…let us work together

The last couple of days’ posts, a recent conversation and some recent news (I’ll let you guess which story.) reminded me of this post. It’s from a couple of years ago and has a couple of minor updates.


 

“If you have come here to help me, then you are wasting your time… 
But if you have come because your liberation is bound up with mine, 
then let us work together.” – Lila Watson

Obviously, I’ve been thinking a lot about the buprenorphine maintenance, the NY Times series and the reactions since it was published. (See here, here, here, here, here, here, here & here.)

At Dawn Farm, we’ve often said that maintenance approaches are often rooted in the belief that opiate addicts can’t recover. Now, I’m the kind of person who tends to be uncomfortable making statements that claim to know the contents of another person’s mind. This week has made me much more comfortable with that statement. None of the responses have argued that maintenance is a great tool for achieving recovery. Several have referred to opiate addiction as a hopeless condition. All the arguments for it have been harm reduction arguments–that it’s associated with reduced use, overdose death, disease transmission, crime and incarceration. (The data is less compelling than many of them would have you believe.)

I want to make clear that I have no interest in getting between an addict and a maintenance treatment. All I want is a day when addicts are offered the same treatment that their doctors are offered–recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose. (However, the only choices these articles are worried about are buprenorphine and methadone. SAMHSA reports that, in 2012, about 23% of opiate addicts had a treatment plan that included medication assisted treatment, while 7% got long term residential. It’s worth noting a couple things. First, SAMHSA’s data set is generally limited to programs that get federal funding. Many of these use methadone, but few use buprenorphine. Buprenorphine had $1.4 billion in US sales and was the number 28 drug in 2012. Second, that quarter of heroin addicts with medication assisted treatment in their treatment plans is only those who actually had medication in their plan–23% doesn’t represent everyone who was offered medication, that number would likely be much higher. Third, their definition of long term residential is very loose and can include “transitional living arrangements such as halfway houses”. So, that 7% is inflated and very misleading. Finally, how many people get the treatment doctors get? I’d feel pretty safe guessing it’s a fraction of a percent. Why is there no hand wringing about access to this kind of care?)

However, when we have professionals, policy makers and researchers who don’t believe in the capacity of patients to recover, the kind of help they are going to offer is going to be unhelpful. They’ll focus on risk factors for overdose like “compromised tolerance”. Of course, decreased tolerance is associated with overdose. Then again, social interaction is associated with transmission of many illnesses. Should we discourage social lives?

One has to wonder if the experts interviewed for these articles know any addicts in full recovery–people who are fully re-engaged in family life, community life, vocations, education, faith communities, etc. If so, do they think of the people they know as belonging to some special category that makes them different from other addicts? (When I teach about addiction and bring up the outcomes for health professionals, many students argue that they are a different kind of addict and better outcomes are to be expected.)

While I don’t want to take choices away from addicts, there’s a big part of me that wants these “experts” to leave us alone. We don’t need your “help.” (A kind of help you would never offer a sick peer.)

malcolmxbirthday16x9

That sentiment brings to mind this Malcolm X story:

Several times in his autobiography, Malcolm X brings up the encounter he had with “one little blonde co-ed” who stepped in, then out, of his life not long after hearing him speak at her New England college. “I’d never seen anyone I ever spoke before more affected than this little white girl,” he wrote. So greatly did this speech affect the young woman that she actually flew to New York and tracked Malcolm down inside a Muslim restaurant he frequented in Harlem. “Her clothes, her carriage, her accent,” he wrote, “all showed Deep South breeding and money.” After introducing herself, she confronted Malcolm and his associates with this question: “Don’t you believe there are any good white people?” He said to her: “People’s deeds I believe in, Miss, not their words.”

She then exclaimed: “What can I do?” Malcolm said: “Nothing.” A moment later she burst into tears, ran out and along Lenox Avenue, and disappeared by taxi into the world.

I can relate to his sentiment that the most helpful thing others can do is leave us alone. (“Other” can be a pretty ugly word, no?) Then, when I’m a little less emotional, I’m left to consider my own cognitive biases and creeping certitude. I have to think about the contributions of people like Dr. Silkworth, Sister Ignatia, George Vaillant, etc.

