We are pleased to announce the release of our newest Tips & Tools for Recovery that Works! video Goal Setting. Once you define your core values, the next step will be to set goals that are in tune with those values. This Tips & Tools episode can help you formalize the process of goal setting and set you up […]

The recovery connection to this post may be a bit tangential, but I do see the processes of critical thinking, self-evaluation and a stance of empathy towards others as vital to the recovery process. As a person who has lived in addiction and experienced conducting myself in ways that were far out of my value system, I see from personal experience how we are vulnerable to alternate ways of behavior under certain conditions.

“We can assume that most people, most of the time, are moral creatures. But imagine that this morality is like a gearshift that at times gets pushed into neutral. When that happens, morality is disengaged. If the car happens to be on an incline, car and driver move precipitously downhill. It is then the nature of the circumstances that determines outcomes, not the driver’s skills or intentions.” ― Philip Zimbardo

I firmly believe that each of us have the power within us to change the alarming dynamics that are readily apparent and  unfolding now in our world. In that light, there are several books that resonate with me now. These books remind me that while there are many big things occurring that may seem out of our control, the “small things” we each do as individuals matter very very much to our shared destiny. This last point is also a recovery lesson, simply lets figure out the next right thing to do and do that thing.

Two books I am thinking about relate to the loss of social capital within our society and the consequences of their erosion. Robert Putnam published Bowling Alone: The Collapse and Revival of American Community twenty years ago. Many of the concerns he expressed seem prescient. I had the opportunity to hear him speak about it in person. His work influenced work around the understanding of recovery capital, a fundamental element of recovery. The book also had an impact on Senator Ben Sasse of Nebraska as he references in his more recent work, THEM Why We Hate Each Other–and How to Heal. Senator Sasse focuses on the dynamics of deaths of despair and the loss of hope, purpose and connection in current American society. My main takeaway from his book is that we used to define ourselves by what we are “for” as a people and now we define ourselves by what we hate. We are defining ever narrower groups of “others” and doing tremendous damage to our frayed national fabric in the process.

The book that has most been in my mind in recent weeks is by American Psychologist Philp Zimbardo, The Lucifer Effect: Understanding How Good People Turn Evil for nonreaders, there is also a 25 minute TED Talk. In short, the truth of the matter is that 99% of us under the “right” circumstances would put our neighbors in the oven, participate in genocide and other really unimaginable things. Acknowledging that each of us have this terrible capacity is key to avoiding it. Dr. Zimbardo breaks it down into Seven Steps or Processes:

1. Mindlessly taking the first small step. Consider the Milgram experiment. It began with the subjects only giving a small 15-volt shock. Later the vast majority would go up to a fatal 450 volts shocks, we tend to follow authority. When a person with a uniform or a lab coat tells us what to do, we tend to do so. Evil starts out small.

• Dehumanizing others. In the Stanford Prison Study the randomly assigned prisoners were arrested and assigned numbers to dehumanize them. The well-known result was that the experiment went out of control. But a quote from Dennis Burning of Charlie Company concerning the My Lai Massacre in Vietnam more potently illustrates the impact of dehumanization: “I would say that most people in our company didn’t consider the Vietnamese human.” In this massacre more than 340 unarmed civilians, women and children included, were killed by members of the U.S. Army’s C-company. Evil involves Dehumanizing the subject(s) of our hate.

• Deindividuation of self. The violent power of anonymity is inherent in the work of anthropologist John Watson, who studied 23 cultures and found that if they don’t change their appearance only one out of eight kills, tortures or mutilates, but when they do 90 percent kill, torture, and mutilate. When we are anonymous we are more violent.

• Diffusion of personal responsibility. Following the New York City murder of Kitty Genovese in 1964, witnesses were said to have seen the slaying, but did nothing to stop the attack. While the initial number and situation of the witnesses has recently come into question, social psychologists John Darley and Bibb Latané began research on what has been called the bystander effect. This line of research demonstrates that the greater the number of bystanders, the less likely an individual is to help a victim. If others don’t do something, we won’t either.

