…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.)


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

Bill White on “Symbolic Firsts”

hopeBill White had a very interesting post a while back on the concept of “symbolic firsts” and how it relates to recovery advocacy and recovery initiation.

The concept is based on the idea that:

. . . the pioneering achievement of a single individual from a historically marginalized group affects the self-identity, aspirations, and performance of other members of that group as well as culturally dominant attitudes toward members of that group (e.g., the effects of Barack Obama’s 2008 election on the academic performance of African American children and attitudes toward African Americans).

This reminded me of an interview I heard on the radio and a previous post on the concept of “the adjacent possible”.

During the interview he discussed the concept of the adjacent possible and it’s importance in forming new ideas. During the interview, he described it as the building blocks of new ideas. Without the right building blocks, any innovation is not possible. He described it another way in a WSJ article:

The adjacent possible is a kind of shadow future, hovering on the edges of the present state of things, a map of all the ways in which the present can reinvent itself.

The strange and beautiful truth about the adjacent possible is that its boundaries grow as you explore them. Each new combination opens up the possibility of other new combinations. Think of it as a house that magically expands with each door you open. You begin in a room with four doors, each leading to a new room that you haven’t visited yet. Once you open one of those doors and stroll into that room, three new doors appear, each leading to a brand-new room that you couldn’t have reached from your original starting point. Keep opening new doors and eventually you’ll have built a palace.

During the interview, he pointed out that it doesn’t matter how smart one is, it was not possible to invent a microwave in 1650, because the building blocks, the adjacent possible, just wasn’t there.

One factor is that the physical building blocks did not exist. The other factor is that the imaginative/inspiration building blocks did not exist.

Bill links the concept to hope and recovery initiation:

Symbolic firsts in recovery stand as a living invitation for individuals, families, and communities affected by addiction and a source of motivation and guidance for those seeking and living in recovery. Through their achievements, symbolic firsts expand the roles and community spaces in which people seeking and in recovery can envision themselves.  Symbolic firsts in recovery diminish the community cues conveying that people in recovery do not belong in particular positions or places. They offer living proof of what can be achieved in recovery and the principles and strategies of how such achievements have been and can be made in the context of recovery.

But Bill doesn’t stop there. He calls on those us us in stable recovery to out ourselves to reduce stigma, inspire hope and make the adjacent possible known.

Symbolic firsts in recovery achieve such status by acts of destruction (tearing down historical barriers of exclusion and their supporting machinery) and acts of creation (forging new niches and styles through which people in recovery can personally excel and socially achieve and contribute).

Symbolic firsts in recovery eschew “passing” (hiding concealable stigma for personal advantage) to achieve a higher social goal–even in the face of personal challenges and socially-imposed limits on opportunities that can potentially flow from this decision.  Symbolic firsts face extremes of experience different in nature and intensity than others who will subsequently fill the space that the trailblazers created. As a result, symbolic firsts in recovery need the full support of communities of recovery.


Book Review: The Recovering Body

download (3)Jennifer Matesa’s The Recovering Body: Physical and Spiritual Fitness for Living Clean and Sober seeks to provide “a roadmap to creating our own unique approach to physical recovery” and frames “physical fitness as a living amends to self–a transformative gift analogous to the “spiritual fitness” practices worked on in recovery.”

She focuses on five areas, blending her own experiences, other recovering people, empirical research and practical to-do lists. The five areas are:

  • exercise and activity
  • sleep and rest
  • nutrition and fuel
  • sexuality and pleasure
  • meditation and awareness

I see two reasons this book is an important contribution to recovery literature.

First, it’s the first book I’ve seen (not that I’m well read in the area) that places such emphasis on physical wellness and self-care as an important element of recovery within traditional 12 step recovery paths. I’ve seen it addressed as an aside, and I’ve seen it offered as an alternative path, but not as an important element within traditional recovery paths.

As researchers and clinicians search for every tool to give addicts any possible edge as they initiate and maintain their recovery, we’d be wise to take notice. There is a growing body of evidence to support Matesa’s assertions that these are important elements of recovery rather than frivolous and indulgent accessories to treatment and recovery programs.

