Addiction, recovery and problem ownership

208071_f260I had a brief but good conversation with a colleague today that reminded me of what’s at stake in the way we define addiction.

How we define addiction determines which helpers and which systems own the problem. Addiction is most frequently being rolled into mental health, but also into criminal justice, public health, traditional medicine, etc.

Of course, good stewardship is important and the categorically segregated addiction treatment system has failed on many counts.

Here are a few thoughts from Bill White on the topic from Slaying the Dragon and some Counselor articles:

On problem ownership:

Whether we define alcoholism as a sin, a crime, a disease, a social problem, or a product of economic deprivation determines whether this society assigns that problem to the care of the priest, police officer, doctor, addiction counselor, social worker, urban planner, or community activist. The model chosen will determine the fate of untold numbers of alcoholics and addicts and untold numbers of social institutions and professional careers.

The existence of a “treatment industry” and its “ownership” of the problem of addiction should not be taken for granted. Sweeping shifts in values and changes in the alignment of major social institutions might pass ownership of this problem to another group.

On the segregation-integration pendulum:

American history is replete with failed efforts to integrate the care of alcoholics and addicts into other helping systems. These failed experiments are followed by efforts to move such care into a categorically segregated system that, once achieved, is followed with renewed proposals for service integration. After fighting 40 years to be born as an autonomous field of service, addiction treatment is once again in the throes of service-integration mania. This cynical evolution in the organization of addiction treatment services seems to be part of two broader pendulum swings in the broader culture, between specialization and generalization and between centralization and decentralization. Once we have destroyed most of the categorically segregated addiction treatment institutions in America, a grassroots movement will likely arise again to recreate them.

On the historical essence of addiction counseling:

If AOD problems could be solved by physically unraveling the person-drug relationship, only physicians and nurses trained in the mechanics of detoxification would be needed to address these problems. If AOD problems were simply a symptom of untreated psychiatric illness, more psychiatrists, not addiction counselors would be needed. If these problems were only a reflection of grief, trauma, family disturbance, economic distress, or cultural oppression, we would need psychologists, social workers, vocational counselors, and social activists rather than addiction counselors. Historically, other professions conveyed to the addict that other problems were the source of addiction and their resolution was the pathway to recovery. Addiction counseling was built on the failure of this premise. The addiction counselor offered a distinctly different view: “All that you have been and will be flows from the problem of addiction and how you respond or fail to respond to it.”

Addiction counseling as a profession rests on the proposition that AOD problems reach a point of self-contained independence from their initiating roots and that direct knowledge of addiction, its specialized treatment, and the processes of long-term recovery provide the most viable instrument for healing and wholeness. If these core understandings are ever lost, the essence of addiction counseling will have died even if the title and its institutional trappings survive. We must be cautious in our emulation of other helping professions. We must not forget that the failure of these professions to adequately understand and treat addiction constituted the germinating soil of addiction counseling as a specialized profession.

On the soul of the field and its future:

In the face of such threats (managed care, facility closures, merger mania & integration into behavioral health systems), the field is experiencing a strange phenomenon. As the core of the addiction treatment field shrinks, the field is growing at the periphery. Where the total amount allocated to residential and inpatient treatment services is shrinking, the numbers of outpatient services is actually increasing, as is a growing number of new specialty programs that extend addiction treatment services into allied fields. The growth zone of the addiction treatment industry is not at the traditional core but in the delivery of addiction treatment services into the criminal justice system, the public health system (particularly AIDS related projects), the child welfare system, the mental health system, and the public-welfare system. If one looks at these trends as a whole, what is emerging in the 1990s is a treatment system less focused on the goal of long-term personal recovery than on social control of the addict. The goal of this evolving system is moving from a focus on the personal outcome of treatment to an assurance that the alcoholic and addict will not bother us and will cost us as little as possible.

The fate of the field will be determined by its ability to redefine its niche in an increasingly turbulent health-care and social-service ecosystem. That fate will also be dictated by more fundamental issues – the ability of the field to: 1) reconnect with the passion for service out of which it was born; 2) re-center itself clinically and ethically; 3) forge new service technologies in response to new knowledge and the changing characteristics of clients, families, and communities; and 4) the ability of the field to address the problem of leadership development and succession.

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Schools giving Scientology a platform with students

01This is not new, but it’s good that it’s getting attention again.

A Church of Scientology-backed anti-drug program is spreading its message to students in dozens of city public schools, DNAinfo New York has learned.

The Foundation for a Drug Free World, which was founded in 2006 by the controversial church, visited 30 city public schools last year, providing free anti-drug programs to elementary, middle and high school students in all five boroughs, according to its Facebook page.

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The collegiate recovery movement is alive and well

ryanhowellIn an open letter to NIDA, a group that enjoys great success with an abstinence based approach is concerned that their recovery path is being discounted and ignored in the attempt to build an evidence-base. (emphasis mine)

The collegiate recovery movement is alive and well across the nation. We are on the cusp of a movement experiencing exponential growth in the last five years. Adding to the fifty established programs in existence, at least fifty more are emerging in various stages of development. We invite you to review the research evidence supporting the efficacy of these programs. Data suggests that CRPs effectively promote recovery, prevent relapse, and improve educational outcomes for the individuals participating in these programs (Cleveland, Harris, Baker, Herbert, & Dean, 2007). Researchers have indicated that peer-to-peer recovery support, together with the infrastructure of a university program, is an essential component to the continuum of care. Institutions are finding that providing supports is necessary for our student populations to achieve success in an otherwise abstinence hostile environment.