We also need to be watchful for ideological resistance to innovations that could help others find recovery.

Malcolm X had a similar experience to this too:

In a later chapter, he wrote: “I regret that I told her she could do ‘nothing.’ I wish now that I knew her name, or where I could telephone her, and tell her what I tell white people now when they present themselves as being sincere, and ask me, one way or another, the same thing that she asked.”

Alex Haley, in the autobiography’s epilogue (Malcolm X had since been assassinated), recounted a statement Malcolm made to Gordon Parks that revealed how affected he was by his encounter with the blonde coed: “Well, I’ve lived to regret that incident. In many parts of the African continent I saw white students helping black people. Something like this kills a lot of argument. . . . I guess a man’s entitled to make a fool of himself if he’s ready to pay the cost. It cost me twelve years.”

Malcolm X realized, too late, that there was plenty this “little blonde coed” could have done, that his response to her was inconsistent with what he, his associates, and his followers wanted to accomplish.

Bill White wrote about the things that have allowed practitioners to avoid the cultural traps in working with addicts:

Four things have allowed addiction treatment practitioners to shun the cultural contempt with which alcoholics and addicts 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 alcoholics and addicts 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 recovery processes.

We must make sure that these qualities and conditions are not lost in the rush to integrate addiction treatment and other service systems.

I don’t know how to engage these experts who may know a lot about the illness, but they often appear to be blind to the fact that full recovery already exists in every community across the country. It’s especially tough when the field is so fractured, there’s so much money to be made, and external forces (like the Affordable Care Act) are going to be pushing addicts toward primary care for their treatment.

As far as Dawn Farm goes, I heard something last week that cast us in a new light for me.

We are unapologetically rooted in culture.
If you want to join us, and you’re not part of that culture,
you need to find ways to respect, honor and celebrate that culture.”  – Dan Floyd

We’ve talked a lot about the concept of cultural competence and that professional helpers need to deliberately develop similar competencies when working with addicts and the recovering community. I still believe this is true. But, at Dawn Farm, we go beyond mere competence. We are rooted in the culture of recovery, and we help non-recovering staff (more than half of our staff) find ways to respect, honor and celebrate that culture.

This puts us out of the mainstream among professional helpers and “experts” on addiction, but we wouldn’t change a thing.

The question is how to develop this kind of competence in these researchers, policy makers and experts. It would seem that recovery advocacy would be an important way to do this. However, drug manufacturers have ingratiated themselves with recovery advocacy organizations and the organizations have tried to ingratiate themselves with experts. As a result, they’ve waded into supporting medication assisted recovery, but have done little to challenge the therapeutic nihilism that PHARMA nurtures and is a theme in the public comments of these experts.

In the meantime, this brings me back to the quote I opened this post with.

“If you have come here to help me, then you are wasting your time… 
But if you have come because your liberation is bound up with mine, 
then let us work together.” – Lila Watson

…let us work together

“If you have come here to help me, then you are wasting your time… 
But if you have come because your liberation is bound up with mine, 
then let us work together.” – Lila Watson

Obviously, I’ve been thinking a lot about the buprenorphine maintenance, the NY Times series and the reactions since it was published.

At Dawn Farm, we’ve often said that maintenance approaches are rooted in the belief that opiate addicts can’t recover. Now, I’m the kind of person who tends to be uncomfortable making statements that claim to know the contents of another person’s mind. This week has made me much more comfortable with that statement. None of the responses have argued that maintenance is a great tool for achieving recovery. Several have referred to opiate addiction as a hopeless condition. All the arguments for it have been harm reduction arguments–that it’s associated with reduced use, overdose death, disease transmission, crime and incarceration. (The data is less compelling than many of them would have you believe.)

I want to make clear that I have no interest in getting between an addict and a maintenance treatment. All I want is a day when addicts are offered the same treatment that their doctors are offered–recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose.

However, when we have professionals, policy makers and researchers who don’t believe in the capacity of patients to recover, the kind of help they are going to offer is going to be unhelpful. They’ll focus on risk factors for overdose like “compromised tolerance”. Of course, decreased tolerance is associated with overdose. Then again, social interaction is associated with transmission of many illnesses. Should we discourage social lives?

