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Is calling addiction a disease harmful?

In recent years there’s been a lot of attention and energy devoted to reclassifying addiction from a disease to something else–a “disease” of despair, a lack of social connection, a product of injustice and hardship, a product of deprived environments, a learning disorder, etc.

Now, there’s a recent study getting attention that suggests teaching clients addiction is a disease may be harmful.

Drug addiction is a disease. That has long been the consensus in the medical community, and in recent decades it has filtered down to the general public.

The hope among public-health officials has been that such messaging decreases the moral stigma that traditionally surrounds addiction, and instead will inspire suffering people to stop blaming themselves and get professional help. But newly published research suggests this framework “may have unintended negative consequences.”

The results of a new study suggest that, for many people who need help, “I have a disease” translates to “There’s nothing I can do about it,” or “It’s out of my hands.”


So . . . should we stop talking about it as a disease?

I’d say no, for a couple reasons.

First, it is a disease.

Second, I suspect that the problem is not with addiction being categorized as a disease, it’s the context for that categorization. I’d imagine there are contexts in which it’s harmful and contexts in which it’s helpful.

Off the top of my head, these contexts might revolve around questions like:

  • What treatment outcomes are possible or can be expected for this disease?
  • Who’s responsible for treatment?
  • If the expected outcomes are not achieved, who is responsible for that? And, how should we respond?

What treatment outcomes are possible or can be expected for this disease?

If the patient assumes the prognosis is poor, I’d imagine that diagnosis is likely to have negative consequences, like a loss of agency.

However, I imagine health professionals deal with this situation every day. Patients hear diagnoses like cancer, asthma, or heart disease and assume that the course of their physical well-being is out of their hands.

I hope that, where the prognosis is not poor and active client participation is an essential element to effective treatments, providers have approaches to mitigate the potential loss of agency that may accompany a diagnosis.

What happens if the provider is pessimistic about the prognosis? How does that influence care? How does the provider explain the poor prognosis?

Off the top of my head, I see 4 possible explanations a helper may arrive at:

First, they may conclude that they are not a very good helper. Few providers will give this serious consideration.

Second, they may conclude that we just don’t have good treatments for this disease–the disease is too difficult treat. This is much more common. Whatever the drug crisis of the moment is, that is considered to be particularly difficult to treat. (Crack, then methamphetamine, then opioids.)

Third, they may conclude that the disease is treatable, but the patient is too difficult to treat. They may believe that their clients are too complex, that they don’t want recovery, that they are too chaotic and difficult to engage or retain. This is more common yet. The belief is, “I am competent, we have the knowledge and skills, but these clients won’t/cant cooperate.”

Fourth, they may believe that the disease is treatable but the context makes it impossible to effectively treat the disease. They may believe that these clients can’t be effectively treated because they are too poor, they are homeless, their living environments are too hostile to recovery, they face legal and employment barriers, etc. This may be the most common. With this explanation, like the second and third, the professional experiences a loss of agency.


Who’s responsible for treatment?

Is treatment something that is delivered by a professional who is believe to possess the important knowledge, skills, tools and plan?

Does treatment narrowly focused on pills and procedures? And, is a “good patient” a passive, compliant patient?

Or, is treatment a partnership between the patient and professionals that is based on listening, understanding, shared decision-making, and shared responsibility? Treatment of this kind may involve pills and procedures, but may also involve much more, including behavioral strategies, and interventions to address barriers to treatment.


If the expected outcomes are not achieved, who is responsible for that? And, how should we respond?

When we don’t get the outcome we wanted, who do we ascribe responsibility to?

Is it the patient’s fault for not following the treatment plan? If we share responsibility, there may be some truth to this at times. However, shared responsibility requires that we don’t stop there. If the patient didn’t adequately participate in treatment or didn’t follow the plan, we should consider:

  • Did the patient have sufficient input on the plan?
  • Was the plan aligned with the patient’s goals? (Recognizing that goals often change before and during treatment.)
  • Did we adequately explore and plan for barriers the patient is likely to encounter?
  • Did we approach the patient in a manner that contributed to a loss of agency rather than using approaches then enhance agency?