• Blind obedience to authority. Adolf Eichmann defended his role in the Holocaust by saying he was just following Hitler’s orders. He did what he was told to do. But obedience isn’t only about hurting others. In 1978 over 900 people committed suicide or were murdered in a Guyana jungle because they were blindly obedient to their pastor, the Rev. Jim Jones, head of the People’s Temple. They gave up their lives because they were told to.

• Uncritical conformity to group norms. The notorious Manson family, responsible for the Tate LaBianca murders in was a prime example of both blind obedience and conformity to group norms. The group norm was to do what Manson said, including murder, without question ‘Charlie made me do it?’  Only doing what everyone else does.

• Passive tolerance of evil through inaction or indifference. In 1972 Dr. Jack Hammond was confronted about the conditions inside Willowbrook State School. They were horrific. He responded that “the conditions here are no better or worse than any other facility for the mentally retarded in the state.”  Evil thrives on apathy and indifference.

So here we are in the grim days of early 2021 and the stark truth of the matter is that we actually could go down and even darker pathway than the one that got us to our current crossroads. The “right” hates the “left” and vice versa. We lack a common narrative about what we believe, who we are and even what is happening right now. Conduct is shifting and can shift even further under the “wrong” circumstances. We seem increasingly to be moving it into the gear of acting towards each other in a way that leads us to physically harm each other in widespread way. We need to shift out of that gear as a people as soon as possible. We need to shift back to good or very dark days may be ahead.

I was thinking about all this when I read the account of a police officer in the assault on our capitol on January 6^th and how people were beating him and yelling to kill him with his own gun. When he pleaded that he had children, a smaller group surrounded and protected him. The mob saw him as a thing to kill, not a person. A handful of people saw him as a fellow human and made a conscious decision to step in and save his life. My guess is that he was saved by one person who stood up and a group followed him. The lesson for all of us is that we can flip into a kill mode all to easily, and right now those conditions in America are ripe. Like this anonymous hero, we can also stop atrocities.

It must have been very hard for that smaller group to step out of the mob energy and act independently. I hope very much I would do the same thing. I am not willing to go down this pathway of atrocities, and I hope that the vast majority of my brothers and sisters in this grand experiment called America feel the very same way. It can be harder than one may think on first consideration. Events from grade school, where a bully picked on a kid that was different haunts me. I sat by the side, afraid to act, afraid I would be next. I stood by without acting.

Blinding hate and the seven processes can flip most of us into thinking and doing things we would not ever consider in other circumstances. Many if not all of these processes described in the seven points above are in operation at this moment in history. Our outcome is not fate, we all have the capacity and responsibility to identify that this is happening right here, right now in our society and do what we can do as individuals to step off this horrible path we are walking on. Atrocities have happened here, can happen again and yes we can do something about it. It starts with the recognition that we have a problem and each of us is vulnerable to acting like a member of a mob.

We have some profound problems as a nation and I am going to continue to work to build community and common purpose with anyone I can. I hope you do to. This is a recovery lesson for me, but I see it as a part of our larger social compact. Our shared future and the next generation is counting us to do the right things and be heroes. This is our moment in history.

We must work on a shared story of the hero’s journey out of darkness and towards the more perfect union our founders hoped for us. We will have to account for what we do, may it be a story of rising above rather than a story of decent into the abyss. At least, this is my perspective as a person in recovery with the lived experience of being in an altered state of conduct that in retrospect was frightening and foreign to how I see myself as a person.

Pulling this back to addiction and recovery, if someone needs help with an addiction problem, my mindset if to help them without regard to any other factor. Perhaps we should look at hate and the deindividuation of other people in the same light. Thinking about the Seeds of Peace program that serves to bring youth and educators from areas of conflict together to find common ground and to empower youth from conflict regions to work for a better future. Phil Zimbardo has a similar project, the Heroic Imagination Project that serves to train people to act in more heroic ways. How do we reconnect as a society and step back from this abyss? I don’t pretend to know.

I can however suggest that it will be one step at a time.

