Toward a “Conspiracy of Hope” (Bill White and Jason Schwartz)

This is being cross-posted from williamwhitepapers.com. Please visit and subscribe. (You won’t regret it!)


conspiracy-of-hopeSo it is not our job to pass judgment on who will and will not recover from mental illness and the spirit breaking effects of poverty, stigma, dehumanization, degradation and learned helplessness. Rather, our job is to participate in a conspiracy of hope. It is our job to form a community of hope which surrounds people with psychiatric disabilities. —Pat Deegan

With those words, Dr. Patricia Deegan, Adjunct Professor at Dartmouth College Geisel School of Medicine and indomitable recovery advocate, introduced two ideas with potentially profound implications for the future of addiction treatment and recovery. Below we offer a few reflections on these ideas.

A conspiracy of hope is an organized movement to inject the optimism of lived recovery experience into an arena historically fixated on addiction-related pathology and its progeny of injuries to individuals, families, and communities. But why is there need for such a conspiracy? Opposition to prevailing conditions often arises within the context of oppression. People suffering from addiction and those seeking recovery face innumerable sources of such oppression.

Addiction itself inflicts a rising cascade of consequences, crushing one’s sense of value and blinding one’s vision beyond the insatiable immediacy of drug hunger. Addiction-related social stigma—fueled by media fixation on the most lurid caricatures of addiction—further damages personal identity, fuels social isolation or entrenchment in subterranean drug cultures, and prevents or slows help-seeking. The resulting addiction-based social network behaves like crabs in a bucket—those trying to escape are repeatedly pulled back in. The paucity of helping resources and their lack of accessibility, affordability, and quality all reinforce the view that reaching out for help would be a waste of time and money. When help is sought, the therapeutic pessimism and paternalism of professional and nonprofessional “helpers” can also reinforce low recovery expectations.

As a result of such conditions, addiction-fueled despair whispers and then shouts that we are not deserving or capable of anything different—that recovery is a myth and that the ever-present threats of incarceration, disability, or death are rightful consequences of our unworthiness. Only an organized conspiracy of hope can challenge the oppressive conditions that stand as major barriers to long-term addiction recovery.

Character of the Conspiracy

But what would such a conspiracy of hope require? It would require the cultural and political mobilization of individuals and families in recovery and their allies. It would require a vanguard of such individuals and families willing to share their recovery stories at a public level. It would require those in recovery to move beyond their own personal stories and their particular recovery pathway to identify themselves as “a people” with a shared history, shared needs, and a shared destiny. In short, it would require a social movement aimed at shifting the governing image of addiction from that of the repeatedly relapsing celebrity to the millions of people living quiet lives of stable, long-term recovery. Shifting the dominant view of addiction from one of pessimism to hope will require the involvement of a broad spectrum of people and professions, but people in recovery will be central to this achievement through their individual and collective storytelling and their leadership within recovery advocacy efforts.

There are whole professions whose members share an extremely pessimistic view of recovery because they repeatedly see only those who fail to recover. The success stories are not visible in their daily professional lives. We need to re-introduce ourselves to the police who arrested us, the attorneys who prosecuted and defended us, the judges who sentenced us, the probation officers who monitored us, the physicians and nurses who cared for us, the teachers and social workers who cared for the problems of our children, the job supervisors who threatened to fire us. We need to find a way to express our gratitude at their efforts to help us, no matter how ill-timed, ill-informed, and inept such interventions may have been. We need to find a way to tell all of them that today we are sane and sober and that we have taken responsibility for our own lives. We need to tell them to be hopeful, that RECOVERY LIVES! Americans see the devastating consequences of addiction every day; it is time they witnessed close up the regenerative power of recovery. (White, A Day is Coming, 2001)

What makes this a conspiracy is the knowledge that through these simple acts of storytelling and advocacy we are part of a chorus of others taking similar strategic steps to achieve larger social gains. Built on the back of earlier recovery advocacy efforts, this conspiracy of hope was officially launched at the 2001 Recovery Summit in St. Paul, Minnesota. Christened the New Recovery Advocacy Movement, it has since spread throughout the U.S. and internationally. But the success of this movement hinges on more than our collective storytelling; in Deegan’s vision, it requires a new form of community-building.