Second, I am convinced that the future of treatment and recovery programs (All chronic disease management programs, really.) should emphasize a lifestyle medicine as the foundation of care. After all, “recovery as a lifestyle” epitomizes one of the things addiction treatment has gotten really right historically and something the rest of chronic disease care could learn from us.

Despite this, professionally directed treatment that discusses the idea of the “recovery of the whole person” has mostly been lip service. Matesa brings this concept to life and presents holistic recovery as a lifestyle to be cultivated, practiced and maintained. On this front, she’s far ahead of professionals and researchers. The field is not there yet and too often equates recovery with swallowing pills or passively doing what professional helpers direct them to do. Matesa bypasses professionals and speaks directly to recovering people as a peer, calling them to action and offering experiential and empirical truth. That’s radical, in the best sense of the word.

Her writing is very accessible, is not preachy, and unpretentiously conveyed a lot of deep truths that I hadn’t considered but seemed self-evident as soon as I read them.

On a personal note, as someone who only started paying attention to physical fitness after 20 years of sobriety, the book takes a lot of previously disparate pieces of information that I vaguely knew to be true and organizes them into framework that not only deepened my understanding, but offered a concrete path to continue enhancing and securing my own recovery. I highly recommend it.

Anti-treatment zombie stats


This 90% statistic has been frequently cited to discredit specialty addiction treatment.

Ninety percent of those who enter addiction-treatment programs in the U.S. don’t receive evidence-based treatment

I asked David Scheff about it several weeks back. He said it was from RAND and referred me to his book. I looked in his book and couldn’t find the reference. I asked him about it and he said he’d get back to me. Now, Alcoholism & Drug Abuse Weekly explains why I couldn’t find it.

“Ninety percent of those who enter addiction-treatment programs in the U.S. don’t receive evidence-based treatment” — an assertion David Sheff made in his blog on Time.com last fall, and then restated in another Time.com blog February 2 — is based on an 11-year-old report by RAND, Sheff told ADAW. What the report actually says is that 90 percent of people with alcohol dependence did not receive the treatment that was recommended. But it doesn’t say that they entered treatment at all. In other words, the statement is inaccurate.

To be sure, there’s a lot of bad treatment out there, and it should be covered by the media. However, much of the coverage is biased against specialty treatment and has a pro-physician-directed treatment bias. (As though lousy treatment in medical settings is a rarity.)

There are a lot of fair criticisms that can be made against a lot of the treatment in the US. But these vague blanket criticisms (90%) don’t help addicts or their families find good treatment. And, the implication that any treatment with medication is good while any treatment without is primitive voodoo is false and damaging. Also, the blanket nature of the attacks slanders and alienates ethical professionals who provide good care.

As Alcoholism & Drug Abuse Weekly set the record straight, another journalist defended the error by arguing that it was in an opinion section and the false statistic was used to support a conclusion she said was true.

What can you do when the journalists, who have the soapbox, argue that they’re right, even when their facts are wrong?

. . . most men have bound their eyes with one or another handkerchief, and attached themselves to some one of these communities of opinion.  This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars.  Their every truth is not quite true.  Their two is not the real two, their four not the real four; so that every word they say chagrins us, and we know not where to begin to set them right.– Ralph Waldo Emerson

via McLellan on the state of evidence-based treatment, and an old RAND report.

Waiting for Breaking Good?

Bill White shares his perspectivetv on what the media misses in coverage of drug and alcohol problems.

3.   The media mistakenly conflate recovery with active addiction and addiction treatment with addiction recovery.  

4.   Media outlets portray addiction recovery as an exception to the rule.

5.   Media coverage of drug-related celebrity mayhem and death contributes to professional and public pessimism about the prospects of successful, long-term addiction recovery.

6.   When the story of recovery is told, it is most often told from the perspective of the recovery initiate rather than from the perspective of long-term recovery.

7.   When personal recovery is conveyed by the media as a dramatic story of redemption, the media often inflate and elevate the recovering person to a pedestal position and then circle like piranhas in a feeding frenzy at the first sign of any failure to live up to that imposed image.

Read the rest here.

Sober fun on St. Patty’s day


I teach at a local university and some years I teach on Saint Patrick’s day. It’s bad. Green beer starts flowing early, there are very drunk people wandering around all day, people passed out on the sidewalk, etc. Worst of all, it’s the default thing to do if you’re a young college student on St. Patrick’s day.

