This interview was done by Chris Budnick. Thanks Chris and Jude!

Who are you?

Well, I will first start by saying I’m a woman in long term recovery. What that means is that I haven’t found a reason, since June the 13th, 1991, to use any substance. I’m also a mom, a grandmother, a wife. I am a therapist. I work in the [addiction and recovery] field. And what else? Oh, I’m a minister. I don’t want to leave that out. And I’m a life coach.

What do you do professionally?

So professionally, I work with women and children. I serve as a coordinator for the Perinatal Substance Use Project with the Alcohol and Drug Council of North Carolina. I also serve as a consultant for the division of Mental Health Development Disabilities and Substance Abuse Services, and also Public Health, the Women’s Health branch, that’s one position. I do capacity management with them to make sure that the programs are reporting their weekly beds, and that I compile those numbers into a report that goes out to over 600 people in the state of North Carolina. I do technical assistance around gender responsive treatment. I also have a private practice. So I see clients… Now it’s virtual, but I see them in my office in Holly Springs when I’m seeing clients in-person. So that’s what I do professionally. Also, I do some ministerial work at Victoria’s Praise in North Carolina. I’m a part of the ministerial staff there.

And we’ve been fortunate in Healing Transitions to have you do some mentoring for our staff.

Yes. And I love it. It’s been such a great experience.

So you already mentioned that you’ve been in recovery since June 13th, 1991, do you have any additional experience that you’d want to share about your addiction and recovery?

Well, you know what, the one thing I will say is that when it comes to recovery, some people have the idea that things are gonna be perfect once you come into recovery, that is not the case. Things are gonna continue, life happens, that’s the bottom line. It rains on the just and unjust. So that means that things are always going to be going on, and it’s up to you to personally take care of your recovery. As I would say, especially for people that work in the field, there are often people who come in the field, might have their own personal experiences with addiction or personal experiences that needed counseling, and they think, “Well, I wanna be able to give this back.” And that if they come in, and they help other people, that will help them. It may help you a little bit. But the bottom line is your personal work that you do for yourself is what stands. I mean, you do your clients and anyone that you work with [a disservice], if you don’t take care of your own personal recovery, it’s just like when you get on a plane and you see the stewardess say, “Put the mask on yourself first.” So if you don’t have that mask on yourself first, you can’t help those that you serve. So I think that is very important to know.

Tell us about your professional experience in the area of addiction and recovery, maybe you could get into a little more detail about what aspect of the work that you’ve done and what’s been meaningful about it.

Okay, so I’ve been working in this field for over two decades. I used to work as a lab technician. I initially started volunteering, again, trying to help my own recovering. So I started with teenagers because I was very young when I came into recovery. That worked for a little while for me, but that just wasn’t my fit. Then I worked in a halfway house with men over 80 men in this facility. That was nice. I learned a lot there. But that just wasn’t my fit either. So, I think in 1998, I was a part of a major project that was about bringing gender responsive care in my area. I’m from New Jersey, and this was one of the first women’s programs, and we had an opportunity to do partial care, where the women was with us all day long and it was an 18 month program, which was very long, if you think of it, but they needed that. So, it was an 18 month program, maybe 22 women at the most, two clinicians, and we had case managers.

So that was where I found my love. I grew so much, I was able to really be able to pour into those women, but also grow myself emotionally, physically. I did that work for a long time and that program was very successful. They were there in place for over 20 years. Then, something fell into my lap, it was a position, and I wasn’t qualified for it. I didn’t have a master’s degree at the time, but it was being the coordinator of FASD, Fetal Alcohol Spectrum Disorder. So I went in that direction and it is pretty much the work that I do today, the only difference is it’s not specific to Fetal Alcohol Spectrum Disorder. So that allowed me to be able to do public speaking, technical assistance, work specifically with the providers that were able to offer those services for the women.

So, I love working with women, and in my private practice, I have now been working a lot with the children. I’m not specifically working with FASD, but I do have some clients with that particular diagnosis. 

I went back to school, got my graduate degree, and I’m a licensed clinical mental health counselor, associate, because I’m new to North Carolina so I had to get those 3000 hours. So that’s the work I do today, and I absolutely love it. There’s definitely a need for someone that has the passion and to show compassion and love for the work that we do.

What are you most proud of, professionally?

Well, I am most proud of that, the work with the women, I really… I love it. Some people burn out in this field. I haven’t because I’ve had great supervisors that taught me through supervision that I have to take care of myself in this work. So what I’m very proud of is that I never allow my love for working in counseling to wear me down. I really knew and learned that it’s important for me to take care of myself in order to be an asset to those that I serve. So I’m very proud of that, that I’ve been in this field for over two decades.

What keeps you working in addiction and recovery as opposed to something else?

Well, I would say that one of the things that when I did go back to school, I did wanna have that opportunity to work more specifically with the children that may have been affected by [addiction] or are affected by other things like divorce. So I would say, continuing to grow in this process, always keeping myself educated, always staying on top of the next thing, not keeping myself at a place where I started because things are forever changing. When I came to North Carolina, I had 19 years in recovery, and I actually had been working in the field for 18 years at that point. I was on a trajectory of really climbing in my field… people knew me. So, when I came to North Carolina, I felt I had to start completely over, but I’m glad I came in with a mindset, being open, willing to learn, not coming in as if I knew it all because I had been in the field almost 20 years at that point. So I allowed myself to come in as a sponge and I learned that I didn’t know all that I thought. North Carolina is doing great work when it comes to recovery, and not putting down North New Jersey where I was from, but the work was different here. So I am glad that I allowed myself to come in and be open, be a student, and continue to be at that place where I’m willing to be a student, not ever getting to the place where I have arrived.

