The opioid crisis as a disease of despair?

The narrative that the opioid and overdose crisis is a product of despair has become very popular. The logic is that people in bad economic conditions are more likely to turn to opioids to cope with their circumstances, and that their hopeless environmental conditions make them more likely to die of an overdose. This model frames addiction and overdose as diseases of despair.

This model fits nicely with other writers who have garnered a lot of attention on the internet.

  • Johann Hari presents addiction as a product of a lack of connection to others.
  • Carl Hart frames sociological factors as causative and argues that there’s a rationality to escaping terrible circumstances via drug use and that a form of learned helplessness eventually takes root.
  • Bruce Alexander is frequently cited to support these theories. He did the “rat park” study that found rats deprived of stimulation and social interaction compulsively used drugs, while rats in enriched environments did not.

These understandings are so intuitive, but what if they are wrong?

These narratives make so much sense, and they support other beliefs and agendas many of us hold. Further, it feels like no one is going to harmed by efforts to improve economic, social, and environmental conditions, right?

Well, that’s not quite true. Bill White pointed out that how we define the problem determines who “owns” the problem, and that problem ownership has profound implications for addicts and their loved ones.

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.

With so many bad actors in treatment right now, there is not a great rush to protect the treatment industry.

To be sure, we’d be better off of a significant portion of the industry disappeared. However, the disappearance of specialty addiction treatment would be tragic for addicts and alcoholics in need of help.

Further, it just so happens that there’s good reason to doubt the “diseases of despair” narrative.

New study casts doubt on “diseases of despair” narrative

A new study looked at county level data and examined the relationship between several economic hardship indicators and deaths by overdose, alcohol-related causes, and suicide.

Mother Jones describes the findings this way:

Economic conditions explained only 8 percent of the change in overdose deaths from all drugs and 7 percent of the change in deaths from opioid painkillers—and even that small effect probably goes away if you control for additional unobservable factors. It explained none of the change in deaths from heroin, fentanyl, and other illegal opioids.

They quote the researcher as observing:

Such results probably should not be surprising since drug fatalities increased substantially – including a rapid acceleration of illicit opioid deaths – after the end of the Great Recession (i.e. subsequent to 2009), when economic performance considerably improved.

If it’s not economic hardship, what is it?

Vox describes the study’s conclusions this way [emphasis mine]:

. . . the bigger driver of overdose deaths was “the broader drug environment” — meaning the expanded supply of opioid painkillers, heroin, and illicit fentanyl over the past decade and a half, which has made these drugs much more available and, therefore, easier to misuse and overdose on.

Leonid Bershidsky from Bloomberg noted the following:

The absence of an opioid epidemic in Europe indirectly confirms Ruhm’s finding. European nations have experienced the same globalization-related transition as the U.S. In some of them — Greece, Portugal, Ireland, Spain, even France — economic problems were more severe in recent years than in the U.S. Yet no explosion of overdose deaths has occurred.

. . .

There’s also a notable difference in what substances are causing overdose deaths. In the U.S., heroin accounted for 24 percent of last year’s overdose deaths. In Europe in 2018, its share of the death toll was 81 percent. That should say something about how supply affects the outcomes.

Piling on

Then, as if to drive the point home, BMJ posted a study examining the relationship between opioid exposure and misuse. They looked at post-surgical pain treatment,

Each refill and week of opioid prescription is associated with a large increase in opioid misuse among opioid naive patients. The data from this study suggest that duration of the prescription rather than dosage is more strongly associated with ultimate misuse in the early postsurgical period. The analysis quantifies the association of prescribing choices on opioid misuse and identifies levers for possible impact.

The study “excluded patients with presurgical evidence of opioid or other non-specific forms of misuse in the six months before surgery.” (I would have liked more stringent exclusionary criteria, but it’s still instructive.)

Where does this leave us?

I’ll repeat (a modified version of) what I wrote in a post in response to Johann Hari’s TED talk that emphasized lack of purpose and connection as the cause of addiction and add economic factors to the mix.

  • Do economic/social/environmental factors cause addiction? No.
  • Are they important? Yes.
  • Could they influence the onset and course of addiction? Yes.
  • Is addressing those factors important in facilitating recovery for many addicts? Yes.
  • Do economic/social/environmental factors cause addiction? No.

Ok, but what about policy?

This leaves us with some uncomfortable (but obvious, to anyone paying attention to this crisis) findings to consider.

