Revisiting recovery-oriented harm reduction (part 3)

So . . . we’ve dusted off and reviewed my history with recovery-oriented harm reduction.

We’ve also explored why I believe recovery and harm reduction should remain distinct constructs.

This sets the stage to revisit and update the concept.

What is recovery-oriented harm reduction?

Recovery-oriented harm reduction (ROHR) seeks to address the historical failings of both abstinence-oriented treatment and harm reduction services. ROHR views recovery as the ideal outcome for any person with addiction and uses recovery (for addicts only) as an organizing and unifying construct for treatment and harm reduction services. Admittedly, these judgments of the historic failings are my own and represent the perspective of a Midwestern U.S. recovery-oriented treatment provider.

Addiction is an illness. The defining characteristic of the disease of addiction is diminished and/or loss of control related to their substance use.

Drug use in addiction is not freely chosen. Because the disease of addiction affects the ability to choose, drug use by people with addiction should not be viewed as a lifestyle choice or manifestation of free will to be protected. It is not a expression of personal liberty, it is a symptom of an illness and indicates compromised personal agency.

All drug use is not addiction. There is a broad spectrum of alcohol and other drug use. Addiction is at the extreme of the problematic end of that spectrum. We should not presume that the principles that apply to the problem of addiction are applicable to other AOD use.

ROHR is committed to improving the wellbeing of all people with addiction. ROHR services are not contingent on recovery status, current AOD use, motivation, or goals. Further, their dignity, respect, and concern for their rights are important are not contingent on any of these factors.

An emphasis on client choice—no coercion. While addiction indicates an impaired ability to make choices about AOD use, service providers should not engage in coercive tactics to engage clients in services. Service engagement should be voluntary. Where other systems (legal, professional, child protection, etc.) use coercive pressure, service providers should be cautious that they do not participate in the disenfranchisement or stigmatization of people with addiction.

For those with addiction, full recovery is the ideal outcome. People with addiction, the systems that work with them, and the people around them often begin to lower expectations for recovery. In some cases, this arises in the context of inadequate resources. In others, it stems from working in systems that never offer an opportunity to witness recovery. Whatever the reason, maintaining a vision of full recovery as the ideal outcome is critical. Just as we would for any other treatable chronic illness.

The concept of recovery can be inclusive — it can include partial, serial, etc. While this series argues for a distinction between recovery and harm reduction, Bill White has described paths that can be considered precursors (precovery) to full recovery.

Recovery is possible for any person with addiction. ROHR refuses cultural, institutional, or professional pressures to treat any sub-population as incapable of recovery. ROHR recognizes the humbling experiential wisdom that many recovering people once had an abysmal clinical prognosis.

All services should communicate hope for recovery. ROHR recognizes that hope-based interventions are essential for enhancing motivation to recover and for developing community-based recovery capital. Practitioners can maintain a nonjudgmental and warm approach with active AOD use while also conveying hope for recovery. All ROHR services should inventory the signals they send to individuals and the community. As Scott Kellogg says, “at some point you need to help build a life after you’ve saved one.”

Incremental and radical change should be supported and affirmed. As the concepts of gradualism and precovery indicate, recovery often begins with small incremental steps. These steps should not be dismissed or judged as inadequate. They should be supported and possibly even celebrated and they should never be treated as an endpoint. Likewise, radical change should not be dismissed as unrealistic or unsustainable pathology.

ROHR looks beyond the individual and public health when attempting to reduce harm. ROHR wrestles with whether public health is being protected at the expense of people with addiction, whether harm is being sustained to families and communities, and whether an intervention has implications for recovery landscapes.

ROHR should aggressively address counter-transference. ROHR recognizes a history of providers imposing their own recovery path on clients while others enjoy vicarious nonconformity or transgression through clients. These tendencies should be openly discussed and addressed during training and ongoing supervision.

ROHR refuses to be a counterforce to recovery. ROHR seeks to be a bridge to recovery and lower thresholds to recovery rather than position itself as a counterforce to recovery. Recognizing that addiction/recovery has become a front in culture wars, ROHR seeks to address barriers while also being sensitive to the barriers that can be created in this context. When ROHR seeks to question the status quo, it is especially wary of attempts to differentiate from recovery that deploy strawmen, recognizing that this rhetoric is harmful to recovering communities and, therefore, to their clients’ chances of achieving stable recovery.