So I would say that’s what keeps me here… It’s always growing and changing, and we’re doing great work when it comes to working in the field of addiction, being able to have peer support specialists that are able to help the clients that we work with. So I would definitely say, being able to never allow yourself to get to that place where you feel you have arrived or that you know it all, or that the way you got it was the way that every client you serve is going to get recovery, because it’s not.

How has the pandemic affected your work?

I would say it’s busier than ever at this point. For the women that I work with, what we’re seeing now is a lot of primary mental health. If your primary is mental health, if you have a diagnosis of schizophrenia, then that is your primary diagnosis and, if you’re using substances, then that would be your secondary. So we’re not able to refer that particular woman to the women’s programs because she doesn’t meet the qualifications and might not be able to keep up with the groups that are going on, being unable to get along with her peers and the staff. So I would say with the pandemic there has been an increase in mental health, there’s definitely been an increase in our calls at the Alcohol Drug Council. In my private practice, there is an increase in clients that I’m seeing.

What effects of the pandemic are you observing in the people that you serve, particularly women in need of perinatal substance use services?

Well, when it comes to them being able to access the services, one of the concerns that some of them have or many of them may have is that if they are referred to a residential program, are there protocols in place? Now, some may say, why would they wonder if there’s protocols in place if they are homeless and don’t have anywhere to go, but they have every right to wonder if there’s COVID protocols in place, and wonder if they and their children are going to be safe. They have the right to know that. Some people will believe that every person that uses substances, that they are neglecting their children or that they have lost all of their humane decisions. That’s not always the case, and some of them are concerned about that.

All of the programs have COVID protocols in place. We are meeting with them… there’s a management team meeting that we meet weekly. My leader, Starleen Scott Robbins, is making sure that she keeps us abreast of what’s going on. That’s what I see a lot of, but once the women know that they’re gonna be fine, it’s a great resource for them, then they’re excited that there are still choices, because that’s the other thing… folks are thinking because of COVID that there are no resources available at this time, or that they stop taking referrals when that is not the case. We’re still taking referrals, and there are actually a lot of beds available at this time.

What, if any, long-term effects do you anticipate on the field?

Well, as I said, there’s been an increase in mental health [problems]. I think about how it will affect people socially, when you think of people that have connected themselves to 12-step meetings, not having that in-person relationships that are able to bond as opposed to doing virtual, I think that that will be a long-term effect. I believe that financially, we’re gonna see a big change when it comes to hotels and restaurants and all of the things… Even when you drive downtown Raleigh, just what has happened there, I believe that we’re gonna be seeing years of this effect in our country, and our state of North Carolina. So I do believe that will make a difference. One of the things I appreciate is that if this would have happened 10 years ago, we might not have had platforms like Zoom and be able to still do training, and still do conferences, and see clients. That has been good. That’s a nice thing, and I hope that the boards that we work with, the addiction board, the LPC board, the Licensed Clinical and Mental Health Counselor board, the Social Worker boards, allow this to continue. I hope that this is something that is here to stay. Because, if you think about it, we’ve had clients that are in rural areas that are unable to access services, and they’re able to do it now.

That kind of goes nicely into the next question about any benefits or new opportunities in the pandemic, so anything additional to add to that?

I would just say that I hope… I put my plug in at the board, sent a email at my board, and I’m hoping that that is something that stays. I think even when you speak to the programs that have clients that have been able to access meetings or access groups via virtually, they loved it.

You also have your people that have issues with social anxiety, so they might not even come out and say, “Well, I don’t wanna go to the meeting because I’m uncomfortable with being around people,” and it just gives them that opportunity to take away that fear of facing someone head on, especially, when you’re at a place where you’re pretty vulnerable right now. So I think that is something that’s been nice. 

I believe it’s gonna be here to stay. I have a women’s conference that I participate in every May in Asheville. I was really upset that we couldn’t go this year. And I remember a few years ago, when I first started participating in that conference, it was at Kanuga, which is a lake in Hendersonville, and so many people were very upset about us not being at Kanuga when we moved it to Asheville to the MAHEC, but it was easier for us to maintain and work on the conference there for the people that were a part of the conference planning committee. So we went through that transition, and what we saw was little bit by little, our numbers started coming back up, ’cause we did lose quite a few because people wanted that place to be able to come to the campgrounds and unplug.

So when this happened, and our conference was cancelled, it was almost like that same kind of feeling, “Wow, the conference has been cancelled.” I remember that week I was really mourning not being there because I looked forward to it. And so that day, I had a training, and the training was with FIRST at Blue Ridge, so they’re out of Asheville. And so when I got on the conference, one of the things I saw was a couple of the women from the women’s conference, and that allowed me to plug in, be present, and participate in some different breathing exercises, so that allowed me to plug in to that and participate. 

We had our women’s conference in September, it was successful. I mean, we kind of felt like, “Wow, how is this gonna go off?” But it did, it went off, and it was a successful conference. And so, I hope that as time moves on and we’re putting things back into place, that we will allow virtual platforms to be a part of what we do.

