What do patients want when they come to treatment? My own experience suggests simple things: relief of emotional pain; a healed life; to be a better mum, dad, partner, human being; to let go of shame; to have a job and to be free from the Groundhog Day experience of addiction. Modest goals.

Some people set specific goals in terms of their substance use. Wanting to control use is common. In my practice, most have set the goal of abstinence. How common is this?

DORIS

A large-scale Scottish study DORIS (Drug Outcome Research in Scotland) undertaken by academics at Glasgow University was published in 2004. Researchers suggested that the majority (57%) of those coming to treatment wanted to achieve a goal of abstinence. The finding was both welcomed and condemned depending on perspective. “Of course, that’s what people are going to say,” was a commonly heard response from detractors. It all became a bit political. Some felt that, for opiate use disorder in particular, such a goal was both unrealistic and dangerous.

For these people, DORIS seemed like an attack on harm reduction and on MAT (medication assisted treatment), the prevailing treatment mode. I remember thinking that even if the proportion seeking abstinence is not as great as 57%, it’s still true that some do want to be free from illicit and prescribed opioids. And, of course, there is the fact that there already are many people in the UK and elsewhere in long term recovery from opiate addiction – so it’s clearly been achievable for them. Why can’t our systems accommodate many needs and goals?

Independent Expert Review on ORT

There’s been an unhelpful stigma about methadone programmes which has largely failed to bend to the weight of evidence on the harm reduction benefits of being in MAT. It’s not all about stigma though. I remember taking evidence from families for the Independent Expert Review on Opioid Replacement Therapies in Scotland a few years ago. It was a bruising experience. 

The venue was a Scottish Families Affected by Alcohol and Drugs (SFAD) conference. Here’s the thing: families did not like methadone. I listened to dozens of frustrated and angry delegates on the subject. As a prescriber, I came away feeling responsible for the perceived sins of all clinicians. 

But these views had little to do with stigma – what I heard behind the anger was family members’ views that the sort of treatment we were delivering did not go far enough. Back then, what was on offer was not doing enough to help our patients and their families reach their goals, something confirmed when the review was published.

To be honest, as both a harm reductionist and a supporter of recovery, I was less interested in getting involved in the polarising debates that came out of the DORIS study, than in finding answers to the questions: how have recovering people done it and how can we help to make the process safe and more successful? 

What do service users and their families want?

Ten years after DORIS, a small qualitative study by Sarah Thurgood and colleagues from Leeds took a nuanced look at what service users and their families wanted from treatment and found that they placed weight on abstinence and ways of maintaining abstinence. That’s what ‘being better’ was about for them it seems. It chimed with my experience with the SFAD conference delegates – they had higher ambitions for those in treatment than they felt treatment was delivering.

Thurgood and colleagues found that the challenges around defining what constitutes a ‘good outcome’ are considerable. Abstinence can seem like an absolute term (though there are various views on what it actually means) and in any case it gives little indication of life quality. 

Recovery, on the other hand, may encompass more complex domains such as “physical, biomarker, psychological, psychiatric, chemical dependence and family, social and spiritual”, so it can also be difficult to pin down.

In this study, six focus groups involving 24 service users and 12 family and friend members were recruited from a broad range of treatment modalities and recovery journeys. 

Although an attempt was made to recruit those currently on MAT, there were difficulties with engagement. However, a significant number who did participate in other groups had been on opiate replacement in the past.

Twenty ‘outcome elements’ were identified and categorised into sub-themes. The numbers mean we have to be careful about generalisation, but the purpose of this type of research is to look at themes and detail, which is valuable in a different way. The numbers were good for a qualitative study.

What did they find?

On abstinence: 

“Many felt that stopping substance use was a prerequisite of effective treatment and created a virtuous circle of feeling better, which in turn helped to motivate more effort to make change.”