ROHR sees harm reduction as a means to an end. ROHR views harm reduction as strategies, interventions, and ideas to reduce harm. As such, it is wary of harm reduction as a philosophy or ideology, which sets the stage for seeing harm reduction as an end unto itself. Back to Scott Kellogg’s point, “at some point you need to help build a life after you’ve saved one.” The end we seek is recovery, or restoration, or flourishing. Seeing harm reduction as a philosophy or ideology risks viewing it as “the thing” rather than “the thing that gets us to the thing.”

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Revisiting recovery-oriented harm reduction (part 2)

Yesterday, we began to revisit the concept of recovery-oriented harm reduction. Why recovery-oriented harm reduction and not just recovery? 13 years ago, recovery-oriented harm reduction was thought of as a bridge between harm reduction and treatment or recovery. Today, in some circles, it might invite questions about why one would want to maintain a distinction between harm reduction and recovery.

Defining harm reduction

Harm Reduction International defines harm reduction this way:

Harm reduction refers to policies, programmes and practices that aim to minimise negative health, social and legal impacts associated with drug use, drug policies and drug laws. Harm reduction is grounded in justice and human rights – it focuses on positive change and on working with people without judgement, coercion, discrimination, or requiring that they stop using drugs as a precondition of support. Harm reduction encompasses a range of health and social services and practices that apply to illicit and licit drugs. These include, but are not limited to, drug consumption rooms, needle and syringe programmes, non-abstinence-based housing and employment initiatives, drug checking, overdose prevention and reversal, psychosocial support, and the provision of information on safer drug use. Approaches such as these are cost-effective, evidence-based and have a positive impact on individual and community health.

Harm reduction emerged in response to the failures of medical, public health, and addiction treatment systems to meet the needs of people currently using alcohol and other drugs. Harm reduction saves lives and has challenged other systems (like my own) to face their shortcomings and biases and improve our services. Harm reduction is an essential part of the service continuum and its existence has created pressure to improve the care delivered by other systems.

Defining recovery

There have been several proposed definitions of recovery by academics, professional associations, panels, federal agencies, and state agencies. The trend among these definitions is toward more porous conceptual boundaries and greater inclusion. The first wave of attempts to define recovery seemed to originate from a sentiment like the following, “There are people out there who are doing what you call recovery. They just are not doing it in 12 step groups or they are using medication to assist their recovery. They are just using another pathway to get to the same destination (i.e. outcome). To exclude this people from the boundaries of recovery is inaccurate and wrong. And, by the way, you might want to wrestle with whether there are ways in which your thresholds are too low (e.g. tobacco use and other unhealthy behaviors). Recovery is less about the pathway and more about the destination/outcome.” The best example of a definition arising from this wave is from the Betty Ford Consensus Panel:

Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.

The next wave of definitions seemed to arise from something like, “What you’ve thought of as recovery is way too narrow. It shouldn’t be confined to addiction. There’s a whole spectrum of problems and changes within the context of those problems that constitute recovery. It’s not a outcome at all. It’s a process, and anyone engaged in a process to improve their wellness is in recovery. Recovery is the pathway not the destination/outcome.” SAMHSA’s definition is an example of this is type:

A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

Another, more recent, example is from the Recovery Science Research Collaborative:

Recovery is an individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.

Process, direction, outcome?

Long before researchers and scholars took an interest in recovery, recovering people have described recovery as a process. What’s interesting here, is that I think recovering people have thought of recovery as a process and a destination/outcome. Some might think of it as a process that leads to an outcome, while others might think of it as an outcome maintained by a process. Whatever the case, both elements are considered essential. The Betty Ford Consensus Panel definition integrates a lifestyle (destination) that is voluntarily maintained (process). This more recent wave of definitions emphasize a process and a direction (“improvement . . . striving . . . full potential” and “sustained efforts to improve wellness”) rather than an outcome or destination.

Does it matter?

In is paper on the conceptual boundaries of recovery (read the whole thing) Bill White observed:

Defining recovery also has consequences of great import for those competing institutions and professional roles claiming ownership of AOD problems. Choosing one word over another can shift billions of dollars from one cultural institution to another, e.g., from hospitals to prisons. Medicalized terms such as recover, recovery, convalescence, remission, and relapse convey ownership of severe AOD problems by health care institutions and professionals, just as words such as redeemed and reborn, rehabilitate or reform, and stop and quit shift problem ownership elsewhere. It is important to recognize that rational arguments for particular definitions of recovery may mask issues of professional prestige, professional careers, institutional profit, and the fate of community economies. The answer of who has authority to define recovery will vary depending on the question, “define for what purpose?” Given that defining recovery could generate unforeseen and harmful consequences, efforts to define recovery should include broad representation from: 1) individuals and family members in recovery, 2) diverse recovery pathways and styles, 3) diverse ethnic communities, and 4) policy, scientific, and treatment bodies, including leaders of the major institutions that pay for behavioral health care services.