In opioid use disorder treatment, there’s been a persistent (though not always acknowledged) tension between what’s good for public health and what individuals and their families want from treatment. I’ve written about it before. For public health, there’s plenty of evidence that MAT (medication assisted treatment) reduces illicit drug use, improves health and reduces crude mortality rates.

There can’t be many people in Scotland who wouldn’t agree with the importance of the prioritisation of saving lives and reducing physical and mental health harms as a first response to a life-threatening condition.

Titrating a person with an opioid use disorder onto replacement therapy was usually my first suggestion to them when I worked in community clinics. It would again be if I were to go back to that setting – though it wouldn’t be my only suggestion. In Scotland where we have a shameful level of drug-related deaths, MAT needs to be our first step for those with opioid use disorder in most cases. But then the question ought to be: ‘what’s next?’ because patient-important outcomes need to be addressed alongside public health priorities.

This week, in an online meeting of treatment providers, we heard stories of those who wanted to move on from MAT, but who were blocked in various ways from doing so. Their prescribers had refused to lower their dose or refer them to rehab. The reason that was most commonly given was ‘it’s too dangerous’. But we also heard more encouraging stories of personal choice helped by high level support, connection to mutual aid, flexible reductions in dose with close monitoring, early re-titration where necessary and referral on to residential rehab with good long-term outcomes.

I absolutely understand the risk element and the fears that exist of destabilisation and relapse. These are legitimate. But there are four questions worth thinking about here. 

1. What do individuals and their families want? 
2. Is it what’s on offer?
3. Can people move on safely?
4. If so, how do we mitigate risks?

Meeting people with opiate use disorder who were in long term abstinent recovery from illicit and prescribed drugs changed my mind about what was possible. I suppose I have met hundreds of such people over the years. That’s a game changer. I worry that some prescribers don’t spend enough time with people in recovery.

Although there are substantial benefits to MAT, there are also problems: non-engagement with those who would benefit and timely access for instance. Then there are other issues too: stigmatisation of those on methadone, poor retention in treatment and how MAT fits in with the management of problem polysubstance use, including alcohol.

Some of these challenges are related to treatment delivery and can be improved. Indeed, there is much work going on in Scotland at the moment to address some of these through the MAT standards. MAT is a vital weapon in the battle against drug deaths – in that sense a major public health intervention – however, in community clinics we deal not with the public en masse, but with individuals whose own goals will sometimes clash with the public health imperative. 

So, does MAT help patients achieve their wider goals – those person-important outcomes? We don’t really know is the short answer. A systematic review published in 2017^[1], found that health related quality of life measures are rarely used as outcomes in MAT research. When looked at from a recovery perspective, we have more evidence on the negatives that go than on the positives that arrive. There are studies showing improved quality of life, but we need more on whether people reach their goals and get improvements in the things that matter to them.

A small in-depth Norwegian study^[2] involving 7 women and 18 men on MAT found evidence of them being ‘stuck in limbo’ in terms of not moving on despite national guidance that the patient’s own goals ‘should be the basis of treatment’. These drug users were still engaged in illicit drug scenes. The researchers found four themes:

1. Loss of hope
2. Trapped in MAT
3. Substitution treatment is not enough
4. Stigmatisation of identity

Some of this will chime with service users here too, though I see such themes as systemic issues rather than a problem with MAT per se. We can address some of this through the introduction of hope at every encounter – from safe injecting spaces to residential rehab, and if we can get recovery-oriented systems of care operational, have nobody ‘trapped’ anywhere in our services.

Another Norwegian study^[3] found that health-related quality of life for those on long term opiate replacement therapy was significantly lower than the general population – indeed lower than that of those with severe mental and physical health conditions.

Recognising these issues, a major review^[4] has been announced in the British Medical Journal, which moves away from public health-important outcomes to look at patient-important outcomes. The researchers state:

“Recent guidelines indicate there is little consistent evidence to evaluate the effectiveness of MATs [Medication assisted treatments]. Reviews evaluating MAT effectiveness have found great variability in outcomes between studies, making it difficult to establish a real treatment effect. 

