2014’s Top Posts: #3


imagesThere’s a lot of commentary out there on Philip Seymour Hoffman’s death. Some of it’s good, some is bad and there’s a lot in between. Much of it has focused overdose prevention and some of it has focused on a need for evidence-based treatments.

Anna David puts her finger on something very important. [emphasis mine]

Let’s explain that this isn’t a problem that goes away once you get shipped off to rehab or even get a sponsor—that this is a lifelong affliction for many of us. There seems to be this misconception that people are hope-to-die addicts and then get hit by some sort of magical sunlight of the spirit and are transported into another existence where the problem goes away.

[NOTE – I know almost nothing of Hoffman or the treatment he received from his doctors or anyone else. My comments should be considered commentary on the issues involved rather than the specifics of Hoffman or the help he received.]

What I haven’t heard discussed much is his reported relapse a year or so ago. How could that have been prevented?

From what I understand, this is someone who had been in remission for 23 years. And, it sounds like his relapse began in a physician’s office when he was prescribed an opiate for pain.

  • What’s the evidence-base around treating pain in someone who has been abstinent for 23 years?
  • What are the evidence-based practices around how professional helpers should monitor and support the recovery of a patient who has been sober for decades?
  • What are the behaviors associated with recovery maintenance over decades through pain and difficult life experiences?

20090101-new-yearCould the outcome have been different if some sort of recovery checkup had been performed by his primary care physician or the doctor who treated his pain?

If he had been in remission from some other life-threatening chronic disease, wouldn’t his doctors have watched for a symptoms of a recurrence? Or,  given serious consideration to contraindications for the use of particular medications with a history of that chronic disease?

What if he had been asked questions like:

  • How’s your recovery going?
  • Have you had any relapses? Cravings?
  • How did you initiate your recovery?
  • How have you maintained your recovery?
  • Have there been changes in the habits associated with your recovery maintenance? (Meetings, readings, sponsor, social network, etc.)
  • How’s your mood been?
  • What do your family and friends who support your recovery say about this?

Also, if it’s determined that a high risk treatment (like prescribing opiates to someone with a history of opiate addiction) is needed, what kind of relapse prevention plan was put into place? What kind of monitoring and support?

There are two issues here. One is the lack of research, training and support that physicians get around treating addiction and supporting recovery.

The second issue is the role of the patient.

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.

So…this was someone who had been in remission for decades. He clearly had a responsibility to maintain his recovery. At the same time, the medical and/or treatment system has a responsibility to monitor and support his recovery.

I happen to have celebrated 23 years of recovery several months ago. I’m still actively engaged in behaviors to maintain my recovery. (Much like I’m actively engaged in behaviors to keep my cholesterol low.)

In 23 years, has a doctor or nurse EVER asked me how my recovery is going? No. Have they ever evaluated my recovery in ANY way? No.

Do they want to check my cholesterol every so often. Like clockwork.

This is a critical failure of the system and the evidence-base. And, we don’t just fail people with decades of recovery. Even more so, we fail people with 90 days, 6 months, a year, 5 years, etc. Then we blame the approach that helped them stabilize and initiate their recovery when the real problem was that we never helped them maintain their recovery. (Then, too often, our solution is to insist that they get into that passive patient role, just take their meds and let the experts do their work.)

via Another Senseless Overdose.

2014’s top posts: #11

Philip Seymour Hoffman

psh2It’s nice to see a victim of addiction  be remembered not just for their talent, accomplishments, personal drama or whatever else, and instead be remembered for his goodness.

It’s being widely reported that Philip Seymour Hoffman died of a drug overdose. He was found in a West Village apartment with the syringe still in his arm and several bags nearby.

He had 23 years sober before he relapsed on heroin last year.

In “Almost Famous,” as legendary 1970s music critic Lester Bangs.

The news literally knocked the wind out of me and I cried, the way I cried the day I heard David Foster Wallace (another addict) topped himself. My first thought in both cases was selfish: Now we never get any more of their brilliant work.

My second thought was for their partners, and Hoffman’s kids. Hoffman had—has? had?—three kids. “Young children,” they are described in the New York Times story. Village residents who saw him around the neighborhood are describing him on Twitter as a generous dude who was kind and unpretentious when he brought his kids to the coffee shops.

23 years? Damn. Just goes to show that is you’re a real addict (not just a heavy user), you can never stop maintaining your recovery.