So . . . yes, it matters. A lot. To a lot of people and a lot of interests. I don’t presume any nefarious motives. I imagine everyone believes their definition will ensure more people recover or will protect recovery from a harmful erosion of its boundaries. In some cases, they wish to extend it to include mental illness and other problems. In other cases, they wish to include people who are taking steps toward change, but have not yet crossed the threshold into traditional notions of recovery. Others want to secure the status of MAT patients within the boundaries of recovery. Others see opportunities for stigma reduction and political action by enlarging the number of people in recovery. Others see opportunities to address the needs of people with lower severity problems. Others may see progress on stigma reduction benefiting people in recovery but neglecting people who still use alcohol and other drugs. Others see the concept of recovery as imbued with moral panic and wish to challenge that. There have been attempts to address some of these issues and bridge the divide between harm reduction and recovery. Scott Kellogg has proposed a model he calls gradualism. He describes it as follows:

[Gradualism] seeks to create a continuum between the world of harm reduction interventions and the abstinence-oriented treatment field. Again, this approach differs from other calls for integration (Denning, 2001; Marlatt et al., 2001) because there is a much greater emphasis on making abstinence the eventual endpoint of most harm-reduction enterprises. This paradigm would combine the harm reduction emphases on outreach to the addicted, incremental change, and gradual healing with the abstinence-oriented therapeutic perspective that the use of substances in an addictive or abusive manner is antithetical to the growth and wellbeing of humans.

Bill White has proposed the concept of precovery, which he described this way:

Precovery is a recovery incubation period arising during active drug use that moves one from the center of addiction to the edge of addiction. Experiences within this stage prepare us for the potential break-up of the person-drug relationship and move us close enough to the recovery territory to feel its contagious pull. Brief sobriety experiments within this boundary region do not constitute sustainable recovery, but they have the potential to incrementally move us to the center of the recovery experience and the physical and cultural world in which that experience is nested. The center of recovery is a region of stability and safety within the recovery process.

These models embrace harm reduction, but not as recovery. They embrace harm reduction as a path to recovery.

Why does it matter?

Why does it matter if harm reduction is placed inside the definition of recovery? There are a few concerns:

  • It defines recovery in a way that is contrary to the lived experience of cultures and communities that have identified with the concept.
  • This tension between professionally developed definitions and organic, indigenous definitions is likely to alienate communities of recovery rather than engage them. Bill White suggested that the job of professionals “is to do what the community at any given moment cannot do.” It is our role to fill gaps, address unmet needs, support the community, or even try to facilitate the creation of new communities, rather than try to bend the community to our vision of a better community.
  • These definitions fail to consider who “recovery” is important to and what its redefinition might mean to them. For example, consider the founding of AA. The date of Dr. Bob’s achievement of sobriety (or, recovery) is considered to be founding date of AA. By some of the proposed definitions, Dr. Bob was in recovery for some time prior to this. One could argue that he was in a “individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.” Was this period of time recovery to him? His wife? His children? His coworkers? His patients? If that period is characterized as recovery, what does that do to the relationship between all of these people and the concept?
  • “Recovery” is an attractive label for a reason. It’s become associated with wellness, citizenship, and other positive attributes. It’s clear that these attributes do not accurately described many people traditionally considered to be “in recovery” and may exclude others who do live up to those attributes. However, extending the label too far risks eroding the positive associations that make “recovery” attractive in the first place.

Tomorrow’s post will revisit the parameters of recovery-oriented harm reduction.

UPDATE: One more relevant thought from a recent post. I believe, if these new definitions take root, recovering people will feel a need to establish typologies of recovery or select a new word to convey the identity they share. Productive discussion around typologies is likely to become very challenging. The need for typologies stems from the desire to distinguish one type from another, and use them. How might they be used? They would likely be used to organize research and programming around each type. This means these typologies would be used in inclusion/exclusion criteria for everything from research to treatment to recovery housing to collegiate recovery programs to physician health programs to state or unstated hiring practices. And, if there was success in establishing typologies, wouldn’t that bring us back to our starting point?