On ORT: 

“The use of medication, such as methadone, was discussed and especially so in the court-mandated rehabilitation group. It was felt that substitute prescriptions masked the problem and were simply a parallel addiction… The use of methadone can support an individual in a controlled and managed way. It can also reduce the risk of injecting behaviour. However, SUs felt that even with these benefits, their end goal was to be free of heroin and any substitute drugs.”

Other domains

The researchers found dramatic improvements in health and that these “naturally happened with abstinence.” Service users found structure and activity important when recovering from addiction, relationships improved, but at the same time they had to let go of using and drinking friends. Participants also developed coping skills to deal with cravings.”

Perhaps mindful of the reaction to the DORIS study, the researchers reinforced the value of other outcomes that recovering people may achieve earlier on.

“The weight given to abstinence, strongly supported by family and friends, may be controversial. Of course, this does not mean that other outcomes, which some may consider less ideal, are not worthy achievements.”

Given the differing goals patients set for themselves and the sometimes aligning and sometimes opposing public health imperatives, we need a range of options laid out to service users coming for help. This should stretch from outreach and needle exchange to rehab. This does happen to some extent, but is patchy and not very joined up. It’s not just about having the options though; it’s about having a vision that people can and do move on into abstinent recovery.

Service users don’t always get what they want from services and that can be because expectations are unrealistic or that it is going to take time to get where they want to go. Sometimes though it is because what the service user wants and what the addiction worker thinks the service user wants are mismatched. 

Great or low expectations?

There are earnest and caring practitioners who believe that MAT is best when entered into for life. There are some convincing public health reasons why this view is held, but could it also be limiting for individuals who don’t want this? It is undoubtedly true that some of the time our expectation of what people can achieve is set too low. I’m thinking of the David Best study of the UK drug workers who estimated only 7% of their clients would ever recover. (Long term remission rates are much, much higher).

As I write I’m remembering a medical colleague (from a different city) who told me at a MAT clinic that to stay sane and prevent burnout, it would be better for me to accept that nobody was ever going to recover. This advice was too late in coming; by the time she told me, I’d already met hundreds of people who were in abstinent recovery from opiate addiction. 

It is also clearly possible to be in recovery through MAT. People can and do reach their goals on opiate replacement therapy. New options like Buvidal (long-acting injectable buprenorphine) have changed the landscape for the better. If someone reaches their goals on MAT, then there is much to celebrate and little more to be said. But I’m thinking of those who have different goals or who are not able to achieve what they want from what we have on offer – where the system is not flexible enough.

The voice of lived experience

In this regard, service users and recovering people have found a voice. They have found it in lived-experience recovery organisations (LEROs), service user groups, national organisations, and in the recovery advocacy movement.

Recovery advocates are not shy about speaking up and there is evidence that they are being heard. In addition, it seems to me what we now have activists who call for improvements in harm reduction services, but also for access to treatment options focused on recovery, like rehab. 

We need to be aware that one of the reasons we have a recovery movement at all is the very thing I’m writing about: service users and their families were not getting what they wanted from our services. Some voices may sound angry and baying. There is a reason for this. It’s easy to get defensive when we feel we are going the extra mile for our patients, but we really need to listen and open up conversations. 

Equal partners or ‘clinician knows best’?

Quoted in the Telegraph a while back, Professor David Haslam, then chair of the National Institute of Health and Care Excellence (NICE), said British patients should become more assertive and see themselves as “equal partners” with their doctors, with legal rights.

“I think it is essential for the future of the health service and for the future health of the nation that patients understand their conditions, their treatments and work with their health advisors so they can have the best care,” he said.

Ironically Professor Haslam was talking about accessing evidence-based medication, but the points could equally apply to accessing Recovery-Oriented Systems of Care (ROSC) which sets the bar high with regard to recovery– that’s what the evidence tells us some people want after all – and uses evidenced interventions to help patients get there. 

I wonder how many of us working in the field could list the elements of ROSCs if asked. We do need to support the service user’s expectation of what is achievable, let them be equal partners, and we need to deliver the sort of active interventions to make it happen. Enacting ROSCs would help – the intention is laid down in policy but getting it to work has proved difficult.