Much of the policy discussion over the last several years has been dismissive of supply as a factor in addiction. This poses very serious concerns about that stance.

I’ve never been dismissive of supply as an important consideration, but I am coming to believe that I’ve underestimated its importance.

A lot of that dismissiveness is in response to the drug war and the moral horror of mass incarceration.

The problem demands more of us than we are typically capable of. We need to figure out how to address illicit and licit supply without resorting to mass incarceration AND assure treatment of adequate quality, duration, and intensity.


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Love and Addiction Counseling (Bill White and Jason Schwartz)

[Cross-posted at]

Addiction counseling has become an increasingly professional and pristine affair, and service relationships reflect a more detached process than in years gone by. And yet one worries about the loss of something precious in our current fixation on the technical mastery of evidence-based counseling practices. We would suggest that this endangered precious quality is captured in a word rarely if ever written in the professional counseling journals or spoken in addiction counselor training programs. The word is LOVE.

Today, love in the context of addiction counseling is more likely to be thought of in terms of ethical violations than a quality of the most effective addiction counselors. But having trained and supervised addiction counselors for decades, we contend that the most effective of such counselors bring a deep, non-possessive love of those they serve. The importance of love as a foundation of addiction counseling is understandable only when one considers the historical disrespect, contempt, and even hatred those with the most severe, complex, and prolonged addictions have so often experienced in their encounters with helping professionals.

Few health conditions are so deforming of character that one’s humanity gets lost in what is sometimes a most unlovable veneer. No one can be expected to love traits so endemic to addiction. What distinguishes the best addiction counselors and recovery coaches is their recognition of such traits as an expression of the disorder and not the essence of the person. The guiding mantra of the best counselors is a very simple one: hate the disease, love the person.  In our preoccupations with the technologies of effective addiction counseling, we must not lose a much more foundational requirement: the ability to not just accept and respect those with whom we work, but to love the person beneath this unlovable veneer.

Below are a few quotable observations that set the value of such love in perspective.

What is this attitude that I call the key to successful [alcoholism] treatment? First, it is accepting of the other person just as he is, for exactly what he is. Second, it accords him the dignity of his humanity quite apart from his illness which may have buried that humanity deep out of sight. He is regarded as a person, in great trouble to be sure, but not a non-person for all that. Third, it offers him understanding and, as a result of that, compassion, or as many recovered alcoholics flatly put it, love. Finally, and perhaps most important of all, it exhibits faith, a belief that he too, this alcoholic whoever he may be, can and will recover.….[Too many professionals are] condemning, and therefore often hostile. They are quick to blame the alcoholic for his condition and to see the horrors of the condition as the man. They unwittingly treat him as less than human because he is not as they are. They are contemptuous of his weakness, his failure to stand up to life. They are sometimes punitive, believing that what he really needs is to be taught a lesson. They do not understand him and so they do not really like him. And he knows it….The first requirement for successful counseling of the alcoholic is the correct attitude….If you don’t have this, then it doesn’t matter how many techniques you use, they aren’t going to work. –Marty Mann, 1973, Attitude: Key to successful treatment. In: Staub, G. and Kent, L., Eds. The Para-Professional in the Treatment of Alcoholism. Springfield: Illinois: Charles C. Thomas Publisher

I can remember in my own time some of the early NAAC and NAADAC awards going to people who were obviously not educated. You could tell from their choice of language when they stepped forward to receive the awards. But what they had was so much more important than that. They had love. They had a passion for helping within them that was so powerful that they were selected by their peers—many of whom had all kinds of degrees—to receive outstanding awards. They represented the soul of alcoholism counseling as it originally existed. They had the power to help somebody understand that he or she is a loveable human being and a child of God. This is a quality that is hard to transmit in a classroom. –Mel Schulstad, 2011 interview

What the addiction counselor knows that other service professionals do not is the very soul of the addicted—their terrifying fear of insanity, the shame of their wretchedness, their guilt over drug-induced sins of omission and commission, their desperate struggle to sustain their personhood, their need to avoid the psychological and social taint of addiction, and their hypervigilant search for the slightest trace of condescension, contempt or hostility in the posture, eyes or voice of the professed helper.—William White, The Essence of Addiction Counseling, 2004

Four things have allowed addiction treatment practitioners to shun the cultural contempt with which the addicted 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 people with severe AOD problems 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 the recovery process. We must make sure that these qualities and conditions are not lost in the rush to integrate addiction treatment and other service systems. –William White, 2003, A History of Contempt

So let’s review. The experience of addicted people with professional helpers is often characterized by:

  • condemnation and hostility,
  • blame for their condition and circumstances,
  • conflating the illness and the person,
  • objectifying the person due to their illness;
  • contempt for the person’s perceived “weakness” and failure at life, and
  • a desire to punish and “teach a lesson.”