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Revisiting recovery-oriented harm reduction (part 1)

meet them where they are at

The opioid crisis, for good reason, has elevated the role and visibility of harm reduction over the last decade. This seems like a good time to revisit a concept I’ve discussed here several times over the years—recovery-oriented harm reduction.

In 2003, we wrote an article about harm reduction that articulated 6 values that guide our approach to services.

  1. Drug use by addicts is inherently bad and oppressive.
  2. Every addict must be treated with the belief that recovery is possible for him or her, and interventions must place supreme value on recovery from addiction.
  3. Any intervention must attempt to assess “aggregate harm” done to the addict, other interested persons and the community.
  4. Any intervention targeting addicts must communicate hope to both the individual and the community.
  5. Does the program reinforce the culture of addiction or the culture of recovery?
  6. Stewardship of community resources must be integral to this dialogue.

We encouraged other providers to identify their values and hoped that this might lead to more productive dialogue and collaboration.

In 2006, I suggested that this article was really a call for “recovery oriented harm reduction.”

In 2008, I proposed an outline of recovery-oriented harm reduction:

Recovery is all about freedom. The freedom to live one’s life in the way one chooses without being a slave to addiction or being controlled by treatment or criminal justice systems.

. . .

I’ve been thinking about a model of recovery-oriented harm reduction that would address the historic failings of abstinence-oriented and harm reduction services. The idea is that it would provide recovery (for addicts only) as an organizing and unifying construct for treatment and harm reduction services. Admittedly, these judgments of the historic failings are my own and represent the perspective of a Midwestern U.S. recovery-oriented provider:

  • an emphasis on client choice–no coercion
  • all drug use is not addiction
  • addiction is an illness characterized by loss of control
  • for those with addiction, full recovery is the ideal outcome
  • the concept of recovery is inclusive — can include partial, serial, etc.
  • recovery is possible for any addict
  • all services should communicate hope for recovery–recognizing that hope-based interventions are essential for enhancing motivation to recover
  • incremental and radical change should be supported and affirmed
  • while incremental changes are validated and supported, they are not to be treated as an end-point
  • such a system would aggressively deal with counter-transference – some people may impose their own recovery path on clients, others might enjoy vicarious nonconformity through clients

By this time, harm reduction was already moving toward the mainstream. (Maybe it would be more accurate to say that the mainstream was already moving toward harm reduction?) However, the opioid crisis and, more specifically, the overdose crisis has accelerated the process. A result has been not just a mainstreaming of harm reduction, but an effort to redefine recovery from a process involving “sobriety” to a process of improved wellness, effectively placing harm reduction inside that definition of recovery.

More on that tomorrow.

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Follow up – Responses to charges against Invidior

So . . . a week and a half ago, Indivior, the manufacturer of Suboxone, was charged with conspiracy, health care fraud, mail fraud and wire fraud.

Prosecutors said:

Indivior misled doctors and government health programs into believing that the drug, Suboxone Film, was safer and less likely to be abused than rivals, the Justice Department said in a statement Tuesday.

. . .

Federal prosecutors in the Western District of Virginia said Indivior’s deceptions had contributed to an epidemic that has killed thousands of people.

I posted the story, along with discussion about SAMHSA’s proposed guidelines for recovery homes. The proposed guidelines acknowledge diversion as a reality and a risk to be managed. This acknowledgement is important, though I worry that their attitude may be cavalier.

The problem of diverted maintenance medications has been well-known by people with addictions and practitioners for at least a decade. However, in public treatment and recovery advocacy forums, the problem has been taboo and raising the issue often resulted in having one’s judgement and motives questioned. (I was actually in a forum with a high level official from the Office of Drug Control Policy where an attendee very diplomatically raised the concern. That attendee was politely advised that discussion of the matter is likely to complicate accomplishing the goals of his office. He, therefore, discouraged discussing those concerns in public forums.)

About 9 days after news of the charges against Indivior were made public, an organization called the Addiction Policy Forum posted an article by an esteemed addiction scholar. The article used a recent study about the diversion of buprenorphine to argue that diverted buprenorphine is typically used in ways that are consistent with therapeutic purposes.