Building Communities of Hope

Communities of hope involve creating the physical, psychological, and social space (recovery landscapes) in local communities and the culture at large in which recovery from addiction can flourish. Assuring such space requires building sustainable institutions through which recovery is supported within every area of community life, e.g., government, business and industry, housing, education, medicine, social services, religion, music, the arts, sports, and leisure. The idea of communities of hope means that people in recovery have opportunities to be supported by and in turn support other people in recovery and that those in recovery have opportunities individually and collectively to participate in the larger life of their communities. It also suggests the presence of safe sanctuaries that can serve as incubation chambers for those early in their recovery. We are now witnessing the spread of such new institutions (e.g., recovery community centers, recovery homes, recovery industries, high school and collegiate recovery programs, recovery cafes, recovery ministries, recovery-focused sports and entertainment venues, and recovery celebration events) that transcend the historical categories of addiction treatment or recovery mutual aid societies.

We are also witnessing the emergence of an ecumenical culture of recovery with language that links the distinctive cultures that have historically evolved within these professional and mutual aid settings. Within the addictions arena, the communities of hope that Deegan refers to are under construction across the U.S. and in other countries. That stands as a notable historical milestone within the history of addiction recovery. It is a trend that will benefit individuals seeking recovery and the service systems designed to serve them, but it will also mark a step in elevating the broader health and quality of communal life. We have followed closely the work of John McKnight, Peter Block, and Bruce Alexander on the value of deliberate welcoming, sharing gifts, and collaborative community building and commend their writings to recovery advocates and addiction professionals.

Implications for Addiction Treatment Programs

What does all this mean for addiction treatment programs? Addiction treatment programs could participate in this conspiracy of hope and recovery community building by taking actions such as the following:

*Elevating resilience and recovery as the central organizing constructs for the design and delivery of all services, e.g., strengths-based assessment protocol, recovery-focused training of all service personnel on the prevalence, processes, pathways, stages, and styles of long-term personal and family recovery. Identification and mobilization of client gifts are essential. Conspiracies of hope and communities of hope are built upon participant’s gifts, not their needs.

* Reconnecting what have become ever-briefer episodes of addiction treatment to the larger and more enduring process of addiction recovery via embracing  models of recovery management nested within larger recovery-oriented systems of care, e.g., precovery outreach services, assertive linkage to indigenous recovery support institutions, sustained post-treatment recovery checkups, and support services for families in long-term recovery.

*Assuring the presence, diversity, and visibility of people in long-term recovery within the treatment milieu.

* Actively supporting (without controlling or exploiting) local recovery advocacy and recovery community building activities.

* Using community standing to expand the conspiracy beyond people in recovery and beyond service providers, e.g., engaging employers and faith communities as well as other social institutions to make the community “recovery ready.”

Joining the Conspiracy

The journey from addiction to recovery is as possible and fulfilling as it is challenging. Few things are as spiritually energizing as being part of a “conspiracy of hope” to support those journeys. Such journeys are eased when nested within a community of fellow travelers. Few things are as fulfilling as being part of building such communities. Are you ready to join the conspiracy of hope and nurture the development of communities of hope? What steps could you take today to assert such a commitment?

1 Comment

Filed under Uncategorized

Blue Cross Blue Shield Publishes Major Opioid Report

Blue Cross Blue Shield issued a report on the opioid crisis with their data from all members in their commercial plans.

Early in the document, they report a pair of striking numbers.

First, that 21% of members filled a prescription for an opioid in 2015. I’ve heard these kinds of numbers before, but I never get numb. That’s 1 in 5 members, despite growing attention to excessive prescribing of opioids.

Second, a 493% increase in diagnosis of opioid use disorders over 7 years. My reaction is that this has to reflect changes in coding or diagnostic practices rather than the population. It’s implausible that there was an increase this large in the number of people with an opioid use disorder.

The document then devotes a great deal of attention to opioid prescribing.

Toward the end, there are a couple of graphics that caught my attention.

First, a map showing rates of opioid use disorders.

Then, this:

Though critical to treating opioid use disorder, the use of medication-assisted treatments (e.g., methadone) does not always track with rates of opioid use disorder (compare Exhibits 10 and 11). For example, New England leads the nation in use of medication-assisted treatments but it has lower levels of opioid use disorder than other parts of the country

So . . . they note that New England has average rates of opioid use disorders, yet they have high rates of utilization of medication-assisted treatment.

This caught my attention because New England has higher rates of overdose, as depicted in the CDC graphics below.

Number and age-adjusted rates of drug overdose deaths by state, US 2015

Statistically significant drug overdose death rate increase from 2014 to 2015, US states

(It’s worth noting that BCBS is not among the top 3 insurers in Maine or New Hampshire, but they are the biggest in Massachusetts and Vermont.)

It begs questions about what the story is, doesn’t it?

I don’t presume to know the answers.

