Gut check

gut-check-image2Bill White has a great post on anonymity and advocacy. He examines the changing cultural context for anonymity and the different functions of anonymity.

On anonymity as a spiritual principle:

When AA literature speaks of anonymity as a “spiritual principle,” it does so out of a profound understanding of the importance of self-transcendence as the vehicle for sobriety and serenity. You can hear people depicting AA as a “selfish program” to mean that the alcoholic must get sober for self and not for others, but you find a quite different orientation on the issue of anonymity. The “spiritual substance” of anonymity according to AA’s core literature is not selfishness but “sacrifice.” (AA, 1952/1981, p. 184). What is sacrificed in AA (and in acts of heroism) are one’s “natural desires for personal distinction,” which in AA are eschewed in favor of “humility, expressed by anonymity” (AA, 1952/1981, p. 87). Applying this understanding, one could see how an AA or NA member choosing public recovery advocacy could technically meet the letter of Tradition Eleven (not disclosing AA affiliation at the level of press), but violate the pervading spirit of the Traditions (Tradition Twelve). This could occur when advocacy is used as a stage for assertion of self (flowing from ego / narcissism / pride and the desire for personal recognition) rather than as a platform for acts of service, which flow from remorse, gratitude, humility, and a commitment to service. (2013)

He closes with a call for a gut check on our advocacy efforts:

There is a purity—perhaps even a nobility—to recovery advocacy when it meets the heroism criteria. There is a zone of service and connection to community within advocacy work, and I think we must do a regular gut check to make sure we remain within that zone and not drift into advocacy as an assertion of ego. The intensity of camera lights, the proffered microphone, and seeing our published words and images can be as intoxicating and destructive as any drug if we allow ourselves to be seduced by them. If we shift our focus from the power of the message to our power as a messenger, we risk, like Icarus of myth, flying towards the sun and our own self-destruction. To avoid that, we have to speak as a community of recovering people and avoid becoming recovery celebrities—even on the smallest of stages. We must stay closely connected to diverse communities of recovery and speak publicly not as an individual or representative of one path of recovery, but on behalf of all people in recovery. The fact that no one is fully qualified to do that helps us maintain a sense of humility even as we embrace the very real importance of the work to be done. The spirit of anonymity—that suppression of self-centeredness—can be respected when we speak by embracing the wonderful varieties of recovery experience rather than as individuals competing for attention and superiority. (2013)

I’m grateful for Bill’s reminder. Personally, I’m bothered be some of the slogans coming out of the newest generation of advocates. “Silent no more”, “I am not anonymous” and “The silence ends” are just a few examples.

First of all, anonymity, as practiced within communities of recovery, never demanded silence. All one needs to do is read AA’s chapter on the 12th tradition, published in 1952.

When opportunities to be helpful came along, he found he could talk easily about A.A. to almost anyone. These quiet disclosures helped him to lose his fear of the alcoholic stigma, and spread the news of A.A.’s existence in his community. Many a new man and woman came to A.A. because of such conversations. Though not in the strict letter of anonymity, such communications were well within its spirit.

But it became apparent that the word-of-mouth method was too limited. Our work, as such, needed to be publicized. The A.A. groups would have to reach quickly as many despairing alcoholics as they could. Consequently, many groups began to hold meetings which were open to interested friends and the public, so that the average citizen could see for himself just what A.A. was all about. The response to these meetings was warmly sympathetic. Soon, groups began to receive requests for A.A. speakers to appear before civic organizations, church groups, and medical societies. Provided anonymity was maintained on these platforms, and reporters present were cautioned against the use of names or pictures, the result was fine.

We may not have organized recovering people into a national advocacy movement, but we’ve never been silent. As a community, we haven’t cowered in shame. Communities of recovery are so frequently painted as “secretive”, with all of it’s pejorative connotations–implying shame, hiding, cultishness, etc. Why are we reinforcing this?

“I am not anonymous” seems dismissive of anonymity as a spiritual principle.

The issue isn’t advocacy. The first wave of this advocacy movement was much more respectful of tradition and the people who blazed the trail for building a recovering community capable of engaging in this level of advocacy. They made the case for “advocacy with anonymity” rather than dismissing it as quaint.

There’s nothing wrong with evolving. There’s nothing wrong with questioning the confines of tradition. We don’t have to be bound by tradition, but we should respect the traditions, principles and values that brought us this far.

I hope this movement grows, matures and succeeds in reducing stigma and improving access to help of adequate quality, intensity and duration.


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Blog love

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Kind words from After Party Magazine. I made their list of top blogs. Nice!