What did the Leeds researchers find?

I’ve digressed – back to the Leeds study. Broadly speaking they found that the desired goal in their sample of service users was abstinence from psychoactive substances. A second tranche of outcomes was about achieving changes that maintain the abstinence goal. 

A third tranche, and seen rather as a bonus, were the positive benefits of abstinence, for example, improved health. “We believe that practitioners will find it helpful to be mindful of the ‘being better’ goals while recognising that the day-to-day business of therapy often means negotiating small steps along the way to the desired goal.”

Although some of the participants had experience of MAT, this paper would have been strengthened by having input from those currently on MAT. There’s a risk of bias and of hearing only one part of a story, but, on reflection, I think the emerging themes are still relevant for debate in 2021. Who can say, particularly in light of our drug and alcohol related deaths, that we could not do better in treatment? 

Here’s the essence of this paper in a sentence.

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

Thurgood & colleagues

It’s time to raise the bar.

Neil McKeganey, Zoë Morris, Joanne Neale & Michele Robertson (2004) What are drug users looking for when they contact drug services: abstinence or harm reduction?, Drugs: Education, Prevention and Policy, 11:5, 423-435, DOI: 10.1080/09687630410001723229

Sarah Thurgood, Helen Crosby, Duncan Raistrick & Gillian Tober (2014) Service user, family and friends’ views on the meaning of a ‘good outcome’ of treatment for an addiction problem, Drugs: Education, Prevention and Policy,21:4, 324-332, DOI: 10.3109/09687637.2014.899987

Community Picture

I have been thinking Don Coyhis this week. For those who do not know of him, Don Coyhis is the founder of White Bison the American Indian/Alaska Native recovery community organization. Last year he received the distinguished lifetime achievement award at the Faces & Voices America Honors Recovery Award Dinner. He certainly deserved that award. It was a great honor simply to spend time with him on that night, which was also one of the most memorable nights of my own recovery journey.

One of things he talked about was how when federal funding came to support the work of White Bison. Federal grant officers were concerned at the time that their methods were not evidence based in ways that traditional services are defined. White Bison told the grant officers that they had several thousands of years of evidence on what worked in their community. Ultimately, they were allowed the latitude to serve their community as they saw fit, as it was recognized that they were the experts on their own community.  White Bison flourished.

This is profound. The experts on recovery community are people who live in the recovery community. I suspect that providing space for the recovery community to define and support its own members is a key ingredient in other recovery community organizations success as well. We must remain ever cognizant of this as we move to integrate peer recovery support services into our care infrastructure or we will lose the vital role and central function these services have in supporting long term recovery nestled within community.

As I have written about in recent weeks, community is fundamental to recovery for all of us. As Americans, we should be thinking about investing in measures to strengthen community in the broadest sense. Americans belong to fewer organizations, know our neighbors less, meet with friends less frequently, and even socialize with our families less often than ever before. It has broad negative implications for our health and wellbeing. The book Bowling Alone Collapse and Revival of American Community published in 2000 focused on the loss of social capital. In 2018, Senator Ben Sasse also focused on the loss of community as a central societal challenge in his book Them – why we hate each other and arrived at similar conclusions about what is happening and what we need to do to change it. I can’t think of anything more important to fix for our collective future as a nation.

Strengthening recovery community is a critical element in the revival of American community. Recovering people become engaged citizens which benefits all society. As Bill White, Pat Taylor and Carol McDaid note in there 2010 paper Recovery and Citizenship, we become involved in volunteerism, with our own families and reconnect with meaningful activities as citizens. Citizenship is central to the recovery identity.

Fundamentally:

  1. People in recovery are the experts on what is needed to develop and strengthen our own communities.
  2. There are broad societal reasons why we should be nurturing community in America right now.
  3. The recovery community is a key element in reviving American community.