Do we blame the illness for being too difficult to treat? In this case, we should consider the following:

  • Is the illness really that difficult to treat, or are we unwilling to invest the necessary resources to achieve remission?
  • If there is no silver bullet treatment, informed consent becomes more important. In this case, what combinations might make sense?
  • Is seeking to reduce symptoms and harms while we wait for better treatments the best we can do? If so, do we communicate this to patients?
  • Do combinations of treatments move us closer to, or increase the likelihood

Do we blame the provider?

  • Are they providing treatment in an adequate dose and intensity?
  • Was the treatment of adequate duration?
  • Was the treatment of adequate quality?
  • Is the provider attending to extra-therapeutic factors that are likely to influence outcomes?
  • While some providers are sure to be poor caregivers, others may be under-resourced.

Do we blame the context?

Do we blame the environments that patients are coming from? Where applicable, do we blame criminal justice policy, homelessness, employment opportunities, anomie, health care policy, social determinants of health, etc.?

Of course, all of these things influence what we’re able to do for patients and the outcomes we achieve together. And, of course, many of these needs fall outside the narrow purview of “addiction treatment.”

We can say, “that’s not my system’s/agency’s job” and complain about other systems’ failures to meet or clients’ needs. We can confine our efforts to reimbursable services. That’s a pretty easy position to defend.

While that is an easy position to defend, it indicates the absence of a mission-based commitment to recovery and our patients.

Anecdotally, it appears to be the smaller, community-based programs that develop housing programs (before any funders would considering reimbursement for these services), employment programs, maintain pantries, and provide meaningful linkages with indigenous sources of recovery support.

I routinely encounter patients from corporate providers who received a time-limited, often high-intensity, dose of treatment followed by inadequate continuing care. The continuing care is often a passive referral to an unaffiliated low-intensity outpatient program near their home. (In the worst cases, corporate programs will complain about smaller, community-based programs that do not adapt their services to accommodate the needs of poorly served corporate patients.)

When I’ve reached out on behalf of patients, the help available to them is entirely contingent on funding.


Negative consequences?

If there are negative consequences to receiving a diagnosis of addiction, it’s worth asking whether it’s the diagnosis itself of something else.

Maybe we don’t need to nuance the language for our patients. Maybe we need to do better for our patients.

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Person-first or identity-first?

This article was shared by a friend today.

Several previous posts have spoken to recent attention to language in recovery advocacy. (See here and here.)

I think may have pointed to LGBT+ communities’ use of words like “queer” when questioning whether we should change our own language to reduce the stigma that others harbor toward us.

It appears other groups are wrestling with the same questions.

You may have been taught not to use the word “disabled.” In fact, you may have been taught to use “person-first” language in which you identify the person before their disability (i.e., person with autism, person who uses a wheelchair, individual with cerebral palsy). There is a shift happening towards “identity-first” language in which we claim our disability and center in the terms that we use (i.e, disabled, Deaf, autistic).

Why this shift?

Using identity-first language makes disability a marker of pride. It’s a little bit “in your face,” but that’s the point. Person-first language potentially diminishes a person’s disability identity by adding it on last. Activists from the disabled community have been pushing for identity-first language, some with a social media campaign called #SayTheWord (the word they want you to say is “disabled”).

And, there’s more . . .

. . . shying away from the actual word “disability” is a form of cultural erasure, because it suggests that people with disabilities shouldn’t identify with their disability or form community with others who have shared experiences. Instead, if the larger population embraces the word disability, it sends a message of acceptance and acknowledgement of disability as identity. A disability is something that shapes our lives, and it’s something to be proud of, not ashamed of.