In short, traditional professionals don’t understand this person masked by addiction, they don’t like this person, and he/she knows it.

But such attitudes are not restricted to allied professions. They can be found within the addictions treatment and recovery support fields among those filling diverse roles–regardless of their personal recovery status. All of us are imperfect human beings. All of us have had thoughts and feelings within the helping process that we are not proud of. Encountering such thoughts and feelings is not a matter of if, it’s a matter of when. The key is to quickly notice when these attitudes creep in during periods of increased vulnerability or when we encounter a particular client or type of client that elicits such sentiments. And most importantly, it’s a matter of what we choose to do about it. Such experiences are ideally gut-check times and a call for supervisory guidance. It is in this process of self-inventory and professional guidance that we can rise above our own defensive reactions and authentically connect with and care for those we are pledged to serve.

The open wounds of the men and women seeking sanctuary within addiction treatment and recovery support settings offer the potential for life-transforming encounters.  What the wounded need in such moments are not just our technologies, but our humanity–not just counseling technique, but the kind of empathy and compassion that transcend the roles of the helper and the helped. We call that love.


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NY state takes on hustlers

New York state is warning people seeking treatment to beware of treatment fraud. More here.

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Another treatment hustle?

A new story suggests that Dr. Phil may be in on the hustle:

A STAT/Boston Globe investigation shows how some carefully placed promotions are also a financial opportunity for a new business venture involving the show’s host, Phillip McGraw, and his son, Jay.

An addiction recovery program the McGraws launched this year comes with an enticing offer: Buy their self-help video product and you could land a valuable spot on the top-rated “Dr. Phil” show.

. . .

The McGraws’ addiction recovery program is a series of virtual reality scenarios starring Dr. Phil. Called “Dr. Phil’s Path to Recovery,” it has been offered to treatment centers at monthly rates ranging from $3,500 to $7,000.

In addition to appearing on “Dr. Phil,” centers that buy the product have been featured on “The Doctors,” a program owned by the production company founded by McGraw and his son.

The appearances by operators buying into the new product is not an accident, said Jim Shriner, the vice president of sales for Path to Recovery, according to one potential customer who spoke with him and shared details of the conversation. Shriner didn’t comment when contacted by a reporter.

Participating treatment centers, Shriner said to the customer, are used by “Dr. Phil” and “The Doctors” as a “go-to resource” for drug and alcohol rehab. That means that when either show does an episode on addiction, participating operators could get a call asking them to fly out to Los Angeles and sponsor a guest’s treatment — unbeatable advertising.

“Our job is to get your phones to ring, and the admissions hopefully follow,” Shriner told the customer. He also boasted that viewers of “Dr. Phil” and “The Doctors” are an attractive demographic: older, high-income people who make treatment decisions for family members and “not the addict calling because I told my mom I’d do it.”

Read the whole story.

The show denies these claims. The writers counter with some numbers of programs mentioned on the show.

In addition, the writers describe the disturbing background of one of the programs mentioned on the show.

Another story makes more disturbing allegations.

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Another treatment hustle

What if some big restaurant group (that owns a bunch of chains) surreptitiously bought Yelp and used Yelp to steer diners to their restaurant? That would be a shady hustle, right?

Well, it happens all the time in the world of addiction treatment:

As the opioid epidemic continues to spiral, more and more people have reason to seek information about addiction and its consequences. But finding unbiased information is extremely difficult — maybe more so than people realize.

According to an investigation by The Verge, several popular publications covering addiction and treatment double as marketing operations for treatment centers. Rehab Reviews and The Fix are controlled by Cliffside Malibu founder Richard Taite, while Addiction Unscripted — a group promoted by Mark Zuckerberg this summer for its use of Facebook — is owned and staffed by the CEO and marketers of Windward Way, a treatment center in Costa Mesa, California.

All three sites have phone numbers that refer callers to the affiliated rehabs, as well as to partner facilities. On The Fix and Rehab Reviews, there’s a note that the phone number routes you to Service Industries, a “network of commonly owned rehabilitation service providers,” but it doesn’t say which rehabs are in the network, or that Taite owns both the publishers and the providers. Users browsing with an ad blocker will not see the note, just the helpline.