This article was widely circulated in treatment/research/advocacy circles in response to the concerns raised by the Indivior charges. The implication was that the evidence-base doesn’t support concerns about non-therapeutic misuse.

What was not mentioned in these tweets and posts is that the Addiction Policy Forum is funded by drug makers, including Indivior. These tweets and posts also failed to note that the study referenced in the article was funded by Indivior.

Disclosures from: Cicero, T., Ellis, M., & Chilcoat, H. (2018). Understanding the use of diverted buprenorphine. Drug And Alcohol Dependence, 193, 117-123. doi:10.1016/j.drugalcdep.2018.09.007

The study found that diversion was pretty common, with  58% of subjects reported having used diverted buprenorphine. It also found that 52% of subjects reported having used buprenorphine to get high.

It seems strange to defend Indivior’s medication from allegations that Indivior has been deceptive by circulating an article published by an Indivior funded organization that cites an Indivior funded study without acknowledging Indivior’s role in the study.

So, if Indivior funded and promulgated research finds high rates of diversion and that “52% reported using buprenorphine to get high or alter mood”, what does other research say?

Well, another post referenced a study that also found misuse of buprenorphine to be very common. One of the authors summarized their findings as follows:

Some claims for buprenorphine products have proven not to be true. People bluntly report ability to get a “high” within clinically approved doses despite early claims otherwise. Buprenorphine is commonly diverted and misused, despite early claims that the drug would not lend itself to such patterns. . . . this study looks at the real-world conditions and experiences collected on 1,674 people who report themselves as having a history of disordered use of many different drugs (including alcohol) and who have recently engaged in a recovery program to become abstinent from all substances that cause a “high,” or which mask unpleasant emotions.

Key Findings for those reporting prior use of buprenorphine products in the prior 6 months:

  • 4.2% had only obtained buprenorphine by legal prescription
  • 60% had only obtained buprenorphine by illegal means
  • 35.9% had obtained buprenorphine by both illegal and illegal means
  • 10% had overdosed with buprenorphine while taking other drugs or alcohol
  • No matter how obtained, 56.1 % to 81.2% report getting a good “high” on buprenorphine
  • Efficacy: 25.2% = helped // 31.5% = no effect // 43.3% = made problems worse

Now, it’s important to note that the subjects in this study were participants in drug-free treatment, which likely creates a selection bias.

With that in mind, one way to read that is that maintenance medications may be unhelpful, bad, or risky for a significant number of people with opioid addiction, many of them know it, many of them find their way to non-maintenance treatment (if available), and that it will not be helpful to push these patients into maintenance treatments or environments with maintenance medications.

I should add that I am open to the inverse being true too. None of this is an argument that maintenance treatments should not be available to any patient that wants them. As I’ve repeatedly stated in this blog, it’s just a push for good informed consent that empowers patients to advocate and choose for themselves.

Bill White’s recent post on chaos and recovery speaks to the variability in what helps some and harms others:

Unique service combinations that are transformative for one individual may exert no effects, minimal effects, or even harmful effects on others. This proposition affirms the need for expansive menus of recovery support elements (as opposed to a fixed “program”) and rapid adaptations in such offerings based on individual responses to services over time. It also suggests that any single pathway model of addiction and recovery will only result in sustained recovery for a limited subset of the total population of AOD-affected individuals and that those outside that subset could be injured when subjected to mismatched interventions. In medicine, such injuries are referred to as iatrogenic illnesses (e.g., treatment-caused harm).

. . .

Suggesting such complex interactions within the recovery process is not an invitation to therapeutic nihilism or abandonment of science, e.g., the suggestion that all treatment and recovery frameworks are worthy and only need their elements combined. (Some may be ineffective or harmful.) It is instead an invitation to bring ALL of  evidence-based, practice-informed ingredients into our service and support milieus, mixing and matching them as we draw from the experiential knowledge of people in recovery, while closely monitoring and adapting personal responses to various service clusters that are chosen. It further calls for a heightened level of professional humility and personal awe that unseen forces may be at work in providing a detonation point for these combustible ingredients.

Again, none of this is an argument to reduce access to any kind of treatment. Rather, it’s a call to talk more openly about what the evidence says and doesn’t say about the benefits, what we know and don’t know about the harms and risks, as well as the limitations.

I should add that non-maintenance treatments are not exempt from ethical concerns, as this week’s news and previous posts indicate.