  • What was the sequence of events for the high OD rates and the utilization of MAT? And, what impact, if any, has the expansion of MAT had on overdose rates?
  • Is the BCBS data representative? (This brand new SAMHSA report suggest that the data about use is representative.)
  • We know that opioid maintenance meds reduce risk of OD, but we also know that people stop taking these meds at high rates. Does this imply that, in the real world, these meds end up providing less OD protection than hoped?
  • What are the policies and practices of the other insurers in the state?  (For example, we know that Anthem [the largest insurer in Maine and Vermont] recently ended prior authorization requirements for MAT. It’s not clear how restrictive they had been. They also are attempting to institute reforms to address the fact that, “only about 16 to 19 percent of the members taking the medications for opioid use disorder also were getting the recommended in-person counseling.”)
  • Are there regional differences in drug potency that explain this?

Let’s hope that more insurers follow suit and share their data.

1 Comment

Filed under Uncategorized

Getting the cannabis tax right

National Affairs recently published an article on the complexity and importance or taxing marijuana correctly:

While marijuana has tens of millions of happy occasional users, they account for a trivial share of industry sales. Consumption is concentrated among the smaller number of high-frequency users; half of marijuana is consumed by people with a medically diagnosable substance-use disorder, and these individuals are disproportionately poor and less educated. Policy — including tax policy — should be designed to protect these problem users from exploitation by industry and from their own bad choices, rather than cater to the convenience of occasional users.

Lower prices for marijuana have been shown to increase use, particularly for younger and heavier marijuana users. Hence, a major goal should be to keep after-tax prices from falling too sharply (ideally by no more than 50%). Dictating that outcome only via minimum-pricing rules, however, would let industry pocket excess profits. Propping up prices with excise taxes — a favored strategy for tobacco — would achieve the public-health goal of discouraging excessive marijuana use, while relieving the public of having to finance government via other less-popular and more-counterproductive taxes.

Alas, taxing marijuana is not simple. Federal legalization — specifically, allowing for-profit corporations to sell marijuana — would unleash a dynamic market that would evolve precipitously and unpredictably, with the potential for aggressive anti-tax lobbying, price collapses, rapidly changing marijuana-derived products, and black- and gray-market tax evasion. All this would create complicated secondary goals: Taxes would need to be nearly uniform across states; they would need to cover a wide variety of products; and they would need to increase dramatically over time.

Here’s just one example of the complexity discussed:

A first impulse might be to say, “If you want prices to be $6 per gram when the cost is $1 per gram, just make the tax $5 per gram.” Alas, it’s not that simple. Weight-based taxes create incentives to sell high-potency forms of marijuana. Potency is already up: Flowers sold in Washington state’s legal market now average over 20% THC, whereas the average potency of cannabis (at least the cannabis discovered and confiscated by law enforcement) did not rise above 5% until 2001.

Take the time to read the entire article here.

Comments Off on Getting the cannabis tax right

Filed under Uncategorized

Opioid users complete residential at higher rates than other patients

Residential treatment has received a lot of criticism and skepticism over the last several years, especially for opioid use disorders. (Some of it is deserved. Too many providers are hustlers and others provide little more than detox with inadequate follow-up. Of course, many of the same criticisms have been directed at medication-assisted treatment. But, that’s not what this post is about.)

At any rate, the Recovery Research Institute recently posted about a study looking at completion rates for outpatient and residential treatment.

The study looked at A LOT of treatment admissions, 318,924.

Residential completion rates appear to have surprised a lot of people:

Results: Residential programs reported a 65% completion rate compared to 52% for outpatient settings. After controlling for other confounding factors, clients in residential treatment were nearly three times as likely as clients in outpatient treatment to complete treatment.

But, what really surprised some readers was this:

Opioid users were much more likely to benefit from residential treatment compared to alcohol users. . . .

We speculate that for opioid abusers, the increased structure and cloistering of residential treatment provide some protection from the environmental and social triggers for relapse or that otherwise lead to the termination of treatment that outpatient treatment settings do not afford. Indeed, environmental risk characteristics in drug abusers’ residential neighborhoods, such as the presence of liquor stores and indicators of concentrated disadvantage at the neighborhood level, have been found to be associated with treatment non-continuity and relapse. Such environmental triggers may play a particularly substantial role for those addicted to opioids compared to those seeking treatment for marijuana abuse. Since opioid users have the lowest raw completion rates in general, this finding that residential treatment makes a greater positive difference for opioid users than it does for any of the other substances represents an important result that merits further investigation. Given the current epidemic of opioid-related overdoses in the U.S., our results suggest that greater use of residential treatment should be explored for opioid users in particular.

