Naloxone rescues good. Naloxone + recovery better

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It's good to interrupt a drowning with a life preserver. It's better to pull them out of a dangerous sea.

From a new report on overdose reversals:

Use of naloxone kits resulted in almost 27,000 drug overdose reversals between 1996 and 2014, according to a new government study. Naloxone is an opioid overdose antidote.

That’s an impressive number and something to be celebrated.

It’s cause for calls for expanded access to naloxone and I have no doubt we’ll hear those calls.

It’s also cause for much more than that.

One has to wonder, what was the follow up care like for these people? How many of them got more than a passive referral to treatment? Of those, how many got linked to treatment of an adequate duration and intensity? Very few, I bet. And, where that did happen, it was more than likely family who were responsible.

Imagine for a moment, 27,000 cardiac patients rescued by defibrillators. What would we think if only a tiny fraction of them got good care following the rescue? Worse, what would we think if doctors with these rescues got good care with good outcomes but other rescued patients got poor care with bad outcomes?

Let’s hope we hear some advocacy around this as well.

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…let us work together

The last couple of days’ posts, a recent conversation and some recent news (I’ll let you guess which story.) reminded me of this post. It’s from a couple of years ago and has a couple of minor updates.


 

“If you have come here to help me, then you are wasting your time… 
But if you have come because your liberation is bound up with mine, 
then let us work together.” – Lila Watson

Obviously, I’ve been thinking a lot about the buprenorphine maintenance, the NY Times series and the reactions since it was published. (See here, here, here, here, here, here, here & here.)

At Dawn Farm, we’ve often said that maintenance approaches are often rooted in the belief that opiate addicts can’t recover. Now, I’m the kind of person who tends to be uncomfortable making statements that claim to know the contents of another person’s mind. This week has made me much more comfortable with that statement. None of the responses have argued that maintenance is a great tool for achieving recovery. Several have referred to opiate addiction as a hopeless condition. All the arguments for it have been harm reduction arguments–that it’s associated with reduced use, overdose death, disease transmission, crime and incarceration. (The data is less compelling than many of them would have you believe.)

I want to make clear that I have no interest in getting between an addict and a maintenance treatment. All I want is a day when addicts are offered the same treatment that their doctors are offered–recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose. (However, the only choices these articles are worried about are buprenorphine and methadone. SAMHSA reports that, in 2012, about 23% of opiate addicts had a treatment plan that included medication assisted treatment, while 7% got long term residential. It’s worth noting a couple things. First, SAMHSA’s data set is generally limited to programs that get federal funding. Many of these use methadone, but few use buprenorphine. Buprenorphine had $1.4 billion in US sales and was the number 28 drug in 2012. Second, that quarter of heroin addicts with medication assisted treatment in their treatment plans is only those who actually had medication in their plan–23% doesn’t represent everyone who was offered medication, that number would likely be much higher. Third, their definition of long term residential is very loose and can include “transitional living arrangements such as halfway houses”. So, that 7% is inflated and very misleading. Finally, how many people get the treatment doctors get? I’d feel pretty safe guessing it’s a fraction of a percent. Why is there no hand wringing about access to this kind of care?)

However, when we have professionals, policy makers and researchers who don’t believe in the capacity of patients to recover, the kind of help they are going to offer is going to be unhelpful. They’ll focus on risk factors for overdose like “compromised tolerance”. Of course, decreased tolerance is associated with overdose. Then again, social interaction is associated with transmission of many illnesses. Should we discourage social lives?

One has to wonder if the experts interviewed for these articles know any addicts in full recovery–people who are fully re-engaged in family life, community life, vocations, education, faith communities, etc. If so, do they think of the people they know as belonging to some special category that makes them different from other addicts? (When I teach about addiction and bring up the outcomes for health professionals, many students argue that they are a different kind of addict and better outcomes are to be expected.)

While I don’t want to take choices away from addicts, there’s a big part of me that wants these “experts” to leave us alone. We don’t need your “help.” (A kind of help you would never offer a sick peer.)