We must avoid defining peer recovery services as similar to counseling – delivered in units on an individual or group level defined externally by others. Funders, even when well-intentioned could actually do harm to us and become a barrier to our work if not mindful of our expertise. The fact is the recovery community itself is the healing agent and the peer professional is more an ambassador of recovery than a service element. We must remain diligent and nurture recovery community and keep community “baked into the recipe” of peer services or we will lose the essence of the work we will do to activate and engage citizens in community.

After-all – we are the experts on what is needed in our own communities and what we have can help restore American community. This kind of service is central to our identity, all we are asking is for the recognition that we are the experts on our own needs. Doing so will help heal America.

Wash Mem 2019

[first posted March 18, 2020]

And just like that, overnight all of our worlds have changed. I already miss things that I did without a second thought less than two weeks ago before COVID-19 took hold. I am sure I am not alone in that. All of us are reeling from unprecedented change and disorienting events occurring wholly outside of our control. For many of us in recovery, this is not the first, second or third time when our worlds have come crashing down around us.

Every one among us have faced immobilizing fear and found our way back into life. We know about overcoming adversity, resilience and service to others. There are few communities better prepared to do the next right thing than the recovery community.  We have experience that can support our own wellness and help those around us. This is exactly what is needed right now.

We are generous community because we have experienced need. We are a humble community because we have experienced life bringing us down, at times as a result of our own doing. We know what it means to be down and out and need to ask for help and as a result, we are there for others. We pay it forward.

Many people are asking me how they can help in this time of crisis. One way we can do this is practicing social distancing and helping keeping COVID 19 from spreading. We must be good citizens and do our part to not spread this virus. A whole lot of lives depend on all of us doing are part in this effort. We should model it for the rest of society.

It also means taking care of ourselves. Taking care of ourselves physically, mentally and spiritually is really important right now. It is a really high stress time and one of the most important things we can do is to keep ourselves in recovery. Each of us is worth that effort. Many who love us are counting on that.

It then means taking care of our families, and then trying to help those around us. I see a lot of groups putting meetings on line, taking the crisis seriously and jumping into action to take care of each other. This is a basic tenant of recovery, and for many of us it is central to our identity.

So what should we do now?

I think we should do what the recovery community does best – service to others, the sharing of hope and the importance of living one day, one hour or one minute at a time when life is difficult. Because what we do have control over is how we react to the events occurring around us. We have valuable experience and tools in our toolboxes. Start thinking about those around you who may need help and check in on them on the phone of through media regularly. This is our chance to be part of the solution.

Let’s focus on what we know best and put it into action. This is our time to model self-care, hope, resilience, good citizenship and service to others.

Let’s do exactly that and show the world how we really are a community of consequence at a time when what we have to contribute has never been needed more.

This really can be our finest hour. Let’s make it so.

Imagine this scenario. You get the terrible diagnoses of cancer, like addiction, it is terminal if left on its dreadful course unimpeded. You are in the depths of despair, facing everything this terrible diagnosis means for your life.

The treating professional turns to you and says “recovery is possible. It is POSSIBLE you might survive this, it does HAPPEN.”

I would not be reassured by such a scenario, and the truth of the matter is that people beat cancer every day. This is a result of an advancement in science, a commitment to fund care and a dedication to follow multiple pathways of care, people who get that diagnosis survive. This occurs because the care team never gives up and keeps working until they hit on the combination of care needed for the person to move into remission. In respect to cancer, the truth of the matter is that the death rate from cancer in the US declined by 29% from 1991 to 2017. This occurred in large part due to a commitment to study outcomes over the long term and to fund care.  What this means for a person sitting in the chair learning that they have cancer is that the treating professional knows which treatments have the best chances of getting you into and sustaining them in remission for five years. They also know that there is wide variation in what works for whom. This means that they use multiple treatments and combinations of care to achieve remission

We know that addiction recovery is a probable outcome given the proper care and support they need 85% of the people who stay in recovery for a period of five years stay in recovery for the rest of their lives. 