UPDATE: One other theme in some of the reactions paint diversion as a product of a shortage of prescribers, citing reports that only 5% of US physicians have a waiver to prescribe buprenorphine.

To me, that seemed like an unhelpful statistic. I don’t know what percentage of US physicians are specialists like ophthalmologists, oncologists, nephrologists, surgeons, etc. I wouldn’t expect most specialists to prescribe something like buprenorphine under any regulatory circumstance.

So . . . I did a little googling.

That number of waivered physicians constitutes the equivalent of 27.8% of all primary care and psychiatrists in the US.

That seems substantial to me.

Further, a post from 3 years ago addressed concerns about access to maintenance medications. One would assume that buprenorphine sales and utilization have increased since these numbers were generated in 2010 and 2013.

 

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Recovery Celebrities?

gut-check-image2

This post is a couple years old. Re-upping.

================================

A couple of days ago, I had a chance to catch up with a friend and recovery advocate. Turns out we share a concern about the emergence of a kind of celebrity culture within recovery advocacy efforts.

It seems like a good time to revisit a post from Bill White that addresses the topic. The post focuses on anonymity and advocacy, examining the changing cultural context for anonymity and its functions.

On anonymity as a spiritual principle [emphasis mine]:

When AA literature speaks of anonymity as a “spiritual principle,” it does so out of a profound understanding of the importance of self-transcendence as the vehicle for sobriety and serenity. You can hear people depicting AA as a “selfish program” to mean that the alcoholic must get sober for self and not for others, but you find a quite different orientation on the issue of anonymity. The “spiritual substance” of anonymity according to AA’s core literature is not selfishness but “sacrifice.” (AA, 1952/1981, p. 184). What is sacrificed in AA (and in acts of heroism) are one’s “natural desires for personal distinction,” which in AA are eschewed in favor of “humility, expressed by anonymity” (AA, 1952/1981, p. 87). Applying this understanding, one could see how an AA or NA member choosing public recovery advocacy could technically meet the letter of Tradition Eleven (not disclosing AA affiliation at the level of press), but violate the pervading spirit of the Traditions (Tradition Twelve). This could occur when advocacy is used as a stage for assertion of self (flowing from ego / narcissism / pride and the desire for personal recognition) rather than as a platform for acts of service, which flow from remorse, gratitude, humility, and a commitment to service. (2013)

He closes with a call for a gut check on our advocacy efforts:

There is a purity—perhaps even a nobility—to recovery advocacy when it meets the heroism criteria. There is a zone of service and connection to community within advocacy work, and I think we must do a regular gut check to make sure we remain within that zone and not drift into advocacy as an assertion of ego. The intensity of camera lights, the proffered microphone, and seeing our published words and images can be as intoxicating and destructive as any drug if we allow ourselves to be seduced by them. If we shift our focus from the power of the message to our power as a messenger, we risk, like Icarus of myth, flying towards the sun and our own self-destruction. To avoid that, we have to speak as a community of recovering people and avoid becoming recovery celebrities—even on the smallest of stages. We must stay closely connected to diverse communities of recovery and speak publicly not as an individual or representative of one path of recovery, but on behalf of all people in recovery. The fact that no one is fully qualified to do that helps us maintain a sense of humility even as we embrace the very real importance of the work to be done. The spirit of anonymity—that suppression of self-centeredness—can be respected when we speak by embracing the wonderful varieties of recovery experience rather than as individuals competing for attention and superiority. (2013)

We stand on the shoulders of others

I’m grateful for Bill’s reminder. Personally, I’m bothered be some of the slogans coming out of the newest generation of advocates. “Silent no more”, “I am not anonymous” and “The silence ends” are just a few examples.

First of all, anonymity, as practiced within communities of recovery, never demanded silence. All one needs to do is read AA’s chapter on the 12th tradition, published in 1952.

When opportunities to be helpful came along, he found he could talk easily about A.A. to almost anyone. These quiet disclosures helped him to lose his fear of the alcoholic stigma, and spread the news of A.A.’s existence in his community. Many a new man and woman came to A.A. because of such conversations. Though not in the strict letter of anonymity, such communications were well within its spirit.

But it became apparent that the word-of-mouth method was too limited. Our work, as such, needed to be publicized. The A.A. groups would have to reach quickly as many despairing alcoholics as they could. Consequently, many groups began to hold meetings which were open to interested friends and the public, so that the average citizen could see for himself just what A.A. was all about. The response to these meetings was warmly sympathetic. Soon, groups began to receive requests for A.A. speakers to appear before civic organizations, church groups, and medical societies. Provided anonymity was maintained on these platforms, and reporters present were cautioned against the use of names or pictures, the result was fine.