Addiction & Recovery News

The brainchild of Jason Schwartz, Clinical Director of Dawn Farm—a non-profit treatment program in Ann Arbor, Michigan—Addiction and Recovery News started out as a list of news links sent to his staff so they could stay on top of industry-related happenings. However, the tri-weekly (or so) email turned into an ongoing resource for those who want to be on the up and up of what is going on in the world of addiction and recovery. A great source for headlines and an even better source for inspiring efforts to help addicts in need.


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More to ponder on advocacy and anonymity

raisedfist1More from that article on advocacy and anonymity:

The fellowships themselves often assert that they should be ‘anonymous but not invisible.’ However, the claim from some sections of the wider Recovery Movement that anonymity is about shame and secrecy fails to appreciate that whilst the public sphere can be a realm of liberation, it is also a realm of potential pitfalls dug by ego and complacency. The quiet work undertaken by anonymous fellowships, ‘under the radar’, generation after generation, may be one of the reasons that recovery is the powerful force that it is today.

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Next steps for preventing OD deaths in Michigan

ambulanceblur-2The Facts

Keep these facts in mind:

  • Overdose is now the leading cause of accidental death in the U.S. Most of these overdose deaths are due to opioids.
  • If help arrives in time, overdoses can be safely and quickly reversed with a squirt of naloxone up the patient’s nose.
  • More than half of all overdoses occur in the presence of other people, usually other drug users.
  • Too often, people do not call 911 in a timely manner due to fear of arrest for possession of drugs.

A Start

At the urging of parents who have lost children to overdose, the Michigan legislature made some good first steps last year. They enacted laws that increased access to naloxone, the drug that reverses overdoses.

On October 13, 2014, Public Acts 311, 312, 313 and 314 of 2014 were signed into law.

These acts will:

  • Allow Narcan to be prescribed to friends and family of heroin addicts, so it’s readily available in the event of an overdose.
  • Protect a person administering Narcan in good faith to be immune from criminal prosecution or professional sanctions.
  • Require emergency medical personnel to carry the drug in their vehicles and be trained in how to administer it.
  • Require the state Department of Community Health to complete annual reports of opioid-related overdose deaths.

911 Good Samaritan Laws

NARCAN-KITThe Drug Policy Alliance provides a really good summary of 911 Good Samaritan laws:

Accidental overdose deaths are now the leading cause of accidental death in the United States, exceeding even motor vehicle accidents among people ages 25 to 64. Many of these deaths are preventable if emergency medical assistance is summoned, but people using drugs or alcohol illegally often fear arrest if they call 911,  even in cases where they need emergency medical assistance for a friend or family member at the scene of a suspected overdose.The best way to encourage overdose witnesses to seek medical helpis to exempt them from arrest and prosecution for minor drug and alcohol law violations, an approach often referred to as Good Samaritan 911.

The chance of surviving an overdose, like that of surviving a heart attack, depends greatly on how fast one receives medical assistance. Witnesses to heart attacks rarely think twice about calling 911, but witnesses to an overdose often hesitate to call for help or, in many cases, simply don’t make the call. In fact, research confirms the most common reason people cite for not calling 911 is fear of police involvement.

It’s important to know that this is not a liberal vs. conservative or Republican vs. Democrat issue. Some of the reddest and the bluest states in the country have passed 911 Good Samaritan laws.

Twenty states and the District of Columbia have enacted policies to provide limited immunity from arrest or prosecution for minor drug law violations for people who summon help at the scene of an overdose. New Mexico was the first state to pass such a policy and has been joined in recent years by Alaska, California, ColoradoConnecticut, Delaware, Florida, Georgia, Illinois, LouisianaMaryland, Massachusetts, Minnesota, New Jersey, New York, North Carolina, Rhode Island, Vermont, Washington and Wisconsin.

Further, these laws don’t protect dangerous or predatory criminals.

Good Samaritan laws do not protect people from arrest for other offenses, such as selling or trafficking drugs, or driving while drugged. These policies protect only the caller and overdose victim from arrest and/or prosecution for simple drug possession, possession of paraphernalia, and/or being under the influence.

Another (small) Step Forward

This summer, Michigan Rep. Al Pscholka (R-Stevensville) introduced House Bill 4843, a bipartisan measure, that would create Good Samaritan protections for individuals under the age of 21 who seek medical attention for themselves or another person believed to have overdosed. However, the Good Samaritan protections are limited to the illegal possession of prescription drugs (in quantities consistent with personal use) for people under the age of 21.

Rep. Pscholka was lobbied to expand the bill to cover people of all ages and all drugs, but he wished to proceed with the bill as-is.

The Next (small) Step Forward

Once House Bill 4843 becomes law, it is my understanding that a co-sponsor of House Bill 4843 will introduce a bill that will expand the Good Samaritan protections to people of all ages.