Personally, I think she puts the emphasis in the right place. It’s the culture that needs to change, not the words. (And, even if we’re successful at changing the words we use, the culture will eventually change the meaning of those words.)

However, her message is not a rant against person-first. In fact, she says both should be accepted.

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Addiction treatment, palliative care, or both?

So . . . Monday I posted about a study of a low barrier buprenorphine program.

Toward the end of that post, I raised the tension between treatment-as-harm-reduction and treatment-as-recovery-facilitation and shared a quote from an emergency physician questioning the evidence-base for buprenorphine dispensed in emergency departments, as well as its effectiveness at facilitating “sobriety.”

I added the following:

I imagine that most people who are enthusiastic about these projects would respond that they are not looking for “sobriety.”

This is where clarity about goals for an intervention becomes especially important. If we can agree that addiction is a treatable chronic illness, it seems important to more clearly categorize interventions as treatments for the illness of addiction or as palliative care.

If we sell an intervention as treatment at the public level but treat it as palliative care at the academic level, the public, people with addiction, and people who care about them are likely to feel deceived. It also has the effect of eliding difficult conversations about resource allocation and capacity development. For example, is this $6,000,000 allocated to palliative care or addiction treatment? Because it’s not both.

I pretty quickly regretted binary framing in that last sentence but failed to add an update to the post. I just wasn’t confident that it was accurate. Sure enough, it ended up getting questioned, which is fair. (However, some reactions framed these comments as anti-palliative and anti-buprenorphine, which is incorrect.)

What is palliative care?

The US National Library of Medicine defines palliative care as:

The goal of palliative care is to help people with serious illnesses feel better. It prevents or treats symptoms and side effects of disease and treatment. Palliative care also treats emotional, social, practical, and spiritual problems that illnesses can bring up. When the person feels better in these areas, they have an improved quality of life.

Palliative care can be given at the same time as treatments meant to cure or treat the disease. Palliative care may be given when the illness is diagnosed, throughout treatment, during follow-up, and at the end of life.

For this conversation, the key elements are:

  • that it prevents or treats symptoms, and
  • it can be given at the same time as curative treatments

Note that they mention that it can be given at the same time as curative treatments. This establishes a distinction between curative and palliative treatments.

Palliative vs. Addiction Treatment. Is it Binary?

I wrote that without any deep consideration or conviction about this binary framing, but I gave the impression that the two approaches look something like the Venn diagram below.

no overlap

Some of push back I got might give the impression that there is a high degree of overlap between the two approaches. They might view the relationship as more like the image below.

stong overlap

I suspect the truth might be more like the one below.

partial overlap

Is [enter intervention here] addiction treatment, palliative care, or both?

I am not an expert on palliative care, but I suppose the answer to this depends on the intentions and expectations of the service provider.

If the service provider’s goal and expectation are that the intervention will lead to addiction remission/recovery, then it is addiction treatment.

If the service provider’s goal and expectation are that the intervention will reduce symptoms/suffering related to addiction (but not lead to remission/recovery), then it is palliative care.

As I’ve spent a little time reading more about palliative care, I’m seeing information about concurrent palliative and curative treatment, but nothing about a single treatment being both curative and palliative.

So . . . how could I imagine an intervention being both? I could imagine, based on patient choice, delivering a treatment in a dose or intensity that is expected reduce symptoms/suffering (e.g. illicit opioid use) but is not expected to lead to remission/recovery. However, it is expected that this intervention will engage the patient into a dose/intensity that can be expected to lead to recovery/remission.

Why does it matter which kind of care it is?

In the original post (and above) I said:

If we sell an intervention as treatment at the public level but treat it as palliative care at the academic level, the public, people with addiction, and people who care about them are likely to feel deceived. It also has the effect of eliding difficult conversations about resource allocation and capacity development. For example, is this $6,000,000 allocated to palliative care or addiction treatment?