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That sentiment brings to mind this Malcolm X story:

Several times in his autobiography, Malcolm X brings up the encounter he had with “one little blonde co-ed” who stepped in, then out, of his life not long after hearing him speak at her New England college. “I’d never seen anyone I ever spoke before more affected than this little white girl,” he wrote. So greatly did this speech affect the young woman that she actually flew to New York and tracked Malcolm down inside a Muslim restaurant he frequented in Harlem. “Her clothes, her carriage, her accent,” he wrote, “all showed Deep South breeding and money.” After introducing herself, she confronted Malcolm and his associates with this question: “Don’t you believe there are any good white people?” He said to her: “People’s deeds I believe in, Miss, not their words.”

She then exclaimed: “What can I do?” Malcolm said: “Nothing.” A moment later she burst into tears, ran out and along Lenox Avenue, and disappeared by taxi into the world.

I can relate to his sentiment that the most helpful thing others can do is leave us alone. (“Other” can be a pretty ugly word, no?) Then, when I’m a little less emotional, I’m left to consider my own cognitive biases and creeping certitude. I have to think about the contributions of people like Dr. Silkworth, Sister Ignatia, George Vaillant, etc.

We also need to be watchful for ideological resistance to innovations that could help others find recovery.

Malcolm X had a similar experience to this too:

In a later chapter, he wrote: “I regret that I told her she could do ‘nothing.’ I wish now that I knew her name, or where I could telephone her, and tell her what I tell white people now when they present themselves as being sincere, and ask me, one way or another, the same thing that she asked.”

Alex Haley, in the autobiography’s epilogue (Malcolm X had since been assassinated), recounted a statement Malcolm made to Gordon Parks that revealed how affected he was by his encounter with the blonde coed: “Well, I’ve lived to regret that incident. In many parts of the African continent I saw white students helping black people. Something like this kills a lot of argument. . . . I guess a man’s entitled to make a fool of himself if he’s ready to pay the cost. It cost me twelve years.”

Malcolm X realized, too late, that there was plenty this “little blonde coed” could have done, that his response to her was inconsistent with what he, his associates, and his followers wanted to accomplish.

Bill White wrote about the things that have allowed practitioners to avoid the cultural traps in working with addicts:

Four things have allowed addiction treatment practitioners to shun the cultural contempt with which alcoholics and addicts have long been held:

  1. personal experiences of recovery and/or relationships with people in sustained recovery,
  2. addiction-specific professional education,
  3. the capacity to enter into relationships with alcoholics and addicts from a position of moral equality and emotional authenticity (willingness to experience a “kinship of common suffering” regardless of recovery status), and
  4. clinical supervision by those possessing specialized knowledge about addiction, treatment and recovery processes.

We must make sure that these qualities and conditions are not lost in the rush to integrate addiction treatment and other service systems.

I don’t know how to engage these experts who may know a lot about the illness, but they often appear to be blind to the fact that full recovery already exists in every community across the country. It’s especially tough when the field is so fractured, there’s so much money to be made, and external forces (like the Affordable Care Act) are going to be pushing addicts toward primary care for their treatment.

As far as Dawn Farm goes, I heard something last week that cast us in a new light for me.

We are unapologetically rooted in culture.
If you want to join us, and you’re not part of that culture,
you need to find ways to respect, honor and celebrate that culture.”  – Dan Floyd

We’ve talked a lot about the concept of cultural competence and that professional helpers need to deliberately develop similar competencies when working with addicts and the recovering community. I still believe this is true. But, at Dawn Farm, we go beyond mere competence. We are rooted in the culture of recovery, and we help non-recovering staff (more than half of our staff) find ways to respect, honor and celebrate that culture.

This puts us out of the mainstream among professional helpers and “experts” on addiction, but we wouldn’t change a thing.

The question is how to develop this kind of competence in these researchers, policy makers and experts. It would seem that recovery advocacy would be an important way to do this. However, drug manufacturers have ingratiated themselves with recovery advocacy organizations and the organizations have tried to ingratiate themselves with experts. As a result, they’ve waded into supporting medication assisted recovery, but have done little to challenge the therapeutic nihilism that PHARMA nurtures and is a theme in the public comments of these experts.