That’s why it’s so nice to see the growth of the Collegiate Recovery Program at University of Michigan. It would be cool no matter what, but it’s even cooler because they’ve been such good friends to Dawn Farm.

USA Today covered their St. Patty’s day event:

“Priority number one is to have fun,” says Molly Payton, 23, a general studies senior at Michigan, who has been sober for one year and attended the Sober Skate. “When I was in recovery, my big fear was that I wouldn’t have fun anymore … it was baffling to think I could have a life outside of drugs and alcohol.”

“For me, Fridays and Saturdays were tough,” adds Garrett Gibbons, 27, a graduate student in pathology at Michigan who is also in recovery.

“Those were nights when I knew I would party, knew I would drink. That’s why this is an important time for us.”

Hope, empowerment, capability, connection and purpose

Hopeworks Community recently listed his core beliefs related to his recovery from mental illness:

The idea was simple. There are a few core beliefs about recovery that make a difference. To the extent you are able to live them your recovery will be positively impacted.

My list of core beliefs was simple:

Life can get better.
I can help make it better.
I can learn the things I need to do to make it better.
I have support. People care about me and what I am doing.
What I do matters. It has meaning and purpose.


This rings very true for addiction recovery as well. Any practitioner or program that ignores these dimensions is inadequate. Some people will need no assistance with this kind of recovery–if we reduce their symptoms they can take care of all of this on their own without mutual aid or extended professional help. (I’m thinking of people with major depression or a problem drinker.) Others will more severe and chronic mental illness or substance use disorder will need lifelong professional and/or peer support. (Here, I’m thinking of an addict or chronic, debilitating mental illness.)

There’s a lot of pushback on this for addiction. Just this weekend, Anne Fletcher tweeted a dismissive reaction to a Bill White post about developing geographic communities of recovery.

Would she have the same reaction to a post about building communities of recovery for people with chronic and severe mental illness? Would she tweet a response that implies it’s overkill and these people (Who, together, are re-engaging in full family, occupational and community life.) need discover that there’s more to life and they need to get out of some growth-limiting bubble?

There’s been a whole new wave of these kinds of reactions recently. To me, they suggest a couple of beliefs:

  • The failure to acknowledge the different needs of people who have less severe or time-limited problems with alcohol and other drugs versus those with severe, chronic and debilitating addictions. Their reactions often focus on the experiences of the former, framing substance use disorders as a lifestyle choice.
  • The perception that recovery advocates (12 step recovery in particular) can’t tell the difference between these two groups and are bent on evangelizing every problem user into their one and only path to recovery while obstructing access to any treatment or recovery support that isn’t perfectly compatible.
  • That this perceived pattern of behavior undermines the legitimacy of mutual aid groups and the empirical evidence for the their effectiveness and their mechanisms of change.

Hopeworks Community closed with a thought that sums up recovery as a way of life.

But I know recovery is never a thing to have, but a way of doing.

Interesting that there is so much resistance to lifestyle change as an approach to managing addiction while there’s no dispute that lifestyle change is critical to successful management of other chronic illnesses and that peer support is important for successfully initiating and sustaining lifestyle change.

I don’t hear any of these reactions regarding people who join a gym, spend an hour there 5 days a week, start eating healthier, integrate being physically healthy into their identity and develop new social networks around these changes, like, say, a tennis league or a biking group. Why is that? We don’t hear that push back, and we’re not even talking about people who were occupationally, socially, emotionally and familially impaired. And, if some faction of these people exhibited evangelical zeal and insisted this was the only way to be healthy and that everyone needed to do this, would we be so dismissive of scholarly work describing the development of some communities organized around this kind of wellness for really sick people?

It will kill people as soon as it’s released

images (3)The upcoming release of Zohydro has been getting a lot of attention:

The hydrocodone-based drug is the latest in a long line of painkillers called opioid analgesics. The FDA approved the medication last fall to treat chronic pain, and it is set to become available to patients in March.

The drug was approved against the advice of the FDA’s own advisory board.

Despite a vote of 11 to 2 by an FDA panel to reject the powerful new drug, it was eventually given approval by the FDA for release.