While the connections between the rehabs and the sites are relatively well-known within the industry — Addiction Unscripted even used the Rehab Reviews practice of generating leads for Cliffside Malibu as an example to emulate in an early business plan obtained by The Verge — people reading the sites had no way to know the connection (until disclaimers appeared after The Verge approached the sites for comment).

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An addiction treatment model that works

For more on rethinking “Treatment Works”, see

A while back, the Huffington Post had a nice piece on a treatment model that delivers outcomes everyone should have access to:

The day Dr. Arthur Green (not his real name) checked into his rustic cabin here at Bradford Health Services, he said he doubted he could beat his decadeslong struggle with alcohol and find joy again in treating patients. Three weeks later, he said, he was convinced otherwise.

For Dr. Mary Waters (not her real name), it took six weeks to see a way out of her depression, anxiety and addiction to prescription painkillers. But now she says she’s confident and excited to return to practice.

They are among hundreds of physicians from across the country who come to this quiet, pine-shaded retreat 25 miles north of Birmingham, where they can get mental health and addiction treatment without jeopardizing their medical licenses.

Bradford’s addiction treatment regimen isn’t unique — more than a dozen other addiction centers across the country offer similar programs — but when combined with other services offered by state organizations known as physician health programs, it is extraordinarily effective.

Studies have found that these confidential programs have about an 80 percent success rate, far higher than the typical success rate of 50 percent for the general population. Researchers believe its rewards-based strategy and extensive follow-up care could help many more of the roughly 20 million Americans who suffer from opioid and other drug and alcohol addictions.

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Continuity of Recovery Support Vs. Replication of Abandonment (Bill White and Jason Schwartz)

[Cross-posted at]

Continuity-of-Recovery-SupportMany people enter addiction treatment in the United States with abuse, abandonment, and loss as central thematic threads within their lives. Such experiences distort one’s self-perceptions (e.g., “I am not worthy of love and respect”), diminish one’s capacity to trust (e.g., “Everyone I love will either abuse or abandon me”) and impede one’s ability to initiate and sustain healthy relationships. The clinical antidote to such wounds has long been posited as a “corrective emotional experience” in which the person, through a helping relationship marked by safety and trust, is able to redefine themselves and their view of the world. In reality, the helping relationship can either achieve such redefinition or reconfirm this self-l

imiting view of self and the world. So what does all this mean for the provision of addiction treatment and recovery support services? Here are five beginning reflections on this question.

Effectively treating people with histories of abandonment and loss requires a time-involved process of testing and engagement. Arbitrarily brief treatment and abrupt relationship terminations (driven by considerations of cost over quality of clinical care) inadvertently confirm self-limiting views of self and the world by replicating the experience of abandonment and loss within the context of professional care at a time the embryo of trust is often just forming. Acute care models of addiction treatment can unwittingly replicate earlier trauma, with each episode of treatment decreasing one’s future capacity to enter into a transformative helping relationship. Continued replications of abandonment within these acute interventions often breed self-defeating styles of relating to those in professional and peer helping roles. In contrast, models of sustained recovery management offer some hope for continuity of support by affording time to work through this testing and relationship building process.

Effectively treating people with histories of abandonment and loss may require continuity of relationship support spanning multiple levels of care and episodes of care. This proposition challenges what have been standard practices in many addiction treatment programs, e.g., refusing to readmit people who resumed alcohol and other drug (AOD) use following one or more earlier treatments, assigning a new primary counselor each time a patient is readmitted, or discharging individuals for behaviors that test the helping relationship.

Also of concern is how people with histories of abandonment and loss can be effectively treated within a system whose workforce is constantly turning over. Such workforce transience is not conducive to quality of clinical care and makes continuity of support impossible for those with the most severe, complex, and chronic substance use disorders. If sustained relational engagement is an essential ingredient in successful addiction treatment, then we as a system of care are failing to meet that challenge. At present, of nearly 1.5 million people annually admitted to addiction treatment in the U.S., only 43% successfully complete treatment. (More than 380,000 leave against staff advice and more than 106,000 are administratively discharged—most for confirming their diagnosis via continued or resumed AOD use.)