Let’s start using more accurate language:

Recovery is the probable outcome for people with substance use disorders when they provided proper care and support.   

We need to focus on long term recovery as our focus of all addiction policy. Let’s study long term recovery and support multiple pathways and service strategies. Let’s do a moon shot, national focus on recovery so that in twenty years we can say that we reduced deaths from addiction dramatically, just like we did with cancer.

That starts with framing our discussion with the proper language of recovery as the probable outcome when people get what they need to get to get better and acknowledging we are a long way from achieving a system that provides that focus for all Americans.

So please stop saying recovery is possible and let’s focus on recovery being probable if we move towards recovery focused policy so we change our care systems to reflect the needs of persons seeking help with a substance use disorder.  

Addiction to alcohol or other drugs is not always easy to recover from. However, there are many pathways to recovery, including through treatment. One group of patients does far better than most other groups. In fact, their results are so impressive that many commentators have urged us to learn from what’s different about their treatment and follow-up to see if we can transfer learning and experience. This group, claim researchers, sets the standard for addiction treatment. Indeed, it represents gold standard addiction treatment. Who are this group? They are doctors.

In 2009, in the Journal of Substance Abuse Treatment, Robert DuPont and colleagues published a study that looked at how addicted doctors were cared for in the treatment system and also what their outcomes following treatment were.

The numbers were large. 906 physicians admitted to 16 different state Physicians’ Health Programmes were followed up for five years or longer.

Treatment

The authors accept that doctors generally come to treatment with more resources than the average patient, but they also point out the hazards that doctors face which potentially increase relapse risk. (Exposure to drugs in the workplace.) What was quite different about doctors in the USA is that they generally have access to specifically designed assessment, treatment and monitoring programmes (Physicians’ Health Programmes). These programmes typically evidence long term abstinence outcomes of between 70 – 96%. Since this paper was written a Practitioner Health Programme has been well established and reports similar results. Here’s what the researchers of the 2009 paper say:

For these reasons, the PHPs appeared to represent one of the most sensible and evidence-based approaches to addiction currently available. We reasoned that an examination of this novel care management approach might provide suggestions for optimally organized and delivered addiction treatment — real-world treatment at its best. If there were clear evidence of positive results from this form of care, the findings might provide guidance for improving mainstream treatment efforts.

The features of the Physicians’ Health Programme model

The study

16 PHPs participated in the national survey which looked at all admissions (intention to treat) over a six-year period. The case records and lab results of 904 doctors were studied. Most (86%) were male with an average age of 44. Two thirds were married.

Drugs of choice

What drugs were problematic?

The primary drugs of choice reported by these physicians were alcohol (50%), opiates (33%), stimulants (8%), or another substance (9%). Fifty percent reported abusing more than one substance, and 14% reported a history of intravenous drug use. Seventeen percent had been arrested for an alcohol or drug-related offense, and 9% had been convicted on those charges.

ORT

And what about our first line treatment for opiate addiction? How many of the hundreds of opiate- addicted doctors ended up on methadone? That would be just one, or to put it another way, 0.001% of the sample.

Work

72% of the doctors got back to work. When they looked at doctors who successfully completed the programme, this rose to 91%.

Overall outcomes

Specifically, of the 904 physicians followed, 72% were still licensed and practicing with no indications of substance abuse or malpractice, 5 to 7 years after signing their contracts. In contrast, the PHP process appears to have moved approximately 18% of these physicians out of the practice of medicine through loss of license or pressure to stop practice.

Of the 904, 180 (19%) had a relapse episode and were reported to their licensing boards. However, only 22% of these had any evidence of a second relapse— generally indicating that the intensified treatment and monitoring were successful in maintaining remission.

Nuggets

What does this mean for treatment in general?

If we applied the principles and standard of treatment that doctors get to other patients, would we see improved outcomes overall?