There are concerns about the manufacturer’s access to the FDA.

Last fall, a series of emails were made public from a Freedom of Information Act request. They were emails between two professors who had, for a decade, organized private meetings between FDA officials and drug companies who make pain medicine. The drug companies pay the professors thousands of dollars to attend.

And here’s what has critics concerned. One of those companies was Zohydro’s original manufacturer, Elan Corp. Zogenix wasn’t in the picture yet but went on to partner with Elan.

One physician group isn’t mincing words about the impact of the drug.

“It’s a whopping dose of hydrocodone packed in an easy-to-crush capsule,” said Dr. Andrew Kolodny, president of the advocacy group Physicians for Responsible Opioid Prescribing. “It will kill people as soon as it’s released.”

Doctor Skeptic reviews the research on opioids as a pain management options and concludes with this:

The bottom line
1. Opioids may not be effective for chronic non-cancer pain, and their use in such patients is associated with side effects, tolerance, dependence, and addiction.
2. Despite this, prescription opioid use is increasing and with that, the rates of opioid abuse and opioid related death are also increasing.
3. Harms from prescription opioids are over-represented in the socially disadvantaged.


Recovery vs. Treatment

Hopeworks Community’s blog speaks from the perspective of a mental health care patient advocate. He draws some important distinctions between recovery and treatment:

Is treatment a necessary or a sufficient condition for recovery??  The answer is clearly on both counts no.  Mental health professionals have stolen the notion of recovery and defined it as the result of some type of professional service.  It has left recovery as an emaciated thing with little power or ability to meet the needs of people in severe distress.  One friend said it succently, “I feeel like I am in the old Wendy’s commercials.   I am still looking for the beef.”

Recovery is the result of succcessful living.  Successful living is always a matter of degree.  Recovery is when the gains in life begin to make a difference in the way you experience and live life.  Recovery is life getting better and that “getting better” giving you increased ability to make life to come better and better.  It is about restoration and transformation.  It is about life anew.  It does not mean things are all sunny and sweet.  It does not mean life is not hard, although it should mean everything is not hard.  It does not change life as much as it changes your capability to deal with life.

Some of the things that make life more successful include (but are not limited to) experiences that help to be more aware and open to the world around you, experiences that help you to learn how to anticipate and and see where things are going and help you to develop tools and skills to deal more successfully with those events, anything that increases your strength and capabilitities in life, anything that helps you to connect with other people and them to connect with you, that what gives you confirmation that life has meaning and purpose, anything that empowers you to make decisions about your life and accept responsibility for those decisions,  anything that helps you to think before you act, and anything that helps you to understand and accept that some things are beyond your control and no matter how bad it feels in any moment that is not all there is and life can and does get better.  And all that probably is just scratching the surface.  Recovery is a difference that makes a difference.

Treatment only matters when it is part of successful living.  For too many people, too often it is not.  No matter how much it helps it is not the same thing as successful living.  It is only a tool and like all tools it only matters how well it works.  By itself it is never enough.  And any program that tries to get their clients to identify their success in life with their participation in that program has done an injury that far outweighs any good they may have done.

Recovery is when you know it can get better, that you can make it better, that people support you in the making it better, that sometimes messing it up is part of it getting better and you can learn from mistakes, and that it is well worth the effort and that you are committed to making these truths guide and inform you in your pursuit of a better life.

via Recovery and successful living | Hopeworks Community.

Recovery is Contagious

Bill White on the infectious nature of recovery:

“We all have the potential to be recovery carriers.  Becoming a recovery carrier requires several things.  It requires that we protect our recoveries at all cost–Recovery by any means necessary under any circumstances.  It requires that we help our families recover.  It requires the courage to reach out to those whose lives are still being ravaged.  It requires that we give back to NET and other organizations that helped us along the way.  And it requires that in our new life, we try to heal the wounds we inflicted on our community in our past life.”

“Addiction is visible everywhere in this culture, but the transformative power of recovery is hidden behind closed doors.  It is time we all became recovery carriers.  It is time we helped our community, our nation, and our world recover.  To achieve this, we must become recovery.  We must be the face and voice of recovery.  We must be the living future of recovery.”

via Recovery is Contagious Redux | Blog & New Postings | William L. White.