Each study measures a different set of treatment outcomes that define success in arbitrary or convenient terms. This is a substantial limitation in addiction research that must be overcome to reach a consensus on which treatment outcome domains should be the goals, how those outcome domains should be measured and what works for opioid addiction management. 

If the outcome for such trials was reduced criminal activity, reduced incidence of infectious diseases, reduced homelessness or other social advantage, the intervention may be helpful for only certain groups of patients.”

The editor of the Journal Drug and Alcohol Dependence, Eric Strain, takes up the same theme this month in an editorial^[5]. My co-contributor, Jason has covered this in more depth recently. While making the point that reducing loss is undoubtedly a ‘worthy goal’, But Strain talks about the risk of stopping there. He says: 

Efforts to address this have  resulted in  a  focus on decreasing overdose deaths as an endpoint

He makes the point that setting a numerical goal for death reduction means it can be celebrated when achieved. He says, ‘it is worrisome and problematic to think that decreasing the percentage of opioid overdose deaths will solve the problem of opioid use. For patients and their families, it will not.’ He goes on to say:

Not overdosing is an insufficient endpoint for treatment or for societal and medical interventions – it’s a starting point. 

Strain talks about the importance of finding meaning and purpose and allowing people to ‘flourish’. He points out that researchers and healthcare providers see these as critically important in their own lives, yet we don’t seem to prioritise these for patients or in research.

I’m glad that quality of life is being taken more seriously by researchers. Recovery research has focussed on this for years, and rightly so, because quality of life is important to the people we are working with and to their families. There are other important things to be explored. We need research to understand what works best to reduce risks to those seeking abstinence, to explore what part our treatment systems play in facilitating and blocking people moving on, and to understand long term outcomes in those choosing abstinence/recovery pathways (where they exist). 

There will be many people who are satisfied with where they are in terms of treatment, including those on long term MAT. If they have been given meaningful choice in our treatment system and chosen MAT, then that’s cause for celebration. I’m thinking of those who have different goals and how we might improve what’s on offer to help them.

The question ‘what’s next?’ is a crucial one if we are to accept that reducing drug deaths is a necessary start but not an end in itself. We have to navigate the dual goals of reducing drug deaths and helping people flourish. These needn’t be in opposition; indeed, many will say that harm reduction interventions saved their lives and allowed them to recover.

I’ll leave you with two other questions. Is that question ‘what’s next?’ being asked enough, and are there safe and supported routes available to help people reach their own important outcomes?

Continue the discussion on Twitter @DocDavidM

^[1] Bray JW, Aden B, Eggman AA, et al. Quality of life as an outcome of opioid use disorder treatment: A systematic review. J Subst Abuse Treat. 2017;76:88-93. doi:10.1016/j.jsat.2017.01.019

^[2] Grønnestad TE, Sagvaag H. Stuck in limbo: illicit drug users’ experiences with opioid maintenance treatment and the relation to recovery. Int J Qual Stud Health Well-being. 2016;11:31992. Published 2016 Oct 19. doi:10.3402/qhw.v11.31992

^[3] Aas, C.F., Vold, J.H., Skurtveit, S. et al. Health-related quality of life of long-term patients receiving opioid agonist therapy: a nested prospective cohort study in Norway. Subst Abuse Treat Prev Policy 15, 68 (2020). https://doi.org/10.1186/s13011-020-00309-y

^[4] Sanger N, Shahid H, Dennis BB, et al, Identifying patient-important outcomes in medication-assisted treatment for opioid use disorder patients: a systematic review protocol BMJ Open 2018;8:e025059. doi: 10.1136/bmjopen-2018-025059

^[5] Eric C. Strain, Meaning and purpose in the context of opioid overdose deaths, Drug and Alcohol Dependence, Volume 219, 2021,

Our contributor David McCartney has a post over at the Scottish Health Action on Alcohol Problems blog. It’s worth your time.

“Rehab? What’s the point of it? There’s no evidence that it works. I don’t refer anyone to rehab. Do you?”