If you were able to work on a fantasy project to improve treatment and recovery support, what would it be?

I would say, an opportunity to help those women that have that primary mental health diagnosis because… Okay, imagine you’re getting a call from five, six, seven, eight women that have mental health primary, but they’re pregnant and they’re using substances, but we have no resources for them. What do we do? Even if we find a way to put them in, maybe Walter B. Jones, which is one of your alcohol-drug treatment centers, they are very helpful when it comes to that difficult population, but once time is up, then what? Her time is up once she delivers her baby. So is the plan that she’ll deliver her baby, and automatically that baby is gonna go into the system? So if I could have any project that I could work on, it would be a project that look at how to help that population because it’s pretty sad when you think about it. When you have a woman that, even if she’s in a state of psychosis, there are times she has her moments of clarity. And so it might be at her moment of clarity she is reaching out to your agency for some help. And so the answer is, “We can’t help you because your primary is not substance use.” And so that would be the project that I would love to work on.

For you, as a woman of color, I could see these questions being asked in a different way, what effects of the recent racial injustice have you been observing on the people you serve? Do you have any thoughts or reflections about how some of these questions that we’ve explored about the pandemic and its impact on the people that are being served that would apply to the racial injustice that’s been going on in our country?

Well, I would not say that we’re seeing that in the population… Of course, it is something that is pressing for people of color. A couple of years ago I had an opportunity to go to a training. I think it’s REI, the Racial Equity Institute out in Greensboro. Every person that is in North Carolina should participate in that training, black, white, whatever. Because in that training, some of the things that we feel as a person of color… See, when you see me, if I’m presenting, I’m always dressed a certain way. I have that mentality because of my parents told me that I had to always dress a particular way, I had to speak a particular way, and I just had to work harder than my next white counterpart.

Now, that was the message that I got. And so as we go through these times and… I mean, it’s horrible. But what we people of color is that we’ll say that we’ve been feeling these injustices for a long time. In the programs that I work for, because of the leader that I’ve had and Starleen Scott Robbins and Flo for the many years, every woman no matter what her color is, is treated fairly. I know that. I could say for each program that they’re in. I think that that makes a difference, the leadership and understanding that, even if you don’t recognize it, that there’s something that we feel different on the inside. 

I grew up in a town, Asbury Park, New Jersey. So it’s on the shore. That’s where the boss [Bruce Springsteen] is from, right? We were sandwiched in between some pretty wealthy towns. And so I was next door to this town called Deal. I mean, they were filthy rich, and we went to school together. So I never experienced that at school because we had that multicultural thing going on at my school. But when I got to college in Buffalo, New York, I experienced racism like I had never experienced before. Oh my god, I was devastated. It happened a few times. Even though my parents gave us that preparation, they didn’t prepare me for that. 

So I will say that your leadership matters. The way you lead and how you treat the people that you serve is what matters. When it comes leadership, we know that trickle down. It trickles down. Everybody should have that same message. So that means that if your woman at the front door is not trauma-informed, then it doesn’t matter, because she might be the first person they see. So it’s the same way. If you’re at the top and you have a very present issue with racism, it will trickle down all through your organization.

Thank you, Jude.

The Power of Pause

When someone says, “Hey how’s it going?” in passing, do you take a moment to think about your response? Or by way of verbal muscle memory do you reply, “Good and you?” Often, you probably respond and keep walking, not even stopping to hear what the person has to say. What if today you took a quick moment to pause your life, and to genuinely respond and actively listen?

In this new age of fast food, fast cash, social media, and constant connection, humans have certainly become accustomed to instant gratification, and rapid reaction. When something in your life happens that is beyond your control, it can be tempting to react immediately because that’s what you’ve become used to. It can become a habit or a pattern to say “yes” to an email quickly to get it out of your inbox, to be snappy with a loved one when they say something you don’t agree with, or even to get angry at yourself quickly when you do something wrong. These immediate reactions separate you from your ability to think ahead, to “play the full tape through,” and they don’t account for what may happen as a result of your response.

Your immediate emotions are almost always rooted in frustration, anger, anxiety, sadness, and fear—because these are the emotions that are familiar to those who have suffered from substance use disorder, the ones that the disease feeds on. These are emotions that don’t require much thought or patience, they’re instant, and they’re what you might know best.

In all the moments of your daily life that you spend rushing through, reacting quickly, what if you took just a few of them to pause? What if you recognized a situation, and took a few seconds to breathe before responding?

Step three offers some of this wisdom

…Made a decision to turn our will and our lives over to the care of our higher power as we understood it.

As you turn your life over to something bigger than yourself, your higher power as you understand it, you can accept your inability to control your problems or situations in your life. The only thing you can control in your life is how you react to things. Step three says:

In all times of emotional disturbance or indecision, we can pause, ask for quiet, and in the stillness simply say: “Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”

Infinite power and spiritual energy lie within the moment between something happening in your life and your active response to it. This includes how you treat others, and how you treat yourself. There are very few things in your life that require immediate action, and it is healthy and productive to take some time to think about what you might say or do before pressing “play” again.

In recovery, this is how you can work to prevent a return to use. When a problem arises in your life, take your moment of pause and ask your higher power for quiet and understanding, or seek counsel from a sponsor or the collective wisdom of a homegroup. In your life, the power of your pauses protects you from returning to use, from hurting others, and from harming yourself.

