Recovery MAINTENANCE

imagesThere’s a lot of commentary out there on Philip Seymour Hoffman’s death. Some of it’s good, some is bad and there’s a lot in between. Much of it has focused overdose prevention and some of it has focused on a need for evidence-based treatments.

Anna David puts her finger on something very important. [emphasis mine]

Let’s explain that this isn’t a problem that goes away once you get shipped off to rehab or even get a sponsor—that this is a lifelong affliction for many of us. There seems to be this misconception that people are hope-to-die addicts and then get hit by some sort of magical sunlight of the spirit and are transported into another existence where the problem goes away.

[NOTE – I know almost nothing of Hoffman or the treatment he received from his doctors or anyone else. My comments should be considered commentary on the issues involved rather than the specifics of Hoffman or the help he received.]

What I haven’t heard discussed much is his reported relapse a year or so ago. How could that have been prevented?

From what I understand, this is someone who had been in remission for 23 years. And, it sounds like his relapse began in a physician’s office when he was prescribed an opiate for pain.

  • What’s the evidence-base around treating pain in someone who has been abstinent for 23 years?
  • What are the evidence-based practices around how professional helpers should monitor and support the recovery of a patient who has been sober for decades?
  • What are the behaviors associated with recovery maintenance over decades through pain and difficult life experiences?

20090101-new-yearCould the outcome have been different if some sort of recovery checkup had been performed by his primary care physician or the doctor who treated his pain?

If he had been in remission from some other life-threatening chronic disease, wouldn’t his doctors have watched for a symptoms of a recurrence? Or,  given serious consideration to contraindications for the use of particular medications with a history of that chronic disease?

What if he had been asked questions like:

  • How’s your recovery going?
  • Have you had any relapses? Cravings?
  • How did you initiate your recovery?
  • How have you maintained your recovery?
  • Have there been changes in the habits associated with your recovery maintenance? (Meetings, readings, sponsor, social network, etc.)
  • How’s your mood been?
  • What do your family and friends who support your recovery say about this?

Also, if it’s determined that a high risk treatment (like prescribing opiates to someone with a history of opiate addiction) is needed, what kind of relapse prevention plan was put into place? What kind of monitoring and support?

There are two issues here. One is the lack of research, training and support that physicians get around treating addiction and supporting recovery.

The second issue is the role of the patient.

I listened to a talk by Dr. Kevin McCauley this morning in which he addressed objections to the disease model. One of the objections was that the disease model lets addicts off the hook. His response was that, given the cultural context, there were grounds for this concern. BUT, the contextual problem was with the treatment of diseases rather than classifying addiction as a disease. He pointed out that our medical model positions the patient as a passive recipient of medical intervention. As long as the role of the patient is to be passive, this concern has merit. He suggests we need to expect and facilitate patients playing an active role in their recovery and wellness.

So…this was someone who had been in remission for decades. He clearly had a responsibility to maintain his recovery. At the same time, the medical and/or treatment system has a responsibility to monitor and support his recovery.

I happen to have celebrated 23 years of recovery several months ago. I’m still actively engaged in behaviors to maintain my recovery. (Much like I’m actively engaged in behaviors to keep my cholesterol low.)

In 23 years, has a doctor or nurse EVER asked me how my recovery is going? No. Have they ever evaluated my recovery in ANY way? No.

Do they want to check my cholesterol every so often? Like clockwork.

This is a critical failure of the system and the evidence-base. And, we don’t just fail people with decades of recovery. Even more so, we fail people with 90 days, 6 months, a year, 5 years, etc. Then we blame the approach that helped them stabilize and initiate their recovery when the real problem was that we never helped them maintain their recovery. (Then, too often, our solution is to insist that they get into that passive patient role, just take their meds and let the experts do their work.)

via Another Senseless Overdose.

14 Comments

Filed under Controversies, Policy, Treatment

14 responses to “Recovery MAINTENANCE

  1. Jocelyn

    Thank you for this post. I am passing it on.

