OD Awareness and both/and approaches

NARCAN-KITYesterday was International Overdose Awareness Day. Where do we stand?

This crisis has brought some good policy changes. Naloxone distribution programs are spreading fast and good Samaritan laws are spreading too. These policy changes will undoubtedly save lives, and that’s important.

There’s also no doubt that there are a lot of deaths that these programs won’t prevent. Consider the death of Phillip Seymour Hoffman. As is common, he appears to have died while using along, which casts doubt on any suggestions that naloxone and good Samaritan laws would have saved him. Even for those they save, they don’t offer a way out of their suffering and a lives that they hate.

fr2plus-overview-main-450x330How are we doing in terms of access to treatment of adequate intensity and duration? We don’t have much in the way of statistics for that, but it’s save to say that we’re not doing so well. We’ve got models that work really well, but we only use them with health professionals, lawyers and pilots.

Too often, we’ve had one faction calling for more treatment and another calling for harm reduction.

Naloxone is not enough. And, even access to quality treatment of adequate duration and intensity were improved, we couldn’t engage and successfully treat everyone.

We need a both/and approach rather than an either/or approach. Let’s increase access to naloxone and make sure that every rescue is followed by the kind of care an addicted health professional would get.



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Are “recovery ghettos” really a concern?

"He left me for the glass pipe."

Beauty, Hunts Point. Courtesy of Chris Arnade. Click image for more in his series.

Cassie Rodenberg’s blog has had a couple of heartbreaking posts recently. They look at the lives of women in the culture of addiction–prostitution, pimp boyfriend, sexual assault, having to provide sex for a place to stay, etc.

It brought back Bill White’s book, Pathways and his discussion of sex within the culture of addiction. Not only does the use of sex as a vehicle to maintain access to drugs or other needs within the context of addiction detach sex from pleasure, intimacy and love, it also is a consequence and contributor to the objectification of others–people become objects to be used or avoided.

All of this got me thinking more about a post a while back where I discussed a post from Bill White on the need for “recovery spaces” and how the concept was getting some push back. DJ Mac (who is supportive of the concept of recovery spaces) titled his post, Does recovery space equal recovery ghetto? Much of the discussion seemed to be between people who are culturally empowered, mobile, do not live in a ghetto and have never been trapped in a ghetto.

Cassie’s posts reminded me that, for some, ghetto isn’t just a metaphor–it’s their world.

These people need more than harm reduction.

They need more than MI, CBT or 12 step facilitation.

They need Recovery Management.

Bill White calls on us to raise our expectations of ourselves and the system while focusing on recovery and the community as the locus of healing. [emphasis mine]

Addiction treatment must always adapt to the evolving context in which it finds itself. Such redefinition may push treatment toward the experience of retreat and sanctuary in one period and toward the experience of deep involvement in the community in another. I would suggest that the focus of addiction counseling today should not be on addiction recovery-that process occurs for most people through maturation, an accumulation of consequences, developmental windows of opportunity for transformative or evolutionary change, and through involvement with other recovering people within the larger community. The focus of addiction counseling today should instead be on eliminating the barriers that keep people from being able to utilize these natural experiences and resources. Our interventions need to shift from an almost exclusive focus on intervening in the addict’s cells, thoughts and feelings to surrounding and involving the addict in a recovering community.

Over the years Bill shifted his language to emphasize “community renewal”:

A major focus of RM (Recovery Management) is to create the physical, psychological, and social space within local communities in which recovery can flourish. The ultimate goal is not to create larger treatment organizations, but to expand each community’s natural recovery support resources. The RM focus on the community and the relationship between the individual and the community are illustrated by such activities as:

  • initiating or expanding local community recovery resources, e.g., working with A.A./N.A. Intergroup and service structures (Hospital and Institution Committees) to expand meetings and other service activities; African American churches “adopting” recovering inmates returning from prison and creating community outreach teams; educating contemporary recovery support communities about the history of such structures within their own cultures, e.g., Native American recovery “Circles,” the Danshukai in Japan;
  • introducing individuals and families to local communities of recovery;
  • resolving environmental obstacles to recovery;
  • conducting recovery-focused family and community education;
  • advocating pro-recovery social policies at local, state, and national levels;
  • seeding local communities with visible recovery role models;
  • recognizing and utilizing cultural frameworks of recovery, e.g., the Southeast Asian community in Chicago training and utilizing monks to provide post-treatment recovery support services; and
  • advocating for recovery community representation within AOD-related policy and planning venues.

It’s worth noting that, over the years, Bill has written about recovery employment, housing, education, etc,

It can be overwhelming. But, the alternative is despair.

UPDATE: This post was re-titled based on reader feedback.


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CVS is selling Narcan in Rhode Island

NARCAN-KITHere’s an interesting development in access to Narcan:

CVS Pharmacy announced that it would offer the opiate antidote Narcan without a prescription at all of its 60 pharmacies in Rhode Island by the end of month.

Narcan, also known as naloxone, offers immediate help for anyone overdosing from an opiate such as heroin or a prescription painkiller such as OxyContin. If given in time, Narcan can reverse an overdose by restoring breathing.

“Over half of our pharmacies are now under a collaborative agreement that allows them to dispense Narcan without a prescription,” CVS spokesman Michael DeAngelis said Friday. “It’s part of our commitment to combat prescription drug abuse. We think it’s a great public service.”

Read the rest here.

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Young people’s experiences of 12 step groups

Students on Campus 6DJ Mac highlights a recent study of 302 18-24 year olds entering residential treatment and their opinions of 12 step groups. The study also included follow-up at 3, 6 and 9 months.