The addiction worker was talking to a colleague – another practitioner working in the field. What he didn’t know was that his workmate was in long term recovery from addiction and felt he owed his recovery, at least in part, to his three months in rehab several years before.

When I heard this, my initial response was a tight smile at the irony of the situation. But as the clinical lead of an NHS residential rehabilitation service (LEAP), I also felt frustration at our colleague’s contempt for the option of rehab as a treatment intervention. In practice, his own beliefs would be a barrier to his clients accessing rehab. Our own attitudes can profoundly affect those we have pledged to help. (read the rest here)

Residential rehabilitation: powering up in 2021

Healthy Goal Setting in Recovery

January is traditionally a month of goal setting—most often the start of New Year is viewed as a clean slate, a new page, and a fresh start. Goals are important because they can motivate us, they help us prioritize, and if utilized correctly, they can contribute to important personal growth and development.

If you’re in recovery, the idea of setting long-term goals can seem like a paradox. How can I set goals for the future, while also taking my recovery one day at a time? The good news is, there is a healthy way to set and achieve goals that can complement and even further your progress in your recovery journey.

Take Inventory and Visualize

The 12 Steps introduced you to the concept of taking inventory. In Step 4, you learned how to take a moral inventory and admit your shortcomings. This is a courageous step of true honesty and humility. In the same ways, when you begin to think about setting goals for yourself, begin by taking an honest inventory of where you’re currently at in different aspects of your life.

You may focus on your personal relationships, finances, career, wellness, other areas, or all of the above! When you reflect on your current situation, think of your position currently, and then visualize what your realistic yet ideal situation would be.

Be as Specific as Possible

You’ve heard it many times before, especially in recovery, don’t get too ahead of yourself, don’t “future trip,” and more importantly One Day at a Time.

The best way to set and achieve goals while also staying present in your recovery is to be as specific as possible with what you’d like to achieve. Goals that are too broad, such as “I’d like to save more money,” can be overwhelming, and frankly, can set you up to fail.

Being specific means setting a goal that is measurable, attainable, realistic, and timely (you may recognize this as a SMART goal!)

For example, a specific (and SMART) goal about saving money would be:

GOAL: I want to save $50 out of each paycheck to put in my savings until May. I’m going to cancel a subscription I have and eat out only once a week to save this money.

This goal is realistic, it gives you direction, a time-line, and sets you up for success.

Write Them Down!

It’s incredibly important to write your goals down! Bring your goals into a physical reality by writing them in a journal that you use often, on a whiteboard, or you can arrange them on a vision board with pictures of what you’d like to achieve. Studies show that you’re more likely to achieve the goals that you write down and review often. Don’t forget to track your progress either, take pictures, make notes, and record updates as you go along to keep you motivated.

Recovery First

No matter what, if you’re in recovery, keep your recovery first in your life. You know that you will lose anything you put before your personal recovery. The beautiful thing about the 12 Steps is that they are the true map and guideline for your ultimate long-term goal of sobriety. Keeping recovery at the forefront of your life affords you the solid foundation and stability to build all of your other goals upon.

If you need extra support, don’t forget to reach out to your recovery network, your sponsor, or your home group to discuss the goals that you feel comfortable sharing with others. You may turn your more personal goals over to your higher power as you understand it.

For more tools to assist you in setting healthy goals that support your recovery…JOIN US TODAY 1/25/2021!

Fellowship Hall and Triad Lifestyle Medicine are teaming up to bring you a FREE live webinar on how to set healthy goals related to overall health/wellness and self-care to keep you successful in your life, and in your recovery!

For those who register on Zoom, you’ll receive a checklist and goal assessment tool to help you succeed.

When: TODAY January 26 at noon EST

Where: Join us on Zoom (check email for registration link) or watch on Facebook LIVE!