One has to wonder if the experts interviewed for these articles know any addicts in full recovery–people who are fully re-engaged in family life, community life, vocations, education, faith communities, etc. If so, do they think of the people they know as belonging to some special category that makes them different from other addicts? (When I teach about addiction and bring up the outcomes for health professionals, many students argue that they are a different kind of addict and better outcomes are to be expected.)

While I don’t want to take choices away from addicts, there’s a big part of me that wants these “experts” to leave us alone. We don’t need your “help.” (A kind of help you would never offer a sick peer.)

malcolmxbirthday16x9

That sentiment brings to mind this Malcolm X story:

Several times in his autobiography, Malcolm X brings up the encounter he had with “one little blonde co-ed” who stepped in, then out, of his life not long after hearing him speak at her New England college. “I’d never seen anyone I ever spoke before more affected than this little white girl,” he wrote. So greatly did this speech affect the young woman that she actually flew to New York and tracked Malcolm down inside a Muslim restaurant he frequented in Harlem. “Her clothes, her carriage, her accent,” he wrote, “all showed Deep South breeding and money.” After introducing herself, she confronted Malcolm and his associates with this question: “Don’t you believe there are any good white people?” He said to her: “People’s deeds I believe in, Miss, not their words.”

She then exclaimed: “What can I do?” Malcolm said: “Nothing.” A moment later she burst into tears, ran out and along Lenox Avenue, and disappeared by taxi into the world.

I can relate to his sentiment that the most helpful thing others can do is leave us alone. (“Other” can be a pretty ugly word, no?) Then, when I’m a little less emotional, I’m left to consider my own cognitive biases and creeping certitude. I have to think about the contributions of people like Dr. Silkworth, Sister Ignatia, George Vaillant, etc.

We also need to be watchful for ideological resistance to innovations that could help others find recovery.

Malcolm X had a similar experience to this too:

In a later chapter, he wrote: “I regret that I told her she could do ‘nothing.’ I wish now that I knew her name, or where I could telephone her, and tell her what I tell white people now when they present themselves as being sincere, and ask me, one way or another, the same thing that she asked.”

Alex Haley, in the autobiography’s epilogue (Malcolm X had since been assassinated), recounted a statement Malcolm made to Gordon Parks that revealed how affected he was by his encounter with the blonde coed: “Well, I’ve lived to regret that incident. In many parts of the African continent I saw white students helping black people. Something like this kills a lot of argument. . . . I guess a man’s entitled to make a fool of himself if he’s ready to pay the cost. It cost me twelve years.”

Malcolm X realized, too late, that there was plenty this “little blonde coed” could have done, that his response to her was inconsistent with what he, his associates, and his followers wanted to accomplish.

Bill White wrote about the things that have allowed practitioners to avoid the cultural traps in working with addicts:

Four things have allowed addiction treatment practitioners to shun the cultural contempt with which alcoholics and addicts 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 alcoholics and addicts 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 recovery processes.

We must make sure that these qualities and conditions are not lost in the rush to integrate addiction treatment and other service systems.

I don’t know how to engage these experts who may know a lot about the illness, but they often appear to be blind to the fact that full recovery already exists in every community across the country. It’s especially tough when the field is so fractured, there’s so much money to be made, and external forces (like the Affordable Care Act) are going to be pushing addicts toward primary care for their treatment.

As far as Dawn Farm goes, I heard something last week that cast us in a new light for me.

We are unapologetically rooted in culture.
If you want to join us, and you’re not part of that culture,
you need to find ways to respect, honor and celebrate that culture.”  – Dan Floyd

We’ve talked a lot about the concept of cultural competence and that professional helpers need to deliberately develop similar competencies when working with addicts and the recovering community. I still believe this is true. But, at Dawn Farm, we go beyond mere competence. We are rooted in the culture of recovery, and we help non-recovering staff (more than half of our staff) find ways to respect, honor and celebrate that culture.

This puts us out of the mainstream among professional helpers and “experts” on addiction, but we wouldn’t change a thing.