  2. A reader sent the following in an email:

    I had six surgeries within about a year and each time told the resident surgeon I didn’t want to be prescribed opiates. Each time this occurred the physician argued that I needed to have an opiate prescription – but not one time did anyone ask WHY I didn’t want to be prescribed opiates. No one asked if I had a history of opiate addiction/recovery, or a problem with opiates; the answer would’ve been no but I have to wonder why no one even asked. Not reassuring for someone who might have had a problem.

  3. It is obviously a terrible tragedy and a warning to people with long term recovery not to binge, which often results in dreadful results. I don’t think it is just as simple as blaming pain pills for this. People can take pain medication if they have really put things behind them but for others it can lead to extra stress. Usually, substance abuse has something to do with events in life especially when a binge occurs. There is normally a trigger in my experience to send somebody out. I do think addiction should be treated more seriously, and although relapses will always occur whatever method is used, I feel we need an update from the old powerless/disease model that can also contribute to a binge being large when somebody feels their situation is hopeless.

    • I’m sure you’re right about there being multiple factors at play here. At the same time, there is a serious problem with opioid prescriptions: https://addictionandrecoverynews.wordpress.com/2013/07/05/women-dying-of-opioid-overdose-at-unprecedented-rates/

      As for powerlessness, we view loss of control as the defining characteristic of addiction. And, most addicts find the powerlessness concept to be an accurate description of the experience of being an addict. (The concept should not be applied to problem users, just addicts. Problem users can choose to quit or moderate.) For someone in relapse, the notion of powerlessness isn’t that they are hopeless. Rather, it’s to ask for help and let go of the notion that they can solve the problem themselves.

      • I think the powerless concept can help for the first few weeks of recovery but is not a great way to think for the rest of your life. I prefer to think that I have beaten my addiction and moved on. I feel that if people define themselves as powerless addicts long term, this will often be at the forefront of their minds if they do relapse. This can lead to a bad binge which is extremely dangerous. A lot of people do not ask for help straight away because they are embarrassed, especially if they have been attending a 12 step group and have lost there “time”. A lot of overdoses are the result of mixing prescription drugs with other substances such as alcohol. I abused substances to block out the reality of life for many years, and have been abstinent for a long time, but I have a different mindset these days to pain medication which is there to block pain rather than reality and life. A good friend of mine (and 12 step meeting regular) went on a binge, lied to everyone in his group and then jumped from a bridge. He will never be the same again.
        I left the 12 step world about seven years ago and I feel my independence, really helped my recovery. If you have worked any recovery program, you know what can happen if you choose to self medicate with heroin or anything else, regardless of what may introduce cravings. You know it is going to be tough to stop again. Telling somebody they are powerless over and over again may put them off trying. Here is a recent piece by Stanton Peele with his views on relapse. http://www.psychologytoday.com/blog/addiction-in-society/201402/another-one-why-so-many-celebrities-die-following-rehab . I found his books very useful when I was in early days, and very thought provoking.

        Although I don’t agree with you on this point I like a lot of the things I have seen here in the short time I have been reading, especially the things by William White that I found through here. Good luck to everybody, which ever way you choose to meet the challenges of putting addiction behind you.

      • Our experience is very different from what you describe. We make it a point of pride that people very frequently reconnect with us within 48 hours of a relapse. This gives us the opportunity to re-stabilize them quickly so that they don’t lose their job, place to live, etc. We attribute this to solid, respectful, supportive and non-shaming relationships with clients.

        I’m very familiar with Stanton Peele. Here’s another perspective: http://www.instituteforaddictionstudy.com/PDF/Addiction%20Q%20%26%20A.pdf

        I’m glad that you found a path that works for you.

        All the best.

  4. Sharing this widely–one of the best reflections after Hoffman’s death that I’ve seen. Thanks.

  5. Agree that this is best reflection after Hoffman’s sad death. I will share it on DBRecoveryResources newsletter tomorrow, to 5,600 people. Keep up the good work.

  6. Another reader sent this comment:
    I went to the dentist a few months ago for an extraction. His very first question was “do you take any prescription opiates?”. I told him I didn’t, that I was a recovering addict. He then said “I’m going to write you a prescription for vicodin.” I asked him why and he said “for the pain”. I was incredulous! I said “from a tooth extraction?,!? I’ll just take ibuprofen…that’s what it is for”.