How we categorize an intervention is how we understand it, evaluate it, and communicate about it. This, in turn, will determine how others will understand it, evaluate it, and communicate about it.

If we categorize an intervention as addiction treatment, it will be (and should be) evaluated on its effectiveness at helping clients achieve recovery/remission. If it is not helping clients achieve recovery/remission, it has failed.

If the intervention is delivered with a dose and intensity that can only reasonably be expected to reduce symptoms (e.g. illicit opioid use) and it’s not accompanied by a commitment to engage the patient into a dose and intensity that can facilitate remission/recovery, it’s palliative.

It we categorize it as both, it should be evaluated on its effectiveness in engaging patients into addiction treatment of adequate dose and intensity to achieve recovery/remission.

The interventions we call treatment and their outcomes will shape how families, people with addiction, policy makers, professional helpers, employers, law enforcement, landlords, neighbors, clergy, and others think about addiction, treatment, and recovery.

Clarity is important to avoid the following traps that have harmed people with addiction:

  • Selling an intervention to policy makers, helpers, the public, families and people with addiction one way, but measuring it in another way. Leading to a loss of trust and fueling stigma against recovering people.
  • Moving the goalposts when outcomes are disappointing.
  • Confusion about the kind of services that are or are not available to people with addiction. This confusion can nurture notions that this is an untreatable condition or that addicts don’t want recovery.
  • The “soft bigotry of low expectations” that we’ve discussed here before.

This is also a time where destabilized notions of recovery with vague conceptual boundaries can create confusion that can (inadvertently) amplify these problems.

UPDATE: None of this should be interpreted as condemning low threshold programs, suggesting terminating services to people who continue to use, or suggesting that palliative services have no place. (The overdose crisis has made the need for these services clearer than ever before.)

I’d add that detox is described as palliative in TIP 19, Detoxification From Alcohol and Other Drugs because it’s not treating the disorder.

Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. Supervised detoxification may prevent potentially life-threatening complications that might appear if the patient was left untreated. At the same time, detoxification is a form of palliative care (reducing the intensity of a disorder) for those who want to become abstinent or who must observe mandatory abstinence as a result of hospitalization or legal involvement. Finally, for some patients it represents a point of first contact with the treatment system and the first step to recovery. Treatment/rehabilitation, on the other hand, involves a constellation of ongoing therapeutic services ultimately intended to promote recovery for substance abuse patients.

My intention is to call for clarity about the goals of an intervention, so we know how to understand it, evaluate it, and communicate about it.

For example, if we call detoxification treatment, and evaluate it as treatment, it will be a fail to put . Elimination of detox will seem sensible under this framing. While detox is palliative, it’s a necessary tool for many circumstances and safe engagement into other interventions.

I’d add that clarity about goals and definitions could also address the shortcomings of impatient and residential programs whose intervention is not delivered in a dose, intensity and duration that can be expected to facilitate recovery.

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Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin

There was a lot of enthusiasm about this study on twitter recently.

It appears to be based on this program highlighted in the NY Times last year.

. . . city health workers are taking to the streets to find homeless people with opioid use disorder and offering them buprenorphine prescriptions on the spot.

The city is spending $6 million on the program in the next two years, partly in response to a striking increase in the number of people injecting drugs on sidewalks and in other public areas. Most of the money will go toward hiring 10 new clinicians for the city’s Street Medicine Team, which already provides medical care for the homeless.

Members of the team will travel around the city offering buprenorphine prescriptions to addicted homeless people, which they can fill the same day at a city-run pharmacy.

We’ve reviewed the evidence-base for buprenorphine in previous posts. (And, that the outcomes were not what most people imagine when they hear that it’s the most effective treatment or the gold standard for care.)

A frequent criticism of research is that it doesn’t reflect real world conditions.