As you pause, you are able to step aside and react to things from a place of empowerment, steadiness, and serenity. You’re able to provide thoughtful responses, exercise your personal boundaries, make the best decisions for your recovery, and meet others with understanding and love.

***

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

About Fellowship Hall
Fellowship Hall is a 99-bed, private, not-for-profit alcohol and drug treatment center located on 120 tranquil acres in Greensboro, N.C. We provide treatment and evidence-based programs built upon the Twelve-Step model of recovery. We have been accredited by The Joint Commission since 1974 as a specialty hospital and are a member of the National Association of Addiction Treatment Providers. We are committed to providing exceptional, compassionate care to every individual we serve.

 

David’s post from yesterday explored some of Robert DuPont’s research on programs for addicted physicians.

Here’s a recent interview with Dupont that explores his experience as a pioneer in methadone treatment, the cultural specificity found in 12 step meetings, the disease model, the “hijacked” brain, physician recovery programs, prevention, and engagement in treatment.

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.

In 2002, with a $1 million grant from the National Institute on Drug Abuse, SMART Recovery introduced the InsideOut program. These are meetings adapted specially for people in correctional facilities. Today, InsideOut meetings are being held worldwide. View the full video on our YouTube channel Learn more about the Courts & Corrections programs Subscribe to […]

Kevin Minnick is the SMART Recovery Regional Coordinator for Indiana. He is also a probation officer for Hancock County.  In this podcast, Kevin talks about: How being a professional golfer paid for his master’s degree in counseling  Seeing an ad for SMART Recovery in an underground newspaper in the 1990s   How working in the chemical dependency unit was luck of the draw  Recognizing that many […]

Radical empathy is not about you and what you would do in a situation that you have never been in and perhaps never will. It is the generosity of spirit that opens your heart to the true experience and pain and perspective of another. . . . The work that goes into learning another person’s reality opens up new ways of seeing the world . . . You gain a greater comprehension of people and systems that may otherwise confound you . . . radical empathy does not necessarily mean that you agree but that you understand from a place of deep knowing. In fact, empathy may hold more power when tested against someone with whom you do not agree and may be the strongest path to connection with someone you might otherwise oppose.

Isabel Wilkerson

There’s been a lot of attention devoted to Biden’s statements on drug policy and people who use drugs. I don’t know that these are representative, but this is how I’d describe the reactions in my inboxes and feeds:

For many, it is beyond comprehension how a smart and knowledgeable person could hold love for addicts, want to prevent addiction, believe no one should go to jail for a drug problem, and want to maintain criminal penalties for drug charges.

It is beyond comprehension if you have a certain world view and immerse yourself in certain subcultures.

However, if you attend meetings of community coalitions full of family members who have been affected by addiction, Biden’s statements will be be familiar and the logic will be obvious, even if you don’t share these views.

People who have suffered along with an addicted child or loved one often bring a different perspective than academics, libertarians, activists, etc. They often don’t see it as a choice, a civil liberties issue, or something secondary to social issues.

They see their loved one out of control, slipping away, in frequent danger, and engaged in a constant struggle with an illness that seems determined to destroy/steal/replace/disable the person they love. The behavior we see in their addiction is not their true self. They are desperate for something, anything, to interrupt this process.

Further, it’s often infuriating to them that so many experts have a lot to say, but look a lot  like passive observers, often fail to acknowledge their loss, fault to see that person making these “choices” is not their true self, and don’t offer an path to bringing their loved one back to themselves and their families.

This post isn’t about Joe Biden or his drug policies past, present, or future, though those are topics worthy of exploration. This post is more about the head scratching and exasperation I read about his statements and positions. If you step outside of your own ways of knowing, your own perspective, and spend time around parents who feel helpless and scared for themselves, their children, and grandchildren, you can hear Joe Biden as a father struggling with the reality that there are no easy answers.

UPDATE: These are people who have to live with contradictions. Many of them simultaneously hold space for the following:

Are people drinking more or less in the UK since the pandemic started? The answer is ‘both’. While overall sales of alcohol are down (sales receipts from HMRC show a 2.4% drop Apr-July 2020), it looks like those who were drinking in the most hazardous fashion previously, are now drinking more. The British Medical Journal identifies a particular subsection of at-risk drinkers:

…those on the brink of dependence during lockdown and beyond. For them, dependence will be triggered by bereavement, job insecurity, or troubled relationships. 

BMJ 2020 ; 369

This week, the journal Addiction published data on the impact of the Covid-19 lockdown on smoking, drinking and attempts to quit. What did they find?

Lockdown was associated with increases in high‐risk drinking but also alcohol reduction attempts by high‐risk drinkers. Among high‐risk drinkers who made a reduction attempt, use of evidence‐based support decreased and there was no significant change in use of remote support.

Addiction 21.10.20 (Open Access)

In other words, risky drinking got worse, people wanted to do something about it, but there was less treatment-seeking or treatment available. The authors also warn that increased consumption is likely to put people at risk of covid-19 and will put strain on already-stretched services. They call for increased public health messaging.

The Institute for Alcohol Studies (IAS) has also just published an excellent briefing which captures the most recent data from surveys and studies. 

It also makes comment on treatment: ‘Changes in referrals for and uptake of alcohol treatment are concerning but are typical of a wider pattern across healthcare. For alcohol, it is important to consider this in the context of future demand in an already stretched system, particularly given that one study found high risk drinkers were over twice as likely to make a serious attempt to reduce drinking during lockdown compared with before. 