We may not have organized recovering people into a national advocacy movement, but we’ve never been silent. As a community, we haven’t cowered in shame. Communities of recovery are so frequently painted as “secretive”, with all of it’s pejorative connotations–implying shame, hiding, cultishness, etc. Why are we reinforcing this?

“I am not anonymous” seems dismissive of anonymity as a spiritual principle.

The issue isn’t advocacy. The first wave of this advocacy movement was much more respectful of tradition and the people who blazed the trail for building a recovering community capable of engaging in this level of advocacy. They made the case for “advocacy with anonymity” rather than dismissing it as quaint.

There’s nothing wrong with evolving. There’s nothing wrong with questioning the confines of tradition. We don’t have to be bound by tradition, but we should respect the traditions, principles and values that brought us this far.

I hope this movement grows, matures and succeeds in reducing stigma and improving access to help of adequate quality, intensity and duration.

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“full recovery or amplified recovery” — toward typologies of recovery?

Recently proposed definitions of recovery could be characterized as defining it downward (or expanding the boundaries outward).

I’ve expressed concern that these proposed boundaries are so broad that most people who currently self-identify as in recovery will not feel a shared identity with the people that advocates are trying to expand the boundaries to include.

I believe, if these new definitions take root, recovering people will feel a need to establish typologies of recovery or select a new word to convey the identity they share.

Bill White and Galen Tinder describe what might be one of those typologies—”full” or “amplified” recovery.

Addiction recovery is far more than the removal of drugs from an otherwise unchanged life. Recent definitions of recovery transcend radical changes in the person-drug relationship and encompass enhanced global health and social functioning. The authors have carried on a decades-long interest in what has been christened full recovery or amplified recovery—a state of enhanced quality of life and personal character in long-term recovery.

First, note that they begin by describing recovery as more than the removal of drugs. (Removal of drugs is more like a floor than a ceiling.) Bill has previously described something he calls “precovery“, which would apply to many of the behaviors that the proposed more diffuse conceptual boundaries seek to include.

Second, some of the rhetoric around recovery advocacy might make a productive discussion challenging. The need for typologies stems from the desire to distinguish one type from another, and use them. How might they be used? They would likely be used to organize research and programming around each type. This means these typologies would be used in inclusion/exclusion criteria for everything from research to treatment to recovery housing to collegiate recovery programs to physician health programs to state or unstated hiring practices.

There are serious and important equity issues that include problems related to access to care, incarceration and privilege. The social justice framing has the potential to illuminate and clarify these inequities. It also has the potential to complicate discussion and disagreement because positions get cast as just vs unjust, moral vs immoral, and valid vs invalid.

I’ve been increasingly concerned that addiction treatment and policy has become a new battleground for the culture wars without many of us even realizing it was happening or conceiving that treatment belonged on any “side” of a culture war. Some good may come of it, but it’s hard to imagine that there would not be a lot damage, polarization, contempt and fragmentation accompanying it. There’s also the question of how patients will respond to a field that’s a front in a culture war.

UPDATE: The FDA’s proposed alternative endpoints are also germane to this discussion and increases the need for productive discussion. Are they appropriate endpoints? Are they recovery?

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Comments on SAMHSA recovery housing guidelines

Below are my comments for SAMHSA in response to their request for comments on your proposed recovery housing guidelines. The deadline is 5pm today. Send your comments, whatever they are.


To whom it may concern:

I am writing in response to your request for comments on your proposed recovery housing guidelines.

I commend your efforts to provide guidance for recovery housing. Recovery housing is a long-neglected and critical element in the treatment and recovery support continuum.

I strongly urge guidelines that maintain options for recovery housing where agonist MAT substances are excluded.

I offer the following as a rationale for this request.

First, there has been relatively little research on the diversion of opioid agonists in the US. The research that exists suggests that diversion is common.