Thanks to Jennifer Matesa for sharing her reactions.

via Philip Seymour Hoffman. | Guinevere Gets Sober.

[UPDATE: The first sentence was edited based on a commenter suggestion. It originally read, “It’s nice to see someone die of addiction and be remembered…”. It’s never nice to see someone die of addiction.]

Top posts of 2014: #12

Abstinence—The Only Way to Beat Addiction?

StrawmanWhat killed Philip Seymour Hoffman? According to Anne Fletcher, it wasn’t the doctor who prescribed him the pain medication that began his relapse, it wasn’t the prescribers of the combination of meds found in his body, it wasn’t his discontinuing the behaviors that maintained his recovery for 23 years, it wasn’t a drug dealer, and it wasn’t addiction itself.

According to her it was 12 step groups for promulgating an alleged myth:

This is exactly what happened when Amy Winehouse, Heath Ledger, Corey Monteith, and most recently, Phillip Seymour Hoffman were found dead and alone. Scores of people most of us never hear about suffer a similar fate every year.

Why does this keep happening? One of the answers is that many people struggling with drug and alcohol problems have been “scared straight” into believing that abstinence is the only way out of addiction and that, once you are abstinent, a short-lived or even single incident of drinking or drugging again is a relapse. “If you use again,” you’re told, “you’ll pick up right where you left off.” Once “off the wagon,” standard practice with traditional 12-step approaches is to have you start counting abstinent days all over again, and you’re left with a sense that you’ve lost your accrued sober time.

She’s describing a theory often referred to as the “abstinence violation effect”. The argument is that the “one drink away from a drunk” message in 12 step groups is harmful and makes relapses worse than they might have been.

One problem. The theory is not supported by research. (See here and here. It hasn’t even held up with other behaviors.)

Two things are important here.

  • First, many people experience problems with drugs and alcohol without ever developing an addiction. Most of these people will stop and moderate on their own. These people are not addicts and their experience does not have anything to teach us about recovery from addiction.
  • Second, loss of control is the defining characteristic of addiction. The “one drink away from a drunk” message is a colloquial way of describing this feature of addiction.

Further, she characterizes AA as opposing moderation for problem drinkers, when AA literature itself says, “If anyone who is showing inability to control his drinking can do the right- about-face and drink like a gentleman, our hats are off to him.” 12 step groups believe that real alcoholics will be incapable of moderate drinking, but they are clear that they have no problem with people moderating, if they are able. This is a straw man.

We’re left to wonder why a best selling author and NY Times reporter would attack 12 step groups with a straw man argument and a long discredited theory.

via Abstinence—The Only Way to Beat Addiction? Part 1 | Psychology Today.

The Misconceptions Go Round

12-Common-Misconceptions-about-Content-MarketingAnna David vents her frustration about recent distortions of 12 step groups in coverage of Philip Seymour Hoffman’s death:

…I grow concerned about factually inaccurate information being spread in ways that are truly dangerous. That happened when I stumbled upon this io9 post which states, about 12-step, both that “the problem is that the sponsor system doesn’t fit with current scientific understandings of how addiction recovery works” and that “most NA groups frown on taking meds and forbid sponsors from doing it or advocating for it.”

I’m no expert but here’s what I understand:

  • The “sponsor system” has nothing to do with “scientific understandings”
  • A 12-step group doesn’t “frown on taking meds.” The literature directly states, in fact that “some A.A. members must take prescribed medication for serious medical problems.”
  • Sponsors are not “forbidden” from doing anything. Sponsors are not, in fact, mentioned in the Big Book. As the literature about medication says: “No A.A. member should ‘play doctor’; all medical advice and treatment should come from a qualified physician.”

Here’s what I don’t understand:

  • Why people blatantly lie when arguing against something when the facts are so clearly easy to find.

Here’s what I think helps:

  • Articles that offer unbiased explanations of alternatives to standard AA, like this one from yesterday’s Times.

via The Misconceptions Go Round.

Tribes of the recovering community


Narcotics Anonymous has gotten a lot of attention this week after Philip Seymour Hoffman’s death, so it’ll be this week’s tribe:

Narcotics Anonymous is a global, community-based organization with a multi-lingual and multicultural membership. NA was founded in 1953, and our membership growth was minimal during our initial twenty years as an organization. Since the publication of our Basic Text in 1983, the number of members and meetings has increased dramatically. Today, NA members hold more than 61,000 meetings weekly in 129 countries.

More on the history of NA here.