Well, this study that actually used real-world, high complexity subjects, and examines an intervention getting a lot of recent attention—low barrier buprenorphine prescribing. The reported the following conclusion:

In conclusion, this study found that a low barrier buprenorphine pilot program successfully engaged and retained a subset of marginalized persons experiencing homelessness in care and in continued treatment with buprenorphine.

What was the intervention being studied?

The researchers studied a low-threshold, same day buprenorphine program co-located with medical outreach and harm reduction services, which they described as follows:

Patients are engaged by peer outreach workers or self-present on a drop-in basis to either a small open-access medical clinic or a nearby syringe access program, where a clinician provides comprehensive substance use assessment and education and calls in a same-day prescription for buprenorphine/naloxone to be filled at a community pharmacy that dispenses the medication free to patients who are uninsured or have Medicaid.

This is especially relevant because of growing calls for this type of low-threshold opioid agonist program.

Who was being studied?

The subjects received a buprenorphine prescription from the street medicine program and were complex cases.

The researchers did a retrospective chart review of 95 patients:

  • 100% used heroin and engaged in injection drug use
    • 61% used methamphetamines
    • 26% used cocaine
    • 8% used benzodiazepines
    • 12% met criteria for unhealthy alcohol use
  • 100% were homeless
  • 58% had a chronic medical condition, such as hypertension or hepatitis C
  • 66% had a psychiatric condition
    • 26% with bipolar disorder or a psychotic disorder.
  • 24% previously sought treatment at this program

How long was the study?

The study was 12 months. (That’s very good. This is considerably longer than most studies. The ideal duration would be 5 years, but studies of that duration are extremely rare.)

What outcomes did the study measure?

This study looked at 4 outcomes over 12 month:

  1. Retention in the program’s medical and harm reduction services
  2. Retention on buprenorphine
  3. Urine drug screen results
  4. Overdoses

Retention in care

Retention in the street medicine program, defined as a visit 1 week prior to or any time after each time point:

  • 74% returned for follow-up after the initial visit at least once during the 12 months of evaluation.
  • 63% at 1 month
  • 53% at 3 months
  • 44% at 6 months
  • 38% at 9 months
  • 26% at 12 months

Retention on buprenorphine

Retention on buprenorphine, defined as having active buprenorphine prescriptions for more than 2 weeks of the month:

  • 55% at 1 month
  • 41% at 3 months
  • 38% at 6 months
  • 34% at 9 months
  • 26% at 12 months
  • 46% had a treatment interruption of 1 month or longer with subsequent return to care

Those percentages seem to be reporting on the % at that particular check-in time, not continuous up to that point.

  • Twenty-nine patients (30%) were retained on buprenorphine for at least two of the evaluation time points (months 1, 3, 6, 9, or 12).
  • Of that 30%:
    • 14 (48%) had continuous active prescriptions for buprenorphine during the time they were treated.
    • 5 (17%) of these patients had an interruption in their buprenorphine prescription of 2–3 weeks,
    • 8 (28%) had an interruption of 4–6 weeks, and
    • 5 (17%) had an interruption of greater than 6 weeks. Seven patients (24%) had multiple interruptions.

Urine drug screens

Two hundred and six urine toxicology tests were completed by the cohort, and 71% of patients who followed up after intake had a toxicology test, with a mean of 2.7 tests and a median of one test per follow-up patient (range 0–25).

If 74% of the 95 followed up after intake, that’s 70 patients. If 71% of them had at least one drug screen, that’s about 50 patients.

The median of one test per follow-up patient would indicate that at least half had only 1 drug screen.

Of the 206 drug screens completed:

  • 63% were positive for opioids
  • 73% were positive for methamphetamines
  • 25% were positive for cocaine
  • 10% were positive for benzodiazepines
  • 81% were positive for buprenorphine
  • 23% of patients had at least one opioid-negative, buprenorphine-positive toxicology test.

Overdoses

Emergency department and hospital records were reviewed for adverse events, including deaths and nonfatal opioid overdoses.