Full 911 Good Samaritan Protections

This  bill is good and should be supported, but it does not go far enough. Prescription overdoses only make up about 50% of all opioid overdoses and medical examiners around the state are only able to pinpoint opioids as the cause of death in 40% of all drug overdoses.

If the second bill passes and becomes law, it is unclear who will champion 911 Good Samaritan protections that cover all drugs.

The Bad News

An overdose is a major medical crisis, right? It’s not unlike a heart attack.

Here’s what happens when someone has a heart attack41KSA2GA12L._SX300_

  1. A person has a heart attack at the grocery store and . . .
  2.  . . . thank goodness, the store has an automatic defibrillator.
  3. Someone has been trained to use the defibrillator and performs the rescue.
  4. Someone else calls 911 to make sure the patient gets all the care they need.
  5. The patient is taken to the emergency department and medically stabilized.
  6. Once stabilized, the patient gets transferred to care that will address the cause of the heart attack and/or care that will prevent future heart attacks.
  7. The patient’s treatment plan will generally include lifestyle changes. (Diet, exercise, etc.)
  8. Then, the patient gets follow-up care that might include:
    • follow up appointments with specialists,
    • periodic tests to monitor for indicators of a recurrence,
    • self-monitoring (blood pressure), and
    • monitoring by the patient’ primary care physician.
  9. If problems recur or there are indications of a potential recurrence, the care plan will be re-evaluated and the patient will get whatever care they need.

Here’s what happens when someone ODs and is rescuednarcan

  1. A person overdoses and . . .
  2.  . . . thank goodness, the someone has naloxone.
  3. The person has been trained to use naloxone and performs the rescue.

Maybe, if they are lucky, these steps happen.

  1. Someone else calls 911 to make sure the patient gets all the care they need.
  2. The patient is taken to the emergency department and medically stabilized.

Naloxone is not enough.

We’d never tolerate cardiac patients being sent home without the proper care. Why should people with an addiction be treated any differently?

The good news

The good news is that there are models that work.

The Gold Standard

A male doctor writes on a patients chart.The best example of what should happen is the the kind of care that opioid addicted doctors, nurses, pilots and lawyers get. They all have low relapse rates and return to work at very high rates.

Here’s what would happen if one of them overdosed at work (or if it was known to their employer):

First, the recovery planning begins with some important assumptions:

  • abstinence is the goal;
  • full recovery with a return to full functioning is the expectation;
  • addiction is a chronic illness and recovery requires long term treatment, support and monitoring; and
  • for recovery to be durable, the addict must be an active participant in treatment and recovery maintenance.

Signpost along the road to recovery.The recovery plan is likely to include the following:

  • Formal treatment. The first phase of formal addiction treatment for most of these professionals is residential care ranging from 30 to 90 days.
  • Supportive services. Supportive services used by these professionals includes AA or NA 12-step groups, aftercare groups from their formal treatment programs, and follow-up from case managers.
  • Long-term support and monitoring. After completion of initial formal addiction treatment, they develop a continuing care contract consisting of support, counseling, and monitoring for usually 2 to 5 years.
  • Drug testing. Regular testing for 2 to 5 years, usually with more frequent testing at the start and reduced testing following periods of stable negative drug test results.
  • Dealing with relapse. Relapses are usually addressed by a combination of increased intensity of care and monitoring and by immediately informing family and colleagues of the physician to enlist their support.

Other options

Buprenorphine (Suboxone) and methadone have been shown to reduce drug use, overdose risk, criminal activity and disease transmission.

Some people are able to stabilize and live normal lives on these medications but, at this point, there is no research demonstrating its effectiveness with quality of life indicators like employment.

Many people hope to use these drugs as an interim step toward abstinence. However, there is no established model for successfully transitioning buprenorphine and methadone patients to abstinence. A large federally-funded study attempting to do this reported, “near universal relapse.”

Another option is an injectable drug called Vivitrol. It is injected once per month and can protect against overdose. Unfortunately, it’s very expensive.

Which to choose?

Hope Traffic SignThe gold standard offers a path to full recovery, but it does demand a lot of structure, effort and lifestyle changes.

Many professionals prefer drug maintenance as a goal. It’s an easier plan to implement and many professionals do not believe their patients are capable of drug-free recovery. (Look for professionals that are optimistic and believe in you ability to achieve full recovery.)

However, most patients and families, for a wide variety of reasons, prefer abstinence as a goal–the most common reason is that they want their life back the way it was before they became addicted.

Patients not sticking with the treatment plan is the biggest barrier to success with both approaches.

It’s harder than it should be

Getting the gold standard for yourself or a family member is likely to be very difficult. But, there are steps you can take to improve the odds.