In the meantime, this brings me back to the quote I opened this post with.

“If you have come here to help me, then you are wasting your time… 
But if you have come because your liberation is bound up with mine, 
then let us work together.” – Lila Watson

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An interesting take on activism

 

There’s been an explosion of recovery activism over the last decade. Here’s the perspective of another kind of activist.

Sister Simone Campbell, a social justice activist, on the role of activism for individualsraisedfist1:

SR. SIMONE: Whatever our part is. Just do one thing. That’s all we have to do. But the guilt of the — or the curse of the progressive, the liberal, the whatever is that we think we have to do it all. And then we get overwhelmed. And I get all those solicitations in the mail. And I can’t do everything. And so I don’t do anything. But that’s the mistake. Community is about just doing my part. I — oh, can I?

MS. TIPPETT: No, go on, yes.

SR. SIMONE: Can I tell you? I decided — you know how in the scripture it — Paul says how we’re one body? Not everybody is an ear, not everybody is an eye. So one day I was meditating, and I was trying to figure out what part of the Body of Christ I am. So I came up with this insight that I think I’m stomach acid, I think that’s my job.

[laughter]

It’s really important for metabolizing food.

MS. TIPPETT: Yes.

SR. SIMONE: And it can — not — you don’t need a large quantity of it. And it needs to be contained.

[laughter]

And if it runs amok, that’s called illness.

[laughter]

But, see, it’s doing…

MS. TIPPETT: It’s a great analogy for lobbying — the whole lobbying industry [laughs].

SR. SIMONE: Exactly, exactly. It generates energy and heat. And it does all kinds of good stuff, but it’s a very specific small piece that depends on a whole system to be healthy and effective. We all have a piece of it. And we can do this.

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The “kinship of common suffering”

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From Ernie Kurtz:

Sometimes, ignorant people–especially ignorant professionals–say that “Alcoholics Anonymous teaches that only an alcoholic can help an alcoholic.” Sister Ignatia is only one of many whose story overturns that canard. Look at all the non-alcoholics who were so significant in AA history: Sister Ignatia, Father Dowling, Willard Richardson, Frank Amos, Dr. Slikworth, and many others. They were not alcoholic, but they did all have something in common: each in his or her own way, had experienced tragedy in their lives. They all had known kenosis; they had been emptied out; they had hit bottom . . . whatever vocabulary you want. They had stared into the abyss. They had lived through a dark night of the soul. Each had encountered and survived tragedy.  . . . you do not have to be an alcoholic to understand one. But it seems that you have to have had this confrontation with tragedy in your own life. You have to have stared into that abyss. You have to have known utter hopelessness or utter helplessness.

Bill White adds to this thought:

The “kinship of common suffering” can transcend such labels as “alcoholic” and “non-alcoholic.” The most important dimensions of the peer relationship are emotional authenticity, humility, and the capacity to offer support from a position of moral equality. One’s addiction/recovery career may be of secondary value, and, as we shall see, does not in itself ensure such traits.

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Welcome our own weakness? Really?

2931888261_c7d2bb40f2_mThis caught my attention in a recent episode of On Being. It speaks to the importance of us (helpers) needing to be able to face our own pain if we are are to help others face theirs.

MS. TIPPETT: Not just in the context of disabilities, you know, you’ve posed this question, you know, the whole — you’ve said the whole question is, how do we stand before pain?

MR. VANIER: Yeah.

MS. TIPPETT: All kinds of pain and weakness are difficult for us as human beings. Why is that so excruciating? Why do we such a bad job with it?

