so my brain stays functional and I remain a fully functional, productive citizen.

In some work with colleagues, I am doing currently on stigma, the topic of this post is one that we are having a fair amount of productive dialogue on. Stigma against addiction, drug users and people in recovery is a profound problem, one we are focused on addressing with hard data in ways that have not been done before. It is an important project. In that survey of thousands of Americans, 71% of respondents believed that society at large considers individuals who use drugs problematically to be outcasts or non-community members. Views on people in recovery were just as abysmal. How can one get help if society sees you as an outcast?  The magnitude is immense, according the 2016 Surgeon General’s Report on Alcohol, Drugs, and Health 20.8 million people (7.8 percent of the population) met the diagnostic criteria for a substance use disorder in 2015.  We need to change attitudes, be seen as human and treated as such. That is not where we are right now, not anywhere close. The perception in the general public is that roughly only one in three Americans see me as a full person because of my addiction and recovery status.

We must ensure that once addicted, a person is treated with respect and offered compassionate help. We don’t treat a diabetic as less than human, but we do treat people with addictions in this manner. It must change if we are to help the large portions of our population who come become addicted more effectively. But do we want to homogenize addictive drug and ignore the devastation that far too often comes with it? I hope not!

Destigmatizing drug users is far different than destigmatizing addictive drug use. There are taboos against addictive drugs for good reason, particularly in relation to addictive drug use by young people. We know that developing brains are more susceptible to addiction and that early drug use increases the risk of addiction. Most of us would not want to destigmatize heroin use for kids. Drug use is dangerous, we draw a fence around it and let people know it is dangerous for good reason. Look at what alcohol, a legal drug can do to a person and change their very nature as addiction takes hold. I don’t want my family members experimenting with methamphetamine. Cannabis related highway fatalities are dramatically increasing. I don’t want the driver in the car heading towards me to be impaired on cannabis or alcohol. We have to be able to talk about these very real and very tragic consequences. Open discourse about such things is becoming hard to do because of the dynamics of tribalism present in our community and in the larger society.

We do not want our babysitters high on heroin for good reason, but we should want to help the person and everyone so impacted. There are serious risks to public safety that come with drug use. We also know that people who use drugs heavily over time often experience significant changes to their personalities and do things they would not do in an era of life prior to their decent into addiction. We should feel compassion not derision. 

We should not be chastising each other for talking about our own realities with severe addiction, even as there is growing awareness that there are people with less severe forms of substance use. Sugar coating the terrible consequences of severe addiction would be wrong of us, even as we work towards reducing stigma aimed at the persons who experience addiction and those of us in recovery to ensure fair treatment in society.  Addiction is a deadly and serious condition, and we must acknowledge risks associated with addictive drug use even as we work to embrace our brothers and sisters in the grips of addiction.

While these are important conversations as a society and as a recovery community, we seem increasingly ill equipped to have them as we move away from nuanced open dialogue and into entrenched ideological camps in parallel with the rest of society. The latter dynamic is perhaps just as dangerous as destigmatizing addictive drug use, in my humble opinion. Many lives are in the balance and history shows us we can and do recover, and that once we do, we have the capacity to come together and do great things. Homogenizing what addiction looks like does not move us in that direction.

Guest blog by Lorie Hammerstrom, SMART Recovery Lead Onsite Trainer

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

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

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

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

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

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

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

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

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

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

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

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

Click here to register for individual training. 

Let’s work together to benefit young lives! 

PLEASE NOTE BEFORE YOU COMMENT:

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

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

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

IMPORTANT NOTE:

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

We look forward to you joining the conversation!

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

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

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

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

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

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

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

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

MAT Standards, 2021

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

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

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

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

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

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

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

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

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

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

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

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

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

Continue the discussion: @DocDavidM

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

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

Watch on our YouTube channel.

Subscribe to the SMART Recovery YouTube Channel

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

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

PLEASE NOTE BEFORE YOU COMMENT:

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

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

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

IMPORTANT NOTE:

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

We look forward to you joining the conversation!

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

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

Watch on our YouTube channel.

Learn more about becoming a SMART volunteer.

Subscribe to the SMART Recovery YouTube Channel

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

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

PLEASE NOTE BEFORE YOU COMMENT:

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

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

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

IMPORTANT NOTE:

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

We look forward to you joining the conversation!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In the podcast, Dave talks about:

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

Additional resources:

Click here to find all of SMART Recovery’s podcasts

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

IMPORTANT NOTE:

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

We look forward to you joining the conversation!

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