Whatever the differences from other populations experiencing SUDs [substance use disorders], it is likely that the successful treatment of physicians with SUDs has important implications for SUD treatment in general. For example, if physicians were found to have significantly better outcomes than other groups when treated for diabetes or coronary artery disease, this would be of great public health interest.

Raising the bar?

‘Recognizing that SUDs are biological disorders with major behavioral components (just like diabetes and coronary artery disease), the relatively high level of success exhibited by physicians whose care is managed by PHP is important with respect to the potential for success in addiction treatment generally. Indeed, the observed rate of success among physicians directly contradicts the common misperception that relapse is both inevitable and common, if not universal, among patients recovering from SUDs.’

They go on to say:

‘Indeed, rather than being a defining characteristic of addiction, the “ inevitable relapse” may be a defining characteristic of the acute care model of biopsychosocial stabilization, which offers an opportunity for recovery initiation but lacks the essential ingredients to achieve recovery maintenance.’

Making all treatment gold-standard

The paper has some suggestions to transfer learning and improve addiction treatment outcomes:

  1. Adopt the contingency management aspects of PHPs
  2. Offer frequent random drug testing
  3. Create tight linkages with 12-step programmes and abstinence standards
  4. Active management of relapse by intensified treatment and monitoring
  5. Continuing care approach
  6. Focus on lifelong recovery

Reflections

The fact that only one doctor ended up on opiate replacement is a remarkable finding. Are there double standards inherent here? Why do doctors so readily turn away from an evidence-based intervention, one they are very happy to prescribe for patients?

The expectation is that doctors will make the journey to abstinent recovery, but there seems to be a much lower expectation of their patients. Some argue this is just realistic, but does such ‘realism’ result in poorer outcomes? Is there a mismatch between professional expectations and client goals? Safety considerations have to be paramount and harm reduction at the heart of everything – but when a patient sets abstinence as a goal, could we do better at helping them get there?

I don’t think there’s much doubt that we could get better outcomes for our clients by raising the bar, increasing the intensity and duration of treatment, actively referring to mutual aid and thinking much more about the bridge from treatment to recovery community support, which is one of the keys to long term recovery.

Should doctors really get better treatment and follow up than the rest of the population? Can we narrow the gap?

—

DuPont, R., McLellan, A., White, W., Merlo, L., & Gold, M. (2009). Setting the standard for recovery: Physicians’ Health Programs Journal of Substance Abuse Treatment, 36 (2), 159-171 DOI: 10.1016/j.jsat.2008.01.004

This blog was previously published a few years ago. It has been lightly edited.

Keith Humphreys nails an elusive and important truth:

walking the talk of recovery advocacy

Thinking about what it means to advocate publicly for recovery. To me, this means showing that recovery is not only possible for persons with substance use conditions, but that given the proper care and support, recovery is the probable outcome for persons with a substance use disorder. As a person in long term recovery, I can’t think of many things that mean more to me than changing our care systems to expand help and reduce discrimination. We can save lives, resources and communities by focusing resources on getting people into and retaining them in recovery.

I think like many people in recovery, I have lost more people I love to addiction than every other way that people can die combined. I have also seen people who seemed to be on the path of recovery fall back into destructive behaviors. In the next breath, I will say that after three decades of working with people with addictions in our public care system, I have seen that people can get better than well – that recovery can lead to dynamic changes and dramatic reductions in criminal justice involvement and the use of healthcare services, increased productivity and civic engagement. I hope we all work together to reduce the former and expand the latter.

Over the last year or so, I have been thinking a lot about what it means to advocate for recovery and how one goes about doing so in a way that helps the community. I don’t hold myself out as an authority on this issue. I am just a guy who has spent a lot of time thinking about the topic and seeing really great examples of what I consider people who are “walking the talk” of recovery advocacy. Unfortunately examples also abound of what my colleague Jason Schwartz wrote about recently in his post titled “Recovery Celebrities?” I really hope other people are thinking about this as well, because a great deal of damage can be done by people with personal agendas driven by ego and aspiration and it really should be discussed constructively within the recovery space.

