Tag Archives: Substance dependence

“narrative truth”

booksThis reminded me of something from Bill White.

At the heart of Perry’s argument — in line with neurologist Oliver Sacks’s recent meditation on memory and how “narrative truth,” rather than “historical truth,” shapes our impression of the world — is the recognition that stories make us human and learning to reframe our interpretations of reality is key to our experience of life

Bill said the following in Pathways [emphasis mine]:

Each person’s life is series of events and experiences. Those events to which one attributes special meaning get selected, abstracted, and massaged into stories that communicate to others the nature of one’s identity. Identity – that sculpted perception of self in relationship to the outside world at any given moment – springs from and is in turn shaped by storytelling. Life is a continuing process through which one adds new elements to his personal story, eliminates old elements from the story that no longer fit, and revises the old story to achieve new meaning. Story Construction forms the bridge between self perception and one’s self-presentation to others.

One’s story places oneself in a particular relationship with the world. The construction of personal history shapes both present and future. It is the justification and defense of one’s existential position. It can dictate the lines one has in a play with terrifying predictability. Each of us plays out the scenes and chapters in our lives in line with the motifs embedded within our own story. The construction of the past shapes the future. By telling you who I am, I tell you my fate. To change my fate, I must redefine who I am; I must reconstruct my story.

Many addicts have a carefully constructed life story that portrays them as being victimized by people and forces and conditions over which they have no control. The “victim” status and role serve as a righteous justification for continued self-destruction through addiction. It is as if revenge against the world can be achieved through obliteration of oneself. Through treatment and recovery, the addict’s history must be reconstructed, portraying the individual not as a victim but as an active player who contributed to the past through personal choices. Addicts present their history through stories of what the world did to them; recovering addicts speak of who they were, what they did, what they valued, and how they thought. Projection of blame is replaced by taking personal responsibility for ones past.

When the addict begins to disengage from the world of addiction, his or her personal story must be reconstructed. The old story will not enhance recovery; it provides permission for relapse. For recovery, the addict must be helped to reconstruct the story of his or her life – a story that will reflect a different conception of self, a different view of the world and a new value system. An essential milestone of recovery is the sobriety-based construction of one’s story. The story that will get the addict through the early months of sobriety will continue to evolve throughout the recovering addict’s life.

It is not particularly necessary that the first story constructed by the addict in treatment or early recovery be factually correct. Factual omissions and distortions are to be expected. It is necessary that the addict’s life be reframed within the story in a manner that supports recovery. The self-story in recovery must be different than the self-story in addiction. Whether factually true or not, the self-story in recovery must be metaphorically true. The story must give some meaning to one’s own suffering. The story must explain the suffering that one has caused others. Factual truth – which the addict may be incapable of in the earliest days of recovery – is secondary to emotional truth. The freedom achieved through purging the emotional content of the story and the power of the injunction for change that emerges from the story should take precedence over factual accuracy. As recovery proceeds, the story will evolve in ways that bring factual and emotional truth closer and closer together.

For me, a critical part of reconstructing my story was reconstructing my stories about the world I lived in and the people in it. My narratives that people would/could not understand and the dangers of vulnerability might have been more challenging to change than my narratives about who I was.

 

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“Recovery High” a Respite for Young Addicts

bridge+way+rebecca+bonner

Maybe this is a better way to address pediatric addiction?

Called The Bridge Way School, the specialized high school in the Roxborough section of Philadelphia focuses on getting teenagers back on track with their education and lives after exiting rehab. It is the only school of its kind in the region – one of only some three dozen nationwide.

“We have kids come in with 30 days [sobriety], they’re not sure how school is going to go, they haven’t done well in school for a while and then they see the environment that we have here,” says Rebecca Bonner, who runs the school. “And in two or three weeks, you see kids who haven’t worked in class for years who say ‘Oh, I’m getting a B’ and they’re actually working.”

Ranging from 9th to 12th grades, every student is recovering from some type of addiction and goes through regular coursework like English, Math and Science. But unlike typical schools, the teens talk about their recovery regularly.

Students begin their day with a 20 minute face-to-face with a counselor and staff to discuss how they’re feeling and whether they’ve been triggered to use again.

“If it’s serious enough, our counselor may just pull that kid for 20 minutes. It is so different from what a regular school does where a kid might sit on something all day,” Bonner said. “They learn nothing because they’re processing whatever that is. We try to catch it early so they can process that and get right back on track.”

Before leaving for the day, the students have another sit down to discuss their plans for the afternoon and evening. They also spend about 50 minutes, four times a week, in group sessions talking about their addiction and recovery with peers.

“The adults can say whatever we say and we can be supportive and encouraging, but the kids are the ones that give each other the support. That is positive peer pressure,” Bonner said.

via “Recovery High” a Respite for Young Addicts | NBC 10 Philadelphia.

 

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Pediatric use of buprenorphine

Adolescent_MedicineDrugfree.org has a piece advocating more use of buprenorphine with children.