Transitions in relationship support of people with histories of abandonment and loss risk rapid clinical deterioration, resumption of excessive drug use, and increased risk of death. Multiple studies (see here for review) confirm that the period of highest risk for post-treatment resumption of drug use is immediately following discharge from a level of care, with most addiction recurrence beginning in the days and weeks following loss of the clinical support relationship. Such abrupt transitions are inherent as an endpoint in the dominant brief models of acute care, but they are also common within these models. The person entering addiction treatment is too often rapidly transitioned from person to person without a single point of relational continuity. Screeners and intake workers give way to a primary counselor and a host of allied roles that can change mid-treatment and with every movement from one level of care to the next. Every passing of the service torch is, in actuality, one more replication of abandonment and loss. Current efforts to integrate recovery coaches within acute models of addiction treatment are, in part, an effort to assure some degree of continuity in what is otherwise experienced as a relay race—conveying the feeling that one is being processed on a fast-moving assembly line.

A just published study by Bogdanowicz and colleagues underscores the high stakes involved in such relationship transitions. Their study examined the risk of death for patients in medication-assisted treatment during their transfer from one program setting to another. Bagdanowicz and colleagues found that patients in medication-assisted treatment transferred to another treatment provider experience increased overdose mortality risks, particularly within the days immediately following the transfer. Earlier studies of all forms of treatment found increased rates of drug use and death following treatment dropout and immediately following planned discharge from treatment, but no earlier study has so definitely focused on the risks of transition within the process of continued treatment. All relationship transitions within the early stages of addiction recovery constitute zones of risk for recovery destabilization. Such transitions must be minimized and assertively managed via increased monitoring and support.

People with histories of abandonment and loss may find it easier entering into relationship with a community of shared experience than the more emotionally risky relationship with a single professional helper. But such communities require great care in their creation and maintenance, particularly when nested within formal service organizations that can drift towards cold hospitality. As Christine Pohl suggests: There is a kind of hospitality that keeps people needy strangers while fostering the illusion of relationships and connection. It both disempowers and domesticates guests while it reinforces the hosts’ power, control, and sense of generosity. It is profoundly destructive to the people it welcomes. In the field of psychiatry, this has come to be christened “sanctuary harm.” When we seemingly do all the right things with a spirit that emphasizes our virtue and the pathology and neediness of those we serve, we inflate ourselves as we deflate those who seek our help. In making them feel small and incapable, we feed hopelessness in the name of hope.

In contrast, The Book of Life describes how. . . the warmly polite person is always deeply aware that the stranger is (irrespective of their status or outward dignity) a highly needy, fragile, confused, appetitive and susceptible creature. And they know this about the stranger, because they never forget this about themselves.Such warmth and empathic identification are built upon our own prior experiences of pain, fear, anguish, hopelessness, confusion, vulnerability, and loss. The former is a noisy hospitality that focuses on the value of the host; the latter quietly focuses on the hidden assets masked by the immediate vulnerability and needs of the guest.

Riane Eisler, in The Chalice and the Blade, has characterized the former style of helping as a dominator relationship model and the latter a partnership relationship model. Achieving the latter requires that traditionally-trained professionals step out of their more detached comfort zone to embrace the value of mutuality and rethink professional boundaries of self-disclosure and personal vulnerability. It also requires a deep understanding of the role of community in recovery.

Effectively treating and supporting people with histories of abandonment and loss requires the creation of what Sandra Bloom has christened healing sanctuaries or what Don Coyhis has depicted as a healing forest.Ernie Kurtz and Katherine Ketcham have described such healing environments and the experience of finally “being-at-home.”

Some places are more conducive to this experience than others. But wherever and whenever we do attain the sense of “being-at-home,” we experience a falling away of tension, a degree of balance between the pushing and pulling forces of our lives. In such a place, we can cease fighting—most important, we can cease fighting with ourselves….Home, then, is the place that is like our pelt, our skin, our hide, in that it is that which covers us less in a concealing than in a protective way….It is the place where I can be naked, which is to say vulnerable—undefended against being wounded because of confidence that I will not be wounded. Or that if I am wounded, that I will also be healed. (Kurtz & Ketcham, 1992, p. 237).

Treating and supporting addiction recovery among people with histories of abuse, abandonment and loss requires, time, safety, systems stability, continuity of support, and community—a place to “be-at-home.” Assuring these ingredients will require moving from a focus on brief clinical micro-interventions to forging healing communities within and beyond the walls of addiction treatment and recovery mutual aid societies.

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