****

Loneliness and isolation are bedfellows of addiction. Anything that intensifies loneliness will come with increased risks in tow. Of course, it’s not just those with substance use disorders who suffer from loneliness. In 2014, Professor John Cacioppo presented at a conference in Chicago, pointing out that that the impact of loneliness on premature death ‘is nearly as strong as the impact of disadvantaged socioeconomic status’. Disadvantaged socioeconomic status alone increases risk by 19%.

An Office for National Statistics report last year estimated that, during the coronavirus pandemic, more than 7M people in the UK felt lonely to the point that it affected their wellbeing. It’s a perfect storm for growth in substance use disorders in the population. Loneliness also holds risks for those in recovery.

When Julianne Holt-Lunstad and colleagues published their gargantuan meta-analysis of mortality risks in 2010 they found a ‘50% increased likelihood of survival for participants with stronger social relationships.’ From their research it looked like this was as strong a predictor of long healthy life as stopping smoking was and we know that smoking-related disease kills half of smokers.

So, having plenty of quality social connections is good for us generally, but it also has a lot to offer for those trying to recover from substance use disorders.

We have all known the long loneliness, and we have found that the answer is community

Dorothy Day

Mark Litt and colleagues from the University of Connecticut conducted a randomised trial of those with alcohol use disorder in treatment. These patients either had case management, contingency management AND social network, or simply social network connection interventions. 

The ones connected to sober social networks did better than the other groups. One mind-blowing statistic coming out of this was that ‘the addition of just abstinent person to a social network increased the probability of abstinence for the next year by 27%.’ If this was a consistent, repeated effect, think of the impact we could have on treatment populations.

What’s the best way to improve the social networks of those seeking recovery (and tackle loneliness in the process)? Answer: Introduce them to other recovering people. Where are recovering people to be found? In mutual aid groups and lived experience recovery organisations. In the UK and elsewhere we are thankfully rich with such resources.

There are many pathways to recovery, but one of the catalysts that is most evidenced is participation in Alcoholics Anonymous. A 2012 study found that the better outcomes associated with AA engagement were explained primarily by adaptive social network changes and increases in social abstinence self-efficacy (the belief that you can do it). 

The Cochrane Review on AA and 12-step facilitation found it to be at least as effective than other evidence-based approaches. Evidence is emerging though for other mutual aid groups, such as SMART Recovery and LifeRing, whose main mechanisms of action are likely to be similar.

Many people in recovery rely on this protective effect of connection to other human beings for recovery maintenance. In lockdown physical contact is very limited – in most cases to online meetings. Will return to substance use (the term formerly known as relapse) increase due to disconnection or will linking up on digital platforms like Zoom have a significant protective effect?

Getting clients/patients in treatment along to recovery mutual aid groups (online at the moment) and other lived experience recovery organisations is not rocket science, but it is less likely to happen if you are juggling a caseload of 50 clients. I hope that some of the resource going into treatment over the next few years will create systems where professionals both understand the salience of this and have time to do the key psychosocial work.

In 2021 with the welcome increase in funding for treatment in both Scotland and England, we have an opportunity to build in such systems and introduce training to ensure that at every point of contact we actively connect service users to others in recovery. I’m firmly of the belief that this should be at every client/patient contact, regardless of stage of recovery. Such connections can introduce and raise hope. Hope is an essential ingredient for recovery.

Public Health England have a great resource in the form of a Mutual Aid Toolkit and FAVOR UK have a helpful myth-busting guide, both of which I recommend. The PHE toolkit has a simple take:

• involvement with mutual aid can significantly improve recovery outcomes 
• more active or frequent involvement, such as becoming a sponsor, is associated with greater improvement in outcomes 
• substance misuse treatment providers can improve sustained recovery outcomes (including abstinence) by actively encouraging service users to engage with mutual aid 

Loneliness needs to be pushed out of the bed. The solution to loneliness is connection. We can reduce the risks associated with loneliness for those with substance use disorders through active connection even if this is only on digital platforms at the moment. This is almost certainly a cost-effective way to improve outcomes. What’s to hold us back?

Twitter: @DocDavidM

Picture credit: http://www.istockphoto.com/gdefilip

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Let’s plant that tree!

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

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

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

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

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

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

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