Since many of our communities require abstinence as a criterion for membership or participation, we maintain that the science of abstinence-based approaches to recovery is meaningful and should not be discounted within National Institute on Drug Abuse (NIDA) priorities.

photo credit: Jeff Tabaco

photo credit: Jeff Tabaco

All of this begs the question of how far we might go with a 2 class system with doctors, lawyers, pilots, nurses and college students get an approach organized around the expectation that they can achieve and maintain abstinent recovery, while everyone else gets an approach that assumes they are not capable of this.

All these groups bring high levels of personal recovery capital. Possibly more importantly, I’d point to 3 things:

  • they bring relatively well-defined identities that provide considerable purpose and meaning;
  • these identities (and their purpose and meaning) and may be threatened by their addiction; and
  • there are tribes within the recovering community based on these identities.

Why not work on ways to identify, construct and enhance these kinds of factors for everyone else.

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Drugs as genocide

capitlasm-plus-dope-pamphletPoints has an interesting post on Michael Tabor, a former Black Panther who warned that capitalism and drugs would result in tragic consequences for blacks.

What’s especially interesting is the way he defies categorization. He talked like a drug warrior, but warned against criminalization of blacks and called for community organization as essential for prevention and treatment.

Before Tabor fled, however, he published a pamphlet entitled: “Capitalism Plus Dope Equals Genocide.” The scathing, often prophetic critique of rising drug use in urban ghettos is a must-read for anyone seeking to understand the complicated relationship between nonwhite urbanites, drugs, and policing. In sum, Tabor likens the heroin problem to other examples of the black community’s political oppression. To fight this reality, Tabor called for community development, self-determination, and self-help. Most importantly, Tabor demanded local control over policing. With respect to local control, Tabor lamented a sad reality: “It is a tragedy that in New York the greatest gains made in the realm of Black community control have been made by Black racketeers, numbers-game bankers and dope dealers, by the Black illegal capitalists.”

Tabor’s warning begins with anecdotes about young black boys and young black girls in the “colony” of Harlem “murdered” by heroin overdoses. Tabor calls heroin and drug abuse a “plague” upon his people, and likens the addicted to “slaves of the plague.” Certainly Tabor is not unique in his use of hyperbolic cliché’s involving slavery and disease. As he refers to sellers as “murdering scum of the planet,” Tabor sounds like a congressional official in the midst of a drug panic. Despite his hyperbole, Tabor also wrote with insight and vision in ways few can. Tabor’s commentary on deterrence, rehabilitation, poverty, capitalism, and the politics of respectability suggest that he understood much about the Drug War to follow that few would grasp.

He’d still be pretty lonely arguing that drugs and criminalization result in genocide for his community.

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The medical establishment’s “best hope for addicts”

Lowering_The_Bar_Cover_2010.09.22I’m sure this piece is going to get a lot of attention. “A treatment that actually works” is the subtitle for the article.

I’m not going to write a lengthy response, but I have written a lot on the subject.

First, how effective is it for someone like the subject of the article? Well, two recent studies are not very promising.

Second, what does “actually works” mean? Works to do what?

The reader needs to stop and ask, “What do I want for the addict?” (Our interest might be for a loved one, out of altrusim or as a tax paying community member.) Am I looking for a reduction is drug use, criminal activity and disease transmission? Or, do I want more for them?  Is my goal for them a full recovery and a return to full participation in family, community, academic and professional life?

When they say, “it works”, we need to ask if it works to facilitate this kind of full recovery.

Finally, let’s take a look at this statement: “The medical establishment had come to view Suboxone as the best hope for addicts like Patrick.”

addicts like Patrick.

What about addicts like members of the medical establishment? They do not view Suboxone as “the best hope” for their addicted colleagues. They have a better approach and enjoy outstanding outcomes. They get long term, high quality, abstinence focused treatment, long term recovery monitoring and support, and rapid re-intervention in the event of a relapse.

Why is that kind of treatment not considered the “best hope” for addicts like Patrick?

UPDATE:

The “they’d still be alive” theme merits a response. Here’s a post I wrote on the argument that Philip Seymour Hoffman would be alive if he was prescribed Suboxone. (Preview: 1) He had Suboxone in his apartment. 2) Even if Suboxone helps prevent ODs, you have to take it to be protected. And, as pointed out above, huge numbers of patients stop taking it.)

 

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More on Ernest Kurtz

interviewing-ernie-kurtzBill White shares a personal tribute to Ernie:

Ernie knew stuff, and he knew people. What he did for me and so many others, including legions of M.A. and Ph.D. students, was connect us to information and sources that escaped the usual search methods. He was a walking encyclopedia of the subjects he held most dear and freely shared those resources. So many people’s research had crossed Ernie’s path that he served as a crossroads continually connecting people with shared interests. Ernie loved connecting people and he played a key role in forging a community of A.A. historians in collaborations with Brown University, A.A. Archivists, A.A. History Lovers, and other such groups.

Read the whole thing here.

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Let it begin with me

photo_20150123_WM0028911_0_ek1991_20150123Points blog has a nice, personal post about Ernie Kurtz and some of the lesser known parts of his legacy.

“Let it begin with me” is not an AA but an Al-Anon slogan, but it’s a fitting way to close.  Scholarly history of AA began with Ernie Kurtz.  His willingness to engage and share, to encourage thought and research among academic disciplines, between the academy and the public, and, yes, across the sectarian rifts within AA itself– this willingness provided a model for the many collaborative projects through which AA history is now being done: the national AA archives workshops, the Sedona-Mago history symposia, the revitalization of Dr. Bob’s House and Stepping Stones, the publication projects of the Hindsfoot Foundation, and the work of Points.  When anyone, anywhere, reached out for help with AA history, the hand of Ernie Kurtz was there– inspiring, prompting, gently correcting, encouraging us all (a couple of generations now) to take part in the mystery of collaborative exploration of our history.  For that I am grateful, and I know I’m not alone.

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