For the differences between residential and outpatient, they say the following:

In general, residential treatment completion rates are usually higher compared to outpatient settings, but what is particularly noteworthy is that even after controlling for various client characteristics and state level variations, the likelihood of treatment completion for residential programs was still nearly three times as great as for outpatient settings. Given the more highly structured nature and intensity of services of residential programs compared to outpatient treatment, it is understandable that residential treatment completion rates would be higher. It requires far less effort to end treatment prematurely in outpatient settings com-pared to residential treatment. Given the strong association between treatment completion and positive post-treatment outcomes such as long term abstinence, the large magnitude of difference between outpatient and residential treatment represents a potentially important consideration for the choice of treatment setting for clients.

This is no surprise to us and it’s consistent with our experience over the life of our program.

Comments Off on Opioid users complete residential at higher rates than other patients

Filed under Uncategorized

Buprenorphine: Being out of treatment increases risk of death nearly 30-fold

Choose you evidence carefully by rocket ship

The title of this post is taken directly from a press release for a recently published study. Here’s the summary:

Buprenorphine reduces mortality for those with opioid use disorder, but periods off treatment are associated with much higher mortality rates. A study of 713 new outpatient users of buprenorphine was conducted in France, where patients with opioid use disorder are usually treated by general practitioners in private practice with periods in and out of treatment. The mortality rate for study subjects was 0.63/100 person-year [95 percent CI 0.40- 0.85], compared to 0.24/100 person-year [0.24-0.25] for other individuals of the same age range during the same time period. The authors encourage physicians to avoid interruption of treatment and encourage patients to remain in treatment for a sufficient amount of time.

There’s no debate that buprenorphine provides protection against overdose when patients are taking it.

However, that’s a very important qualifier and it often gets lost when talking about the evidence for treatment options.

The problem is that studies have not been very successful at getting people to take it on an ongoing basis.

In a study published earlier this year, they looked at records of 38,000 american buprenorphine patients. What did they find?

For their study, Alexander and his colleagues examined pharmacy claims for more than 38,000 new buprenorphine users who filled prescriptions between 2006 and 2013 in 11 states. They looked at non-buprenorphine opioid prescriptions before, during, and after each patient’s first course of buprenorphine treatment, which typically lasted between one to six months. Even though there are no universally agreed-upon guidelines regarding the optimal length of treatment, most people discontinued buprenorphine within three months.

They found that 43 percent of patients who received buprenorphine filled an opioid prescription during treatment and 67 percent filled an opioid prescription during the 12 months following buprenorphine treatment. Most patients continued to receive similar amounts of opioids before and after buprenorphine treatment.

They described buprenorphine’s impact and retention like this:

Buprenorphine therapy was associated with modest declines in most measures of opioid use following the first treatment episode; however, only 33% of patients continued to fill prescriptions for buprenorphine after 3 months.

So . . . protection from overdose is one of the most important benefits of buprenorphine treatment, BUT by day ninety, 67% of buprenorphine patients are no longer taking the drug and therefore not protected from overdose.

PS – This is not meant to imply that buprenorphine is bad, or shouldn’t be an option. One of the limitations of abstinence-based treatments is that they also struggle with retention and the risk of overdose when relapse occurs.

PSS – (For a more comprehensive review of a frequently cited meta-analysis of medication-assisted treatment, check this out.)

1 Comment

Filed under Uncategorized

Drug-free recovery as fantasy?

unicornThere is MUCH less tension these days between harm reduction (HR) advocates and treatment providers.

HR advocates confronted treatment providers with legitimate questions about their thresholds for accessing and staying in care. More recently, the opioid overdose crisis pretty dramatically changed the calculus. As a result, most treatment providers are using harm reduction approaches and have lowered thresholds to accessing and remaining in care.

However, if you want a good example of why some tension remains, check out this article entitled, “Vivitrol offers the fantasy of being drug-free. But that’s not the most important thing in tackling addiction“.

Whatever the sins of Alkermes and the flaws of some drug courts, the author’s repeated reference to abstinence as “fantasy” reveals a lot about his own bias. (At first, I assumed that an editor came up with a provocative, click-baity headline. However, the author used the word 3 more times in his piece.”)

Low expectations

Bill White wrote about Recovery and Harm Reduction in Philadelphia. Here’s a quote he offered in a blog post introducing the paper:

Traditional harm reduction programs have pioneered low threshold services, but they have often also been characterized by low expectations.  Our vision is to expand low threshold services that at the same time elevate peoples’ sense of what is possible for them.  We do this by exposing them to living proof that recovery is possible even under the most difficult of circumstances, confirming that there are people who will walk this path with them, and offering stage-appropriate services to support people in their journeys from addiction to recovery.  –Arthur C. Evans, Jr., PhD, Commissioner, Philadelphia Department of Behavioral Health and Intellectual disAbility Services, 2013

Recovery-oriented Harm Reduction

This reminds me of posts I’ve written about “recovery-oriented harm reduction” over the years.