The Royal College of Psychiatrists has estimated from PHE’s data that 8.4 million people are now drinking at higher risk levels. The College warned that addiction services are not equipped to cope with a post-pandemic surge in demand for alcohol treatment, following years of cuts.’ 

In Scotland, where there is a long history of negative consequences to communities, families and individuals from the nation’s heavy drinking, there are fears that the reduction in alcohol consumption associated with the hard-fought introduction of minimum unit pricing is being adversely affected by the pandemic. Concerns have also been raised about the impact on children of increased home drinking by parents during the pandemic’s restrictions and of increased domestic violence fuelled by alcohol.

Scotland on Sunday ran a feature last month which I recommend. Called ‘The coronavirus hangover and Scotland’s alcohol timebomb’, it captures some of the challenges and implications for the country. They summed up the situation:

It is, in short, a perfect storm; the kind feared by governments and public health experts. The signs are that in Scotland – a nation hardly revered throughout the world for its health outcomes – the crisis is exacerbating our long-standing problem relationship with alcohol.

Scotland on Sunday 27.9.20

What about treatment? Well, despite direction from the Public Health Minister that treatment services should remain open in the pandemic, closures did happen, and capacity continues to be affected. All of which adds to the ‘timebomb’.

Movendi, an international social movement for development through alcohol prevention published an alarming must-read policy report last month about the situation in Scotland which concluded:

Alcohol harm is rising across the country and the deficiency in alcohol services is adding fuel to the fire.

Movendi

We have a crisis, which seems likely to provoke yet further crises in terms of increased presentations of alcohol use disorders and all that means. The recurrent themes from multiple observers of increasing problems and a treatment system not prepared, need to be addressed.

A commendable amount of effort has gone into, and continues to go into, tackling Scotland’s drug deaths problem. While treatment resource has been increased, the focus has been on the opiate problem. It would be good to see similar elbow grease applied to tackling our almost-certain-to-grow alcohol morbidity and mortality – already higher than our drug deaths, but receiving only a fraction of the attention. 

Ian Gilmore and Ilora Finlay, in an BMJ editorial sum up nicely:

Presentations of alcoholic liver disease, already increasing before the covid-19 crisis, will rise further. A similar surge will occur in the need for alcohol treatment services, which are traditionally an easy target for cuts when finances are tight. We know that investing £1 in alcohol treatment services will save £3, as well as directly helping affected individuals, often the most vulnerable in society 

They conclude with an exhortation to look to national, and consequently personal, recovery:

This time, let’s be ready. Tackling alcohol harms is an integral part of the nation’s recovery.

“We are only as strong as we are united, as weak as we are divided.” ― J.K. Rowling

This is a political post; I hope readers give me a chance and hear me out. As I have said before, I am a student of history, and have spent some time learning about the history of addiction and recovery in America. History can teach us important and relevant lessons. Over the last sixty years or so, we have tended to take a few steps forward and then a few steps backwards in respect to supporting recovery efforts. One thing is true however, and that is when we have managed to move things forward, it was because of broad, bipartisan support.

This is true even now in our hyper partisan political climate.  In 2018, HR 6 the SUPPORT for Patients and Communities Act passed the in the US Senate 99 – 1 and in the House of Representatives 396 – 14 before being signed into law by President Trump on October 24th, 2018. That is significant in our current political climate.

This is because addiction and recovery has long been seen as a nonpartisan issue. Addiction impacts everyone. There are great advocacy points that support expanding access to treatment and recovery support services that make sense from Conservative, Liberal and Libertarian perspectives.

When I reflect on this – I think that this is largely a factor of the lack of partisanship in recovery. In the culture of the recovery community, we all depend on each other, without regard to political beliefs. Thinking of a well-known member of Congress who had a very public arrest a number of years back. In reading back on his accounts of his journey in recovery, it was a member of Congress from the other party who quietly reached out to help him. They formed a deep connection based on their common purpose of recovery.

This is our recovery culture.

The one thing that I would want people to know about me is that political perspective are way in the back seat to recovery for me. I suspect that is true for the majority of us. If you have political views that are different than mine, I respect you, hold you in positive regard and want you to know that I am there for you in your recovery journey in any capacity that I can. We have a great deal of common ground, and I recognize that my own recovery is supported by people who have different political beliefs than my own. Said another way, my very life depends on people with different political views than my own. I think that this is true for the vast majority of the recovery community, and it makes me proud of us and what we stand for.

Recovery must always come before personal ideology.

It is also important to note in this hyper partisan environment, if we ever lost that, we would lose all the gains we have made in supporting treatment and recovery efforts over my lifetime. I see policymakers with vastly different ideologies coming together on common ground to support treatment and recovery efforts. We must acknowledge and protect that common ground at all costs.

We have a long way to go to create a world where recovery is seen as the probable outcome for people with substance use conditions if they are given the proper care and support. This is our common ground and it is important for us to maintain our singleness of purpose.

We cannot afford becoming a partisan football. We all have a roll in this. Think twice before posting things that may be seen as hyper partisan on social media that may reflect back on the recovery community. If you run a recovery organization and are asked to provide information to a candidate or a political group, make sure you reach out to the other candidates and groups from the other “side” and offer equal support. Pay attention to hyper partisanship in recovery circles and educate people about the risks of dividing our community and becoming viewed as partisan.