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Sentences to ponder

2046202805_more_than_one_truth_design_xlargeOn recovery advocacy and anonymity:

. . . when supporters of the Recovery Movement conflate ‘spiritual anonymity’ and ‘secrecy,’  they  fail to appreciate the richness of the practice for individuals, and the value of freely available, financially and ideologically independent fellowships, not associated with particular individuals or recovery ‘gurus’, important though these may be.

I’d add ‘shame’ as well. It also seems to get conflated with anonymity.


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Naloxone is not enough

hand drowning

Naloxone saves lives. That’s good. Very good.

However, naloxone is not enough.

Naloxone is not enough for EMS workers.

“As EMS providers, this call is a success,” Hassan says. “In the big picture of health care, is it a success? Well, no, it’s incomplete right now. For it to be a total success he’d get into a rehab program and never do heroin again.”

But, that’s not what usually happens Hassan says. “At some point, we probably took care of him before.”

Naloxone is like a defibrillator. What would we do if patients were being revived by defibrillators and walking out of the emergency department a few hours later with a passive referral to treatment that has a long wait list.

Naloxone is like a defibrillator. What would we do if patients were being revived by defibrillators and walking out of the emergency department a few hours later with a passive referral to treatment that is inadequate and/or has a long wait list?

Naloxone is not enough for addicts.

Joseph says that most of the time he has been brought to an ER because of an overdose, he has been discharged after only about three hours, without any recommendations about getting further treatment.

“They let you kinda sleep it off,” he says. “They just discharge you and they tell you you need to get help — you need to do something.”

. . .

Sometimes, after a Narcan treatment, Joseph says he felt so bad he just went home and shot up more heroin. “It’s a vicious, vicious cycle,” he says.

Naloxone is not enough for doctors.

Many ER doctors say that after a Narcan revival, if a patient appears to be breathing fine and walking, they are indeed discharged within a few hours. Many are so sick and uncomfortable they just want to leave. And even if they do want further counseling and extended treatment for their addiction, access is limited by availability and insurance.

“For myself, basically, they’d have to be able to walk safely, be able to have a conversation, be able to take fluids before they’re released,” says Dr. Edward Bernstein, a professor at Boston University, and an emergency physician at Boston Medical Center. Before the patients leave after a Narcan revival, most are given their own Narcan kit and information about further treatment.

But less than half the overdose patients revived with Narcan at the medical center actually do go on to get follow-up help with their addiction. That’s often because there are no beds available, he says.

“You do feel helpless,” Bernstein says. “Especially since we’re trying our best, and we have all these different tools now.”

Repeatedly having to use Narcan on the same patient can make a health provider feel helpless, Bernstein says. About 30 percent of those revived with Narcan at Boston Medical Center have been revived there more than once, he says, and about 10 percent of patients more than three times. Those statistics are in line with what’s seen in ERs elsewhere, public health officials say.

Naloxone is good, but it’s not enough. We need to talk about what happens after the overdose.

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Good communication equals better outcomes

duhThe Affordable Care Act brought with it increased attention to reducing patient readmission rates. A new finding will surprise many in the medical community and affirm many in other helping professions, like counseling and social work–good communication between caregivers and patients improves readmission rates.

. . . findings from our research using six years of data from nearly 3,000 acute-care hospitals suggest that it is the communication between caregivers and patients that has the largest impact on reducing readmissions. In fact, the results indicate that a hospital would, on average, reduce its readmission rate by 5% if it were to prioritize communication with the patients in addition to complying with evidence-based standards of care.

. . .

If these results are that powerful, why aren’t hospitals focusing on improving this patient experience dimension? The answer is that improving the communication-focused dimension involve significant training costs, in no small part because health care traditionally has focused on the evidence-based process of care rather than the patient experience. This bias is reflected in medical education, which teaches technical skills to caregivers and puts relatively little emphasis on the importance of interacting with the patient.

As there is increasing pressure to medicalize addiction treatment, this casts a light on an important culture difference between medical providers and addiction providers. This brings sharp differences into focus about the role of the patient and the caregiver, as well as philosophical issues about what heals. All of this informs whether the caregiver emphasizes pills, procedures, lifestyle interventions, symptom reduction, hope, choice, self-determination, social support and/or quality of life.

This brings to mind a talk from Kevin McCauley:

I listened to a talk by Dr. Kevin McCauley this morning in which he addressed objections to the disease model. One of the objections was that the disease model lets addicts off the hook. His response was that, given the cultural context, there were grounds for this concern. BUT, the contextual problem was with the treatment of diseases rather than classifying addiction as a disease. He pointed out that our medical model positions the patient as a passive recipient of medical intervention. As long as the role of the patient is to be passive, this concern has merit. He suggests we need to expect and facilitate patients playing an active role in their recovery and wellness.


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