He pulls a few quotes from the paper and one, in particular, leapt out to me.

Clinicians can highlight that 12-step specific content was rarely cited as a reason for discontinuing 12-step attendance among young adults.

He also summarized their findings:

What was most helpful?
  • Removing a sense of isolation
  • Validating experiences
  • A sense of belonging, acceptance and validation
  • Installation of hope (being inspired/encouraged by another member who has a similar problem).
  • Altruism (members help and support each other).

12-step specific responses were rare leading the authors to conclude that ‘general group therapy factors were more important to these young adults in early recovery/post-treatment.’

What did they like least?
  • Meeting structure (length, repetition)
  • Having to motivate oneself to get there

Interestingly, less than 1% of young people found meetings unhelpful.

Why did they stop going?
  • Logistical barriers (e.g. lack of transport)
  • Low recovery motivation and interest
Why did some never attend?
  • Didn’t need treatment
  • Don’t have a problem

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contradictory, pointless, bearing very little relationship to reality

sad girl by .indigo

sad girl by .indigo

On the heels of Robin Williams’ death, some writers are sharing their experiences with depression.

The theme I find interesting are the themes around sufferer’s thoughts and beliefs. Therapists almost universally discuss cognitive distortions. I’ve been wondering if, in the case of very severe depression, framing these thoughts as distortions fails to capture the power of these thoughts and beliefs.

“Cognitive distortions” implies that a person is taking something real and selecting the negative, framing things in a negative light or intensifying the negative aspects/possibilities.

These are more like delusions that are firmly maintained with very little relationship to reality.

First, John Tabin:

To me a lot of the thinking in severe depression is more like a delusional system than distortions. They are not grounded in reality. When you’re that depressed, others seem blind and deluded–you’re the only one who sees things as they really are.

Depression is a skilled liar, using what you know is true as basis for a massive fraud. You know you’ll always be wrestling with your demons, and depression convinces you that you’ll always be in as much pain as you are right now. The kind of pain that’s so unbearable that you’d die to end it is not a permanent part of your life, no matter how much it feels that way.

Next, David Weigel:

If I’d imagined a dream job, it’d likely be the one I have now. But success doesn’t change the patterns of depression. These are the ways it hits me:

One: You earned none of what you have. You’re a fraud. People are going to find out. Everything your critics have said about you, from the guy who lobbed dodgeballs at your head to the hate-mailer who hated your Iowa story, is completely right.

Two: All that other stuff you feel, the negativity and the screw-ups? You definitely earned that, because you’re meant to fail. You’ve succeeded, and you still feel this way? Why, that’s proof that you won’t possibly feel better.

Three: Nobody truly likes you. They can desert you at any moment. They’re succeeding, and you’re not.

It’s contradictory, and pointless, and bears very little relationship to the reality of what you’re going through.

(hat tip: Elizabeth Nolan Brown)

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a beautiful life


Matt Schwartz. Kelley’s brother. My cousin. Great guy.

401962_10201206616432978_317921181_nAward winning author and editor (Also, a cousin of mine.) Kelley Clink shares an interesting insight about the effects of suicide on those left behind and on the victim’s legacy. [emphasis mine]

Here’s the thing about suicide: it can seep backward and stain an entire life. For years after my brother’s suicide, I could only think about him in terms of his death. Any moment of joy or happiness was called into question. He’d suffered so deeply for so long–had any of the pleasure in life he’d expressed been real?

It took a very, very long time for that stain to fade. For me to allow my brother’s life to be about more than his death. He, like Mr. Williams, made people laugh. He comforted. He celebrated. He loved.

But, she does offer hope.

Some people may be angry. Some people may judge. I think most people will just feel sadness, and hopefully compassion. Eventually the stain will fade, and we will be left with his beautiful life.

Kelley’s memoir will be published next May.


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High prevalence of opioid use by social security disability recipients

Proportion of the disabled Medicare beneficiaries under the age of 65 filling 6 or more opioid prescriptions by Hospital Referral Region. There are large regional variations. Credit: Image courtesy of Wolters Kluwer Health: Lippincott Williams and Wilkins

Proportion of the disabled Medicare beneficiaries under the age of 65 filling 6 or more opioid prescriptions by Hospital Referral Region. There are large regional variations.
Credit: Image courtesy of Wolters Kluwer Health: Lippincott Williams and Wilkins

A recent study finds that 43.7% of disability recipients are taking prescription opioids. Many are on very high doses.

The researchers analyzed trends in use of prescription opioids (morphine-related drugs) among disabled Medicare beneficiaries under age 65 between 2007 and 2011. Nearly all under-65 Medicare beneficiaries are SSDI recipients; patients who go on SSDI are eligible for Medicare after two years.

Consistent with reports of an “opioid epidemic” in the United States, the results showed high and rising prevalence of opioid use by SSDI recipients. The percentage of beneficiaries taking opioids increased from 2007 through 2010. In 2011, the most recent year with available data, prevalence dipped slightly to 43.7 percent.

The percentage of these beneficiaries with chronic opioid use rose steadily, from 21.4 percent in 2007 to 23.1 percent in 2011. Chronic opioid users received numerous opioid prescriptions — at least six and generally 13 per year — typically prescribed by multiple doctors. Women were at greater risk of becoming chronic opioid users than men.

Among chronic opioid users, the average “morphine equivalent dose” (MED) also dipped in 2011. Still, nearly 20 percent of chronic users were taking a dose of at least 100 milligrams MED, while ten percent were taking 200 milligrams. “Opioid use of this intensity has been associated with risk of overdose death in the general US population and more specifically in disabled workers,” Dr Morden and colleagues write.

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