We are indeed standing on the shoulders of giants – we must not fumble in our efforts to expand recovery by getting mired down in hyper partisanship. We owe this to the next generation. We stand to lose everything if we fail to stay above partisan politics.

Who are you?

My name is David McCartney and I am a Scot. I live in the southern uplands of Scotland, but I work in the Central Lowlands, which is the middle part of the country.

What do you do professionally?

I’m a doctor who specializes in addictions, and I work for the National Health Service, and part of the Health Service which is focused on mental health, so addictions come under that. I am the clinical lead in the service called LEAP, which stands for Lothians and Edinburgh Abstinence Program, and that is a quasi residential rehab. Normally, when it’s not COVID times, we take around 20 patients at a time. We treat about 100 people a year in a three-month quasi residential treatment program, which is based on the therapeutic community model of treatment.

Why do you call it quasi residential?

Well, the patients that we treat don’t live on the premises where the treatment is delivered so the living accommodation is separate from the treatment accommodation. And it’s a partnership approach, so the city of Edinburgh council provide the staff team which looks after the patients in the evenings, and at the weekends, and overnight, and the NHS, National Health Service team, look after the patients during the day and Saturday morning.

Do you have any personal interest in addiction recovery that you like to share?

Yeah. I’m in recovery myself, have been in recovery for many years now. I guess that’s probably the main reason that I’m working in addiction treatment because of that experience. When I was in my early 40s addiction had brought me to my knees, I was in inner-city GP, in Glasgow, in the west of Scotland, and couldn’t really get my head around why somebody from my background, with my training, and resources couldn’t stop drinking. I had two episodes of treatment, the first was very focused on medication, on getting off the alcohol, so it felt quite a medical approach. All that really happened was that alcohol was taken away, but life didn’t seem to get an awful lot better. It was a lonely kind of recovery, looking back. The second time around, I got introduced to other people who are in recovery, which was a revelation, especially other doctors, ’cause I was carrying a huge amount of professional shame associated with my drinking and not being able to stop.

I went to a residential treatment and I didn’t really know what residential treatment was, despite having looked after people with alcohol and drug problems, some of whom had gone to residential treatment, but I had no idea what they were going to. In a sense, I had no idea where I was going to either. I might have thought twice about it had I known, but it was a transformative experience. It really turned my life around. It’s such a big impact. That’s where the seeds were sewn to change career direction and to do something with the vulnerable population in Scotland, people with alcohol and drug problems, who maybe didn’t get the same privileges as me, as a middle-class doctor who got to go to a fancy residential treatment center. Most people in Scotland don’t get that opportunity, so I wanted to try and make that different. That’s the background to my personal experience and a bit about how it intertwines with my career, and my career choices.

Tell us a little bit more about your professional experience in the area of addiction and recovery.

When I got better from my own addiction, I retrained and went back to university and did a Master’s degree in alcohol and drug studies. I wanted to work in the field. So, first of all, I got a little bit of experience working in a residential treatment setting. In Scotland, most of these are either in the third sector, charitable, or non-government organization sector, or private, so I have to go outside of the NHS to get that experience. I did that for a while, and then I came back to work for NHS in addiction treatment. But the addiction treatment clinics I was working in were very focused on harm reduction, which is really important, I am a harm reductionist at heart, but there was precious little time to do any kind of meaningful work. Time with patients tended to be focused on the prescription, and on the medication, and on testing, and all of that kind of stuff, and I wanted to do something different from that in the longer term.

I had an idea… first of all, I had to look to see what the literature said about residential treatment and there wasn’t an awful lot of stuff published in the United Kingdom so I had look elsewhere, to the United States, of course, a little bit from Australia. Then I went to visit some treatment centers and that was really helpful because the people who were running these places were really good and generous at sharing what was working for them and they had done the legwork, if you like, in setting treatment systems up. I then started to write down some of these ideas based on the evidence that I could find, and I started to pitch it to people that were commissioning services. One person picked up the idea and pitched it to the Scottish government who funded a two-year pilot to set LEAP up, and I knew from my visits and talking to people that run other treatment centers that there was precious little around on outcomes. I couldn’t get my head around this to start with it, so much money was going into addiction treatment, but people were not measuring what was happening to their clients. From the offset I decided whether it was going to be a success or not, we would measure what we were doing, and we’d measure what was happening to the people who we’re trying to help. That evaluation turned into a study, which is still ongoing, we’ve still got data for about up to five years after treatment now.

Long story short, the service got funded. We only had two years of funding, so we really had to prove that we were worth the investment in that time, and we were able to demonstrate to government that we were worth continuing funding being given to us, and that’s what’s happened. Ever since we’ve done the same sort of thing with evidence of what we’re doing, and that evidence has helped with funding. So, unlike elsewhere, patients don’t have to seek funding. As you’ll be aware that the two systems of health in the United States and United Kingdom are very, very different, so patients don’t have to seek funding, there are no insurance companies paying for patients to come to LEAP. If you fulfill the criteria for treatment, you’re given a place, you don’t have to worry about the funding for it.

I’ve also done a bit of work for the Scottish government on drugs policy off and on over a few years. More recently, we’re working on looking at the lie of the land when it comes to residential treatment across the whole Scotland. So, our feeling is it’s quite patchy. Some people have reasonably smooth access to it and other people, unfortunately, don’t seem to have access at all. So the Scottish government have set up a working group, which I’m chairing at the moment, which is looking to see really the scope of what’s actually happening, and then to make some recommendations to government. We’re hoping those recommendations will be along the lines of trying to have equity of access across Scotland so that if it’s the right kind of treatment for someone, they’re able to get there. So I guess that’s the answer to the question.