MR. VANIER: I think there are so many elements. First of all, we don’t know what to do with our own pain, so what to do with the pain of others? We don’t know what to do with our own weakness except hide it or pretend it doesn’t exist. So how can we welcome fully the weakness of another if we haven’t welcomed our own weakness? There are very strong words of Martin Luther King. His question was always, how is it that one group — the white group — can despise another group, which is the black group? And will it always be like this? Will we always be having an elite condemning or pushing down others that they consider not worthy? And he says something, which is quite, what I find extremely beautiful and strong, is that we will continue to despise people until we have recognized, loved, and accepted what is despicable in ourselves. So that, then we go down, what is it that is despicable in ourselves? And there are some elements despicable in ourselves, which we don’t want to look at, but which are part of our natures, that we are mortal.

 

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Umwelt

Mantis Shrimp

Mantis Shrimp have 16 color receptor cones compared to our 3. (Photo credit: PacificKlaus)

Yesterday, I was reading This Will Make You Smarter and thought that the concept of umwelt could be enormously helpful for my social work students and Dawn Farm’s counseling staff:

In 1909, the biologist Jakob von Uexküll introduced the concept of the umwelt. He wanted a word to express a simple (but often overlooked) observation: different animals in the same ecosystem pick up on different environmental signals. In the blind and deaf world of the tick, the important signals are temperature and the odor of butyric acid. For the black ghost knifefish, it’s electrical fields. For the echolocating bat, it’s air-compression waves. The small subset of the world that an animal is able to detect is its umwelt. The bigger reality, whatever that might mean, is called the umgebung.

The interesting part is that each organism presumably assumes its umwelt to be the entire objective reality “out there.” Why would any of us stop to think that there is more beyond what we can sense?

…It neatly captures the idea of limited knowledge, of unobtainable information, and of unimagined possibilities. Consider the criticisms of policy, the assertions of dogma, the declarations of fact that you hear every day — and just imagine if all of these could be infused with the proper intellectual humility that comes from appreciating the amount unseen.

I find two things very attractive about the concept. First, are these ideas of “limited knowledge”, “unobtainable information”, “unimagined possibilities” and “intellectual humility”. Second, it nudges us to consider the possibility that different clients may have different umwelt experiences. Clients with a history of trauma will pick up on environmental signals that others of us are blind to. Women or minorities will have different umwelt experiences and the fact that I can’t sense those signals doesn’t make them less real.

Maybe the concept of umwelt can help keep us out of the “expert” position and keep us in the role of curious fellow travelers. This isn’t simply a matter of attention and empathy. I may not be capable of detecting the signals someone else is experiencing, even if they’re pointed out to me. (However, if we’re tuned into the client, we may notice them experiencing something that doesn’t fit with what we observe and curiously explore rather than dismiss it as pathological.)

Also, we’re probably unaware of most of our own umwelt experience. And, even if we’re aware of it, language will probably fail us–how do you describe a scent to someone who can’t smell?

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An absence of hope

hopeToday, Bill White shared some of my favorite stories.

As I faced these amazingly resilient women, I asked each of them to tell me about the sparks that had ignited their recovery journey.  Each of them talked about the role their outreach worker had played in their lives.  The following comments were typical.

I couldn’t get rid of that women.  She came and just kept coming back–even tried talking to me through the locked door of a crack house.  She wore me down. She followed me into Hell and brought me back.

(Describing the first day she went to treatment–after eight weeks of outreach contacts)  It was like a thousand other days.  My babies had been taken and I was out there in the life.  I’d stopped by my place to pick up some clothes and there was a knock on the door. And here was this crazy lady one more time, looking like she was happy to see me.  I looked at her and said, Don’t say a word; Let’s go (for an assessment at the treatment center).  She saw something in me that I didn’t see in myself, so I finally just took her word for it and gave this thing (recovery) a try.

And she kept sending me those mushy notes–you know the kind I’m talking about.  (Actually, I had no idea what she was talking about.)  You know, the kind that say, “Hope you’re having a good day, I’m thinking about you, hope you are doing well” and all that stuff.  I treated her pretty bad the first time she came, but she hung in there and wouldn’t give up on me.  I can’t imagine where I would be today if she hadn’t kept coming back. She hung in with me through all the ups and downs of treatment and getting my kids back.    

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