From one of those posts:

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

This is the key. We’ve struggled mightily with maintaining a professional culture that is focused on recovery. It often conflicts with human nature and the instincts of professional helpers, so we have to accept that it will be a constant struggle. On the subject, we contributed to this paper.

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

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

I’ve also admired Scott Kellogg’s writing on gradualism. Here’s a quote from a story about him a few years back:

A Gestalt-trained therapist, Kellogg holds some views that seem to place him closer to the harm reductionist’s way of looking at substance use and recovery. He questions treatment center practices that appear to profess abstinence at the risk of losing many clients before they can start making progress. He states his belief that “there’s a crisis in our treatment world because many people don’t like treatment.”

Yet he also says his perspective goes against the tenets held by many harm reductionists. He is most impatient with the attitude in some needle exchange programs and similar initiatives that “we would never tell people what to do.” Offering a shower, a sandwich and a clean needle and then repeating the process time and again are fine in the short term, but at some point you need to help build a life after you’ve saved one, he suggests.

Unicorns?

Some local people in recovery from opioid addiction were growing frustrated with media representations of opioid addiction that suggest full abstinence-based recovery is not a realistic goal.

They decided to start The Unicorn Project and  I’ve helped them with a website.

Media reports and comments from “experts” give the impression that opioid addiction (heroin, vicodin, etc.) is a near hopeless condition and that the only hope is maintenance on other opioids (buprenorphine and methadone).

Some of these reports acknowledge that there are people who achieve drug-free recovery, but imply that they are extremely rare. It almost sounds like everyone’s heard of them, but no one’s seen one—like unicorns.

We know this isn’t true.

. . .

We want people to know that opioid addicts can achieve full recovery without opioid maintenance drugs. And, it’s not rare or unusual when people get the right kind of help.

We’re not here to argue that medications like buprenorphine and methadone are bad, or that our path to recovery or one form of treatment is better than another.

We just want people to know that drug-free recovery is a legitimate path to recovery, that many people already succeed with this path, and that more people could also succeed on this path—if they are offered the right kind of help.

1 Comment

Filed under Uncategorized

Zombie statistic contributed to opioid crisis

Back in February, I shared an article from JAMA, reviewing the role of Joint Commission’s pain standards in the current opioid epidemic and some of the lessons learned.

The fourth lesson was this:

Fourth, carefully review the primary literature on issues of critical importance and do not simply repeat the claims of experts in previous articles. The 1980 letter to the editor by Porter and Jick suggesting that addiction is rare in patients treated with narcotics has been cited almost 1000 times. Yet the report is so brief, methodologically vague, and unlikely to be generalizable to recent medical practice that its finding should never have been disseminated without cautionary notes and calls for research.

Now, the New England Journal of Medicine, the journal that published the 1980 letter, has published a review of its impact.

The prescribing of strong opioids such as oxycodone has increased dramatically in the United States and Canada over the past two decades.1 From 1999 through 2015, more than 183,000 deaths from prescription opioids were reported in the United States,2 and millions of Americans are now addicted to opioids. The crisis arose in part because physicians were told that the risk of addiction was low when opioids were prescribed for chronic pain. A one-paragraph letter that was published in the Journal in 19803 was widely invoked in support of this claim, even though no evidence was provided by the correspondents (see Section 1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org).

The authors reviewed the number of citations for this letter

We identified 608 citations of the index publication and noted a sizable increase after the introduction of OxyContin (a long-acting formulation of oxycodone) in 1995 (Figure 1)

Not only was it cited hundreds and hundreds of times, it was also misrepresented more than 80% of the time.

So . . . what was the impact of this letter?

In conclusion, we found that a five-sentence letter published in the Journal in 1980 was heavily and uncritically cited as evidence that addiction was rare with long-term opioid therapy. We believe that this citation pattern contributed to the North American opioid crisis by helping to shape a narrative that allayed prescribers’ concerns about the risk of addiction associated with long-term opioid therapy.

Their advice?

Our findings highlight the potential consequences of inaccurate citation and underscore the need for diligence when citing previously published studies.

This is why, in this blog, I’m always looking for sources and I try to share information from the actual study rather than press releases or abstracts. It’s always astonishing how often the actual study does not resemble the impression you’d get from other papers, press releases, and abstracts.

Be selective with your trust and verify. There are a lot of “zombie statistics” out there.

3 Comments

Filed under Uncategorized