Professionally, what are you most proud of?

Wow, that’s a good question. Professionally, our patients and their achievements. My team, and a lot of the people I work with they’re in recovery, and they bring something of that into the professional life… a passion I suppose, and the enthusiasm for recovery. And, our service… we’ve managed to achieve a lot to help our patients get where they want to go, and to help keep them there by putting aftercare in place and connecting people up to ongoing sources of support. So yeah, these things… That’s quite a lot of things to be proud of, but professionally, my team, our patients, and the service and what we do with our patients.

In the States, addiction, recovery work is often poorly paid, funding is unstable, it’s often a difficult profession for people to stay in. What keeps you working in addiction and recovery?

I think one of the things that I get to see is people doing well because we provide aftercare for up to two years. Everyone who comes to our treatment service is from the local area, so there is Edinburgh City and then there’s three Lothian counties around Edinburgh and it’s about 800,000 in population. So, people are treated in the area that they are already living in, so when they come back for aftercare, you’re seeing them over a period of time. You’re seeing them doing well, you’re seeing their families, they are coming to the family group, and that feedback is hugely powerful. There’s an excitement to that that comes. I’ve always enjoyed my job when I was a GP in Glasgow, there was a lot of fulfillment and pleasure from that, but this is something different.

I guess you get to see the fruit of our patient’s labors over a long period of time and that’s really encouraging. I remember there was a British researcher that was looking at drug workers in a part of the United Kingdom and he was asking them, “what percentage of your clients, the people you’re working with, what percentage of them do you think will get better over time?” Their estimation was something around 7%, they reckoned only 7% of the people who we’re working with would ever recover. Of course, the actual figure is much, much higher than that. So they had low expectations, not because they were poor practitioners, but because they never saw people getting better. All they saw was people who recycled back in, who relapsed and came back. The people who did well moved out of the treatment service and didn’t need to come back. They would be successes… but they didn’t get to see that. There was no reinforcement. So for me, the reinforcement of seeing the people achieving their goals and maintaining those goals is hugely satisfying–not just satisfying, it’s exciting. I suppose that’s what keeps driving me.

How has the pandemic affected your work?

It has affected it profoundly. When the shutdown happened here in Scotland, it was quite dramatic and sudden and there wasn’t much opportunity to plan. Our service was closed very, very quickly at the beginning. We had to wind down people who were in treatments that we had to finish the treatment much sooner than it should have finished, which was really hard because we knew that was putting them at risk. Then there was a period where we weren’t able to operate at all for a few months, and during that time we lost the accommodation (housing) part of the service because it was put aside for public health to use as a kind of isolation center. We’ve been unable to get that back. So, we’ve had to find alternative premises, and we are working with a hugely reduced capacity. Instead of treating 20 people, we’re treating 8 people, which causes its own problems in a therapeutic community environment because you need a certain threshold, a number for it work effectively.

We are trying to increase capacity, we’ve got permission to do that but we don’t have accommodation to do that. So that’s been very, very hard. In addition, just recently, the city of Edinburgh council team who look after our patients after hours, they have been pulled to work in public health as well. So my team have had to move from working 9:00 til 5:00, to going to shifts which they’ve all agreed to do, amazingly. That has meant fewer people available during the day. So it’s been really chaotic. We have adapted, we’ve done our best. Our waiting list has gone up, we’re looking at ways of trying to support people on the waiting list just now. We’ve moved our aftercare program and our family program to digital platforms… amazingly, that’s actually been a success story. We’ve managed to retain most of people through Zoom and other platforms.

We’re now in a situation where we’re trying to prevent harms coming to people on the waiting list. Almost by definition, people who referred to residential treatment from our wider service –  most of our referrals come from fellow treatment professionals who are working in the community with people. So doctors and community psychiatric nurses and voluntary sector agencies refer into us and they are referring the people that are probably trickiest and have the greatest burden of problems, and the least recovery capital. Maybe they’ve got co-morbid mental health and physical health issues. They’re sitting on a waiting list, and they are coming to harm. We’ve been monitoring a lot of them that had to be admitted to a hospital for emergency care, some of them been seen in accident and emergency departments, and emergency rooms for emergency treatments. We know some of that’s preventable had we been able to bring them into treatment. So, that’s been really, really hard as a doctor.

We’re doing our best to try to meet these needs but it is very difficult. In addition, of course, there is the other anxiety of trying to keep the patients safe, so we’ve put into provision a lot of things to try and do that. But of course, there is always still a risk when you’re bringing people together in a group when there’s a lot of COVID around in the environment. So we’re doing our best but it has been tough and I suppose it’s been tough emotionally as well as practically. Certainly, there’s a sustained effect over a long, long period of time and there’s no end in sight yet. So… just having to keep supporting each other and look to other ways of supporting ourselves. I’ve recently been getting into mindfulness meditation just to try and get myself a bit more grounded and not so distracted when I come home about what’s going on at work and that’s really helped.

How do you see the pandemic affecting the people you serve? You just mentioned some of them coming to harm while they’re on a waitlist. What else are you seeing?