For example, Walker, Logan, Chipley & Miller (2018), in the peer-reviewed journal The American Journal of Drug and Alcohol Abuse, found misuse of buprenorphone to be very common. One of the authors summarized their findings as follows:

Buprenorphine is an opioid that, like other opioid drugs, can produce effects such as pain reduction, a pleasurable “high,” sleepiness, physical dependence and addiction. It has become a street-trafficked drug. . . . Some claims for buprenorphine products have proven not to be true. People bluntly report ability to get a “high” within clinically approved doses despite early claims otherwise. Buprenorphine is commonly diverted and abused, despite early claims that the drug would not lend itself to such patterns. Most of the research studies by developers and marketers carefully selected subjects who only had opioid use disorder, mostly those only with prescription opioid-use disorder and, rarely, those only with heroin-use disorders. In contrast, this study looks at the real-world conditions and experiences collected on 1,674 people who report themselves as having a history of disordered use of many different drugs (including alcohol) and who have recently engaged in a recovery program to become abstinent from all substances that cause a “high,” or which mask unpleasant emotions.

Key Findings for those reporting prior use of buprenorphine products in the prior 6 months:

  • 4.2% had only obtained buprenorphine by legal prescription
  • 60% had only obtained buprenorphine by illegal means
  • 35.9% had obtained buprenorphine by both illegal and illegal means
  • 10% had overdosed with buprenorphine while taking other drugs or alcohol
  • No matter how obtained, 56.1 % to 81.2% report getting a good “high” on buprenorphine
  • Efficacy: 25.2% = helped 31.5% = no effect 43.3% = made problems worse

This is supported by this week’s, Department of Justice charges against Indivior for “deceiving health-care providers and health-care benefit programs into believing that Suboxone Film was safer, less divertible, and less abusable than other opioid-addiction treatment drugs”

Secondly, while there is a large evidence-base for the effectiveness of agonists in reducing illicit opioid use, overdose deaths, criminal activity, and disease transmission, those outcomes only partially overlap with the goals of most recovery housing programs. Most recovery housing programs seek abstinence from alcohol and commonly misused drugs—licit and illicit.

Hettema and Sorensen (2008), in the peer reviewed journal International journal of mental health and addiction, reported the following:

While much of the stigma against the use MMT does not seem grounded in evidence, some important arguments against the integration of MMT and residential treatment have been put forth. Residential treatment programs are faced with a complex context for their clinical decision making (Zemore & Kaskutas, 2008). Unlike methadone clinics, in which the behavior of one client has little effect on others, patients within residential treatment programs are highly dependent on one another. Here the behavior of one individual can have a huge effect on the overall environment and, consequently, what may be beneficial to one client may be harmful to the community as a whole.

The proposed guidelines themselves discuss the potential for diversion and misuse and outline actions provides can consider to manage these risks. If mandatory, this would be a considerable burden to place on providers and many residents.

Thirdly, the guidelines call for access to FDA approved medications. It’s worth noting and considering that legally prescribed medication played a key role in raising the opioid problem to the current crisis level and has helped sustain it. It’s also worth noting that legally prescribed, FDA approved medications can include opioids, benzodiazepines, muscle relaxers, and many other frequently misused drugs.

Finally, if large portions of recovery housing residents have misused agonist medications, isn’t it reasonable for residents to think of a “safe” recovery environment as one that excludes those commonly misused medications?

It is undoubtedly true that agonist patients do not have adequate access to recovery housing. One could explain this gap by accusing housing providers of stigmatization and discriminating. Another way to explain this gap is that agonist treatment providers have failed to deliver this kind of recovery support. Seen this way, the problem is not that many providers prohibit opioids, rather that there is a need to establish recovery housing that allows agonist medications.

The need for both agonist-friendly programs and opioid-free programs is clear. By all means, encourage and support the establishment of agonist-friendly recovery housing programs. However, please do so in a manner that assures we do not pit the needs of one group of patients/residents against the other.

Thank you for your consideration.

 

Sincerely,

Jason Schwartz

 

References:

Hettema, J. E., & Sorensen, J. L. (2009). Access to Care for Methadone Maintenance Patients in the United States. International journal of mental health and addiction, 7(3), 468–474. doi:10.1007/s11469-009-9204-6

Robert Walker, TK Logan, Quintin T. Chipley & Jaime Miller (2018) Characteristics and experiences of buprenorphine-naloxone use among polysubstance users, The American Journal of Drug and Alcohol Abuse, 44:6, 595-603, DOI: 10.1080/00952990.2018.1461876

White, W.L. & Torres, L. (2010). Recovery-oriented Methadone Maintenance. Chicago, IL: Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health and Mental Retardation Services and Northeast Addiction Technology Transfer Center.

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