It is my humble opinion that recovery advocacy is:

We know that fame and notoriety can be intoxicating. This is a particular risk for people in recovery. Those of us operating in the public space to advocate for others are at greater risk for harm because the work can be intoxicating.  History is replete with examples of public figures in recovery using drugs and alcohol after proclaiming themselves in recovery or some other bad thing like stealing money or getting arrested. This harms all of us.

For readers – please read this post as a humble effort to contribute to the common good, I am not holier than thou, I am simply a person trying to contribute to the greater good. Thoughts welcomed.

Although COVID has changed many plans this year, we want you to know that you are not alone this holiday season. In keeping with our holiday traditions here at SMART Recovery, we are excited to once again offer our virtual annual New Year’s Eve Around-the-World event through SMART Recovery Online (SROL).

This nonstop meeting with hourly start times begins at 5:30 a.m. ET on December 31, 2020, and ends at 3:30 a.m. ET on January 1, 2021. Online meetings are laid back and fun with hourly themes selected by that meeting’s host. 

A few of this year’s themes include: 

(See the full schedule at the bottom of this article or downloading this PDF.)

HOW TO PARTICIPATE: This event is completely free-of-charge. To participate, use your SMART Recovery Online (SROL) login credentials. You can create SROL credentials for free at www.smartrecovery.org/community.

Wishing you a safe, happy, and healthy New Year.

Meeting Schedule:

Download this printable PDF to see full schedule with host names.

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Those harm reduction initiatives are great. I would say ‘keep doing that’. But also give people the opportunity to get well because that mantra of ‘keep them alive, keep them alive’ isn’t good enough. As a person in long-term recovery, I see it as a lack of ambition. It’s disrespectful to assume I am not worthy of healing.

Annemarie Ward

I shared a larger quote the other day that included this and it got some pushback from people who read it as dismissive of harm reduction or an expression of one-way-ism. I explained that I don’t read it that way at all.

At any rate, I read a press release about a recently published study and Annemarie’s words about “lack of ambition” came to mind.

The study focused on opioid agonist patients in Vancouver, BC. Here’s what the press release reports:

The paper adds the following:

There are a few things that are a little confusing in the paper, but I believe they report:

Those are the findings.

As with most things, there’s more than one way to understand the findings. Some might question the efficacy of the treatment, others might wonder if there are any psycho-social services provided, and others might wonder about the dosing. I think most people would view these as disappointing findings, particularly given BC’s status as a frequently cited North American leader on drug policy.

These researchers bring a different set of assumptions and reach a different set of conclusions.

What the study and press release don’t tell us:

I have two reactions to this.

First, I can’t help but wonder if the researchers would find these outcomes attractive or promising for themselves or a loved one.

Stigma gets a lot of attention these days. We usually associate stigma with judgmental or punitive responses to to addiction. I believe that low expectations are a too frequently ignored manifestation of stigma. Personally, I believe these outcomes could only be considered good in the context of seeing these patients as hopeless or as an “other.”

Second, we hear a lot of calls to follow the science, for evidence-based treatment, and OAT as the gold standard of care, often to the point of delegitimizing other models.

This study and press release highlight the importance of asking “evidence-based for what?” Does the evidence-base address your goals and hopes for yourself of your loved one? When experts communicate the evidence-base to you, what hidden assumptions are embedded? 4

Continued evaluation of treatments is extremely important. We do not have any silver bullet treatments and need to accurately communicate the strengths weaknesses of each option, and explore how they align with their goals. Yes, OAT dramatically reduces OD, but retention rates are not great and the evidence-base does not speak to the goals of many patients. Yes, PHPs have outstanding outcomes, but many PHP elements are not available to most patients and coercion undoubtedly plays a role in the success of those programs.