I think the biggest thing – certainly for aftercare patients has been the disconnection. Then, of course, all of the mutual aid groups in Edinburgh and Lothian we have… We have so many mutual aid groups. We have Alcoholics Anonymous. We have got Cocaine Anonymous. We’ve Narcotics Anonymous. We’ve got Smart Recovery UK. We’ve got all of these… There is so much of a resource out there and all the meetings just had to stop suddenly. So, of course, they’ve moved to digital platforms as well which has been effective but some people don’t like digital platforms.

So that’s been hard. I know it’s been hard ’cause we’re hearing stories of how hard it’s been for people, sticking to the guidelines when they desperately need the contact of other people. The other thing is more societal. We have got some early… It’s mostly anecdotal, a little bit of hard evidence that people’s drinking has changed in the pandemic. If you think about people who are not yet patients, some of them have reduced their drinking, but some of the people who were probably problem drinking are now drinking in a more hazardous fashion. That, I suspect will result in more referrals coming into the system. Again, there’s a little bit of anecdotal evidence of that happening in clinics in the community. So I suspect what will happen is we’ll get an increase in referrals coming into treatment, not just to residential treatment but, across the board. And we’ll probably see increased demand on hospital emergency departments because of crisis presentations and such. It’s early days but I think it’s a case of watching the space.

What, if any, long-term effects do you anticipate on the field?

That’s an interesting question. I guess other treatment settings where funding has got to be found before the person can come into treatment… Usually in the United Kingdom that would be through either through health funds or more likely through social work funds. I suspect those services which rely on that kind of funding, some of them will fold because of restrictions and numbers that they’re having to apply at the moment. I hope one of the things that’s happened is… this kind of crisis has forced us to look at our own values of what matters. I think looking after vulnerable people with alcohol and drug problems… I hope that we have a more compassionate approach because people can see that a lot of this is coming out of hurt and isolation, and people losing their jobs, and economic crisis, and so on. So it’s a back to the old thing… You know it’s not a moral thing if you suffer from an addiction, it’s an illness. And, like every illness, it’s affected by the environment people find themselves in. This is a really difficult environment. So I hope that compassion will come out of this. But again, it’s a case of watch this space… we’re in the middle of something we’ve never been in before, so it’s unpredictable.

Has the pandemic brought any benefits or new opportunities?

I suppose it’s linked to what I’ve just said. It’s probably been one of the hardest times as a professional to try and keep that professional hat on, and not be reactive and emotional and so on. A part of me knows I’ve got to allow myself to feel, but it’s been tough. The last few months have been really tough. 

I think self-care. As in the United States doctors are regulated, it’s called the Boards in the States, and we have the General Medical Council here. Part of what we have to do is have an annual appraisal, and to re-apply for our license to practice, and demonstrate that we’re able to do that. And, just recently, which I think is a really good thing, we have been advised to look to self-care and to demonstrate how we’re self-caring in our appraisal. I thought it was a really positive move, and it certainly made me sit up and take notice of how I have to care for myself. It’s like that thing when you’re on an aeroplan and you know they say that the masks will drop down, fit your own mask before you help others, you know. I need to self-care before I can really be giving my best to my patients. And, I was aware I wasn’t self-caring, I was fretting and feeling anxious, and struggling a bit, and I’m not feeling the same way now because I’m doing a bit more self-care. I mean for a lot of people who read this or listen to this, that’s probably a pretty obvious thing [chuckle] to do. But sometimes I just don’t bring myself back and think, “You need it to be caring and loving toward yourself as well as the people you’re looking after.”

If you were able to devote yourself to a fantasy project to improve treatment and recovery support, what would it be?

If I think… What would have the biggest impact across a range of different treatment services? I think this is something that is beginning to happen here in the United Kingdom, is to involve people with lived experience embedded into those systems. It has to be done carefully so that you protect the individuals and don’t abuse the privilege. But, when we first started treating patients, we heard the same thing again, and again, and again when people were coming into treatment–they didn’t know anyone else in recovery. So they’ve never met anyone else who recovered.

Back in our early days most of our patients were heroin-addicted and they’d never seen anyone get better. Then one of my colleagues, who was a Community Psychiatric nurse, told me of someone that we treated who got into recovery, and then maintained that recovery, and is still in recovery today actually many, many years later. The impact that guy had on his community… because none of his peers had ever seen anyone get better from heroin addiction. That made such a profound… All of a sudden we had all these referrals coming [chuckle] in from the same town because people wanted something like what this guy had achieved. And that stuck with me and we developed a peer support program and then we got some funding to apply to someone who’d be our peer support coordinator and look-after the peer supporters, develop a training program, and so on. And I think that if we had people with lived experience, who were trained and supported in other services… at the places where needle exchange is happening, and we’re trying to get people engaged into opioid replacement treatment, and we’re trying to save lives essentially. If you had peer supporters there, people with experience, who’ve maybe been there a few years ago, and delivering the needles, and caring for them, and sharing a little bit of the story at the same time, that would generate hope. And, as you know, as we all know who work in addiction treatment, hope is not a thing, you can’t put it in a bottle and you can’t prescribe it, but you can influence it, you can demonstrate it with hopeful people and people whose lives have been changed. 

I’d like to see that… it might be my fantasy to see that role across Scottish Addiction Treatment Services where you had role modeling and enthusiastic recovery of different sorts, and not necessarily one brand, but to give hope to the people that come into our services.

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