  • 1 patient died from fentanyl and methamphetamine overdose
  • 4 patients received emergency or inpatient medical treatment for an opioid overdose requiring naloxone,
    • 1 of these patients had three overdoses that required naloxone,
  • 5 patients were treated for possible opioid overdose events not requiring naloxone

What we don’t know

There are a few questions the study didn’t answer that could have been answered with the data and outcome measures used:

  • How many subjects were continuously on buprenorphine?
  • Were there any subjects were negative for opioids and other drugs at all points (or most points)?

Other unknowns:

  • The article says that patients were offered referrals to methadone and residential treatment. How many accept those referrals and, if successful referral rates are low, why?
  • Were there any quality of life benefits for the patients?

Wrapping up

The study had some interesting thoughts on drug testing and outcomes:

Our urine toxicology results reflect adherence to buprenorphine concurrent with ongoing use of heroin and methamphetamines in a majority of the cohort. We found some evidence of periods of opioid abstinence, with 23% of patients having at least one opioid-negative, buprenorphine-positive test. In our clinical experience, many patients report taking buprenorphine regularly and using substantially less heroin, while still using heroin occasionally. We are exploring this phenomenon further through qualitative research and in-depth interviews with participants, as it is difficult to measure a decrease in amount of heroin use with the binary tool of a urine toxicology test.

And, under limitations:

Frequency of urine toxicology testing varied among participants, so results could be skewed by participants who had more tests and may not be an accurate reflection of the cohort’s substance use. We are not able to report or compare toxicology test results among individual participants at specific time-points because of the variability in testing practices.

Treatment as harm reduction or recovery facilitation?

This discussion of outcomes highlights the tension between treatment as harm reduction and treatment as recovery facilitation.

A recent opinion piece in Emergency Medicine News brings this tension into focus:

Despite press coverage to the contrary, this study [work done by the group led by Gail D’Onofrio, MD, at Yale on ED-initiated buprenorphine/naloxone for opioid use disorder] never demonstrated any impact of ED-initiated buprenorphine on the only objective measure used to assess sobriety, the urine drug screen, nor were any other outcome differences sustained at six months. (JAMA 2015;313[16]:1636; http://bit.ly/2PBwYWdJ Gen Intern Med 2017;32[6]:660; http://bit.ly/2Cj0lbY.)

Despite this, I’m convinced that within the next five years buprenorphine will be routinely administered in EDs for opioid use disorder.

I imagine that most people who are enthusiastic about these projects would respond that they are not looking for “sobriety.”

This is where clarity about goals for an intervention becomes especially important. If we can agree that addiction is a treatable chronic illness, it seems important to more clearly categorize interventions as treatments for the illness of addiction or as palliative care.

If we sell an intervention as treatment at the public level but treat it as palliative care at the academic level, the public, people with addiction, and people who care about them are likely to feel deceived. It also has the effect of eliding difficult conversations about resource allocation and capacity development. For example, is this $6,000,000 allocated to palliative care or addiction treatment? Because it’s not both.

UPDATE: Follow-up post here.

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The APA Meeting: A Photo-Essay

From Slate Star Codex, on the 2018 APA conference:

The first thing you notice at the American Psychiatric Association meeting is its size. By conservative estimates, a quarter of the psychiatrists in the United States are packed into a single giant San Francisco convention center, more than 15,000 people.

. . .

The second thing you notice at the American Psychiatric Association meeting is that the staircase is shaming you for not knowing enough about [fill in the medication].

The author lists 10 things you notice at the APA meeting.

The pharma marketing in the photo essay is striking. Check it out.

Looks like the 2018 conference had 209 exhibitors. The 2019 exhibitor fees start at $1500, with most booths costing $2000 or $2300. That brings the exhibitor fees to somewhere between $400k and $500k. I wonder about the value of all the meals and swag exhibitors bought for attendees, let alone the speaking deals set up. Wow.

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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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