The question is how to develop this kind of competence in these researchers, policy makers and experts. It would seem that recovery advocacy would be an important way to do this. However, drug manufacturers have ingratiated themselves with recovery advocacy organizations and the organizations have tried to ingratiate themselves with experts. As a result, they’ve waded into supporting medication assisted recovery, but have done little to challenge the therapeutic nihilism that PHARMA nurtures and is a theme in the public comments of these experts.

In the meantime, this brings me back to the quote I opened this post with.

“If you have come here to help me, then you are wasting your time… 
But if you have come because your liberation is bound up with mine, 
then let us work together.” – Lila Watson

Two more defenses of Suboxone

SecondOpinion400In the Washington Post, Harold Pollack interviewed Peter Friedmann about buprenorphine and the NY Times series on buprenorphine.

We’re fortunate that that they share their premises.

HP: Buprenorphine provides a “substitution therapy” for people with opiate disorders.

PF: Correct. For many years, opiate addiction was considered an incurable illness. It was Dole and Nyswander in New York who proposed that we might stabilize the social and physiologic effects of opiate addiction by administering a long-acting oral, preferably an oral agent, for substitution therapy.

postcard---heroin-lie

incurable” until Dole and Nyswander proposed methadone substitution. That’s their premise.

Though we disagree on a lot, we share one big concern. I’ve long expressed concern that the Affordable Care Act will shift the locus of care to primary care offices.

We have to decide what we’re trying to do here. Is this like treating simple hypertension, or is this like treating somebody who’s having a myocardial infarction. We don’t treat heart attacks in primary care. People with severe disorders need better access to good care. Some people with fairly mild disorders could be treated in primary care, but right now, we don’t have a way to really do this well. Docs have been notoriously resistant to gaining the skills they need to really do this. The hope was that the Drug Abuse Act would push them in this direction. It’s not clear that docs really embraced this change.

Meanwhile, a HuffPost piece trots out the “most effective” argument and then blames some form of puritanism for concern about buprenorphine.

Unfortunately, we cannot seem to free ourselves from our beliefs that addiction is rooted in moral failing or lack of willpower, and that those who use medications, like methadone or buprenorphine, are not truly “clean.”

In truth, we can’t free ourselves from the knowledge that full recovery is possible for any addict. We want more for them than just “reduced opioid abuse, reduced behaviors that put people at risk for HIV or Hepatitis C, and even reduced incarceration.” Maybe the moral reflex isn’t about the addict at all. It could be argued that the moral failing and lack of willpower exists not in the addicts, rather in the system that is generating billions in revenues while failing to provide addicts with the same care that health professionals provide each other.

 

 

As the ACA expands coverage for addiction, can the system deliver?

The signatures of President Barack Obama, Vice...
The signatures of President Barack Obama, Vice President Joe Biden, and Speaker of the House Nancy Pelosi on the health insurance reform bill signed in the East Room of the White House, March 23, 2010. (Photo credit: Wikipedia)

The AP recently ran an article looking at the horizon for addition treatment under the Affordable Care Act expansion in insurance coverage:

The surge in patients is expected to push a marginal part of the health care system out of church basements and into the mainstream of medical care. Already, the prospect of more paying patients has prompted private equity firms to increase their investments in addiction treatment companies, according to a market research firm. And families fighting the affliction are beginning to consider a new avenue for help.

But will those who suddenly get coverage for treatment have a place to get it?

Haymarket Center in Chicago illustrates what may await many addicts. One Friday morning, seven men slumped in chairs in a small, bare room with only an untouched rack of health brochures to break the monotony of waiting for the chance of a detox bed that night. The six-story brick building is a beehive of programs for 300-plus patients: short term detox, long-term residential treatment, recovery units where people can live sober while looking for work. Everything is overbooked. On this day, the waiting list totaled 91 people who want help.

“Last year the state cut our dollars so we had to cut back our beds,” said Dan Lustig, vice president of Haymarket, which gets most of its funding from the government. “We had clients literally pleading for services. Some were sleeping on our front steps.”

In Illinois, where 92,000 people get treatment now, nearly 235,000 addicts and alcoholics without insurance will be able to get coverage next year. Not only beds are lacking. The pool of physicians who are addiction specialists must grow by 3,000 nationwide, almost double what it is now, to handle the demand, according to health industry experts.