It’s an unfortunate truth that any patient or family member should be very skeptical of anything they hear from treatment providers, advocates, researchers, and journalists. This isn’t to say everyone is untrustworthy or dishonest, but too many of us are focused on a relatively narrow set of concerns. A friend compared understanding addiction, recovery, & treatment to an 8 sided die and added that most practitioners, advocates, researchers, and journalists are focused on only one side of the die.

  1. See table 1, row 1. It looks like 66%, but the fact that the Ns for columns 2 and 3 don’t equal the N for column 1 is throwing me.
  2. It says “at baseline”, which doesn’t make sense to me, because this is just an observation of OAT patients over a period of time.
  3. This statement referred to a study on OAT improvements over a 10 year period with the implementation of a cascade of care model. They defined retention as ≥ two observations in a given calendar year at least three months apart where the participant reported being enrolled on OAT. Retention rates improved from 29.1% to 35.5%. They defined stabilization as no self-reported overdoses, no binge drug use and no fair/poor self-reported health due to drug use among participants retained in OAT in the calendar year. Stabilization rates improved from 10.1% to 17.1%.
  4. This is not specific to OAT. These questions should be applied to all information about treatment and outcomes, whether it’s residential, outpatient, OAT, or whatever.

Thanks to Brian Coon for his comments on this post.

clockThere is a famous quote – “Americans Will Always Do the Right Thing — After Exhausting All the Alternatives” often credited to Winston Churchill. I have been thinking about the quote as it relates to the narrative around deaths of despair and the erosion of social connections, hope and purpose. These deaths are often related to addiction, and addiction seems to be at the heart of so very much that ails us as a nation. To address deaths of despair related to addiction we must focus on developing community recovery capital as a primary intervention strategy.

So what is community recovery capital? For a definition of Community recovery capital, I would refer readers to this 2008 paper by William White and William Cloud titled Recovery Capital: A Primer for Addictions Professionals. They define community recovery capital as encompassing community attitudes / policies / resources related to addiction and recovery that promote the resolution of alcohol and other drug problems.  In short, developing community recovery capital strengthens civic engagement while providing participants hope and purpose.

This is exactly what we should wake up every day trying to increase across America right now.

This is because expanding recovery capital spreads recovery. Yes, recovery is contagious – it spreads.  So “seeding” and nurturing recovery at the community level can offer broad benefit to the whole community. To understand how recovery can be contagious, I would refer readers to a paper by David Best and  Alexandre B. Laudet titled  The Potential of Recovery Capital.  In that paper, they describe how “smoking cessation by a spouse decreased a person’s chances of smoking by 67%, while smoking cessation by a friend decreased the chances by 36%. The average risk of smoking at one degree of separation (i.e. smoking by a friend) was 61% higher, 29% higher at two degrees of separation and 11% higher at three degrees of separation.”  This works for other addictions as well.

Pause and consider that expanding recovery in our communities has protective and preventative elements for the entire community. Additionally, broad, societal focus on expanding hope, connection and purpose within communities would be beneficial to changing the dynamic of our current addiction crisis by spreading recovery.

A huge problem is that as a society, we incorrectly conceptualized our addiction problem as an opioid epidemic (even as 90% of persons using opioids are using other addictive drugs). We are currently measuring “success” as the reduction of overdoses even as addicted persons continue to die from things other than overdose. In short, the wrong metric – reducing overdose deaths will end up having us miss the boat on effective strategies to save and restore lives and communities while keeping us stuck in tragic loss and the cycle of addiction.

It is important to change the narrative to one in which we educate our communities on the broad impact that recovery has and get our policymakers and philanthropic leaders to focus resources beyond our traditional care system (while still supporting care for acute service needs).

We cannot develop the resources and supports necessary to strengthen recovery within our communities if policymakers largely see things from a traditional acute care framework.  We must change the narrative to focus on expanding recovery capital at the community level.  The primary healing agent in healing addiction is community, lets focus resources there.

We must:

We cannot simply hope it will happen without resources and sustained focus. This will require broad sustained effort across government and philanthropic institutions. Advocacy starts with us.

It is beyond time. Our communities are worth it.

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