Notes on the future of the field

I was recently on a panel about the future of the field for an APNC event and thought a couple of questions and the notes I prepared might be worth sharing in a post.

What and how has the COVID-19 pandemic shown us about the importance of a multi-year perspective with individuals and inclusion of recovery management services, rather than medicalized care merely focused on initial disease management and symptom suppression?

A couple of things come to mind as a preface to my thoughts about this.

First, a quote from Robert DuPont, “The most striking thing about substance abuse treatment is the mismatch between the duration of treatment and the duration of the illness.”

Second, the conceptualization of addiction as a chronic disease with bio-psycho-social-spiritual dimensions. A recovery plan should address each of these dimensions if we expect it to be successful.

Biological medical models tend to emphasize the role of the medical provider, often at the expense of the agency of the patient. Often, the role of the patient is passive — a good patient is one that lets the doctor and their medications or procedures heal them.

The pandemic has been a psycho-social-spiritual crisis for many of us. And, with all we’ve learned about the effects of chronic stress, we know that biology can’t be isolated from psychology, spirituality, and the social context.

Successful management of chronic diseases typically requires behavior changes that are sustained over time to manage symptoms and prevent relapse. This is much more complex than it might first seem

• These behavioral strategies often include things like changes in eating habits, physical activity, sleep habits, and stress management.
• In many cases, these behavioral strategies involve changing habits that are practiced daily, often multiple times a day, for years and decades.
• These habits are often deeply enmeshed in the patient’s psychology, spirituality, and social context.
• The behavioral strategies involve extinguishing some habits and establishing others

What do we know about maintaining these changes over the lifespan, for years and decades? Unfortunately, very little.

It would be very helpful to know how the trajectory of chronic disease management is affected by important events over the lifespan. For example, how do life events like dating, marriage, divorce, geographic moves, new jobs/careers, job terminations, having children, loss of family members, natural disasters, health crises, retirement, etc affect the course of the patient’s illness/recovery?

Several years back, I looked for research on weight loss and diabetes management over the lifespan and found very little that was helpful.

All of this is to say that understanding the impact of the pandemic on people with SUDs will require:

• a lot of attention to matters that are typically considered outside of the scope of medicine; and
• for us to be present in the lives of people engaged in management of their recovery. We can’t know if we’re not there.

Finally, I’d add that, while we know too little about the long-term multi-dimensional dynamics of recovery management, there are important ways in which addiction treatment has been ahead of the curve. Many of the interventions we’ve been doing for decades aligns well with emerging concepts like social determinants of health.

Many of these interventions extend the duration of recovery support and monitoring, but we need to go further.

What do you see as the next phase of the New Recovery Advocacy Movement? Has the shift to a medical model of addiction helped or hindered this movement’s growth?

• Next phase? I don’t know.
• As the opioid crisis emerged and accelerated year after year, advocacy focused on access to medication, agonists in particular.
• This brought in a lot of medical and harm reduction advocates, and shifted the focus, goals, and values of recovery advocacy.
• The medical advocates often focused narrowly on medication and challenged its framing as a tool to assist treatment and recovery, often framing it simply as treatment and/or recovery.
• Harm reductionists brought in not just a toolkit of interventions like needle exchange and naloxone distribution, but also a philosophy of practice. 
  • This philosophy often adopts a neutral stance toward drug use, including addictive drug use.
  • This neutral stance toward drug use in the context of addiction is complicated for people in recovery. 
    • Preventing harm, particularly death and chronic disease are unambiguously good.
    • And, people in recovery view their addictive drug use as a symptom of a life-threatening illness with severe bio-psycho-social-spiritual consequences.
    • A neutral stance toward AOD use by people with addiction is generally incompatible with their experience. 
• The scope of advocacy has expanded from advocacy on behalf of people in recovery, to people in active addiction who we want to see get into recovery, and then to people who use drugs. 
  • All of these advocacy activities often get lumped together into “recovery advocacy.”
  • There’s a Venn diagram in there, with significant overlap, but advocacy for people who use drugs and people in recovery are also going to diverge in important areas.
  • Both are important, but they are not the same thing.
  • I think sorting this out is an important task in the coming years.
  • There’s a lot to overcome. For example:
    • Most people in recovery from addiction will describe it as an experience of loss of control or impaired control–a loss of agency to the illness, the addicted self. Many advocates focused on people who use drugs reject the notion of a true-self and an addicted-self.
    • People in recovery see recovery and change at the individual level as a critical outcomes while other advocates see focusing on individual behavior as blaming the victims for social/cultural failures.
    • The lowest hanging fruit might be developing better ways to differentiate addiction from other drug use, and tailor approaches to the type of use. (Maybe recovery-oriented harm reduction?)