Medication-Assisted Treatment (MAT) for opioid dependence is a science-based and proven-effective option for teens and young adults. It should be administered with age appropriate psychosocial therapy and drug testing. Unfortunately, it has been subject to controversy and stigma. Yet the neuroscience of addiction and cravings helps explain why MAT, when properly used and overseen, can be truly life saving for adolescents, young adults, and their families. I see it working all the time. When kids come into treatment, their lives are just chaotic. Parents are desperate — they don’t know what to do or where to turn. The most important thing is to bring stability into the situation, and the best way to do that is with medication.

Ugh!

So now we’re expanding the notion of incapacitating long-term brain changes to adolescents? Who have been using in what quantities? And, for how long? (Apparantly the only people with brains that aren’t permanently disabled by opiate addiction are health professionals. They get abstinence focused treatment and have outstanding outcomes.)

My first thought about the piece was, “Hey, at least he provides some actual numbers.” However, upon closer examination, though the numbers give the appearance of an accountable professional engaging in informed consent, something’s not kosher here.

In our highly-structured program at Boston Children’s Hospital about a third of the children remain completely free from any alcohol and drug use. About another third remain free from opioid use but they might have an occasional slip on alcohol or marijuana. (We tend to not approve of that behavior and keep working with them). And the remaining third, particularly early on, will try opioids once or twice. But even after those early slips they show dramatic improvement over time.

Unfortunately, he doesn’t provide any timeframe. AND, stop and think about the numbers he offered:

  • 1/3 free of alcohol and drug use
  • 1/3 use no opioids but occasionally use alcohol or marijuana
  • 1/3 use opioids “once or twice”

1/3 + 1/3 + 1/3 = 100%

He is saying that approximately 100% will not use opioids 3 or more times? This is an eminent physician at a prestigious institution. He has been a Principal Investigator of studies on adolescent substance abuse funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration, and the Robert Wood Johnson Foundation.

This assertion is so obviously implausible that it should provoke deep skepticism about the people upheld as experts, the funding priorities of government agencies and the biases built into what become “evidence-based practices.” (Remember “no hint of opinion“?)

As you read the comments, you’ll find people complaining about the methadone not being included. (Methadone for adolescents!)

You’ll find one comment, from a physician, explaining that, “Dr. Knight works with adolescents, with most of his patients under age 16, where methadone cannot legally be used (under 18 can be used with parental consent).”

The author’s finger wagging, very certain tone is regarding the use of Suboxone with patients under the age of 16.

I can imagine circumstances where the best path is not crystal clear (I’m thinking of youth that are highly resistant to treatment and at high risk for fatal OD.) but the question any family has to ask is, “How do we want my loved one to return too us?”

Here are Earl Hightower and Anna David:

AD: Should the parents just accept the first recommendation or should they ask for more?
EH: I think the first question they should ask should be one they ask themselves, which is how they want their son to return.

AD: What does that mean?

EH: Well, the majority of the treatment centers out there are 12-step based, which means that the goal for them is for their clients to achieve abstinence. This would be the choice to make if the parents want to get their son back in the same condition that he was in before he got on drugs: drug-free.

AD: But you can’t say for certain that a 19-year-old who was doing Oxy for nine months is definitely an addict who will need 12-step.

EH: You can’t. Maybe he was just dabbling; treatment would be able to help determine that. But maybe treatment will prove something else—maybe treatment will prove that this wasn’t an isolated incident. Maybe he’ll get in there and confess that he’s been using pot since he was 12 and maybe other conversations will turn up the fact that there’s a genetic predisposition toward addiction in the family. And if that’s the case, I believe he will need community-based support in staying clean once he returns home. It could go either way: good ongoing clinical assessment is the backbone of early treatment to determine the direction of care.

AD: But not all rehabs recommend 12-step or even full abstinence.

EH: Yes. And that’s why parents—people—need to know is that if an addict is going to a facility which subscribes to medication-assisted treatment and recovery, the goal is different. Loved ones need to know what medication-assisted treatment really means, which is that treatment will be radically re-defined and their child could be put on a medication which he would remain on for a long time, if not the rest of his life.

AD: So that’s what you mean when you talk about parents asking themselves how they want their child to return.

EH: Yes. But I can tell you from 30 years of doing this work that most parents want their child to come home drug-free—or they at least they want a shot at that. But some members of the treatment community will tell parents—or the addicts themselves—that we have to let go of this notion of abstinence and move more in the direction of medication-assisted treatment. And that means that people who could thrive without being on anything at all are leaving treatment centers on very powerful opiate replacement drugs.

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we can heal

hopeJennifer Matesa has a new piece up at the recently reincarnated The Fix. It’s a response to the recent NY Times series on Suboxone and goes directly after the underlying assumption and its implications for her.

Reckitt can get away with convincing doctors that addicts need to be maintained on Suboxone because—as the Times story notes—common belief holds that painkiller addicts can never be drug-free. We’re told we’ve permanently screwed up our neurology. Popular thinking goes: Once you junkies take drugs, you might as well stay on drugs for life.

To support this belief, Reckitt and its growing army of reps offer twisted interpretations of research studies and anecdotal evidence about addiction and Suboxone. They claim studies “prove” that replacing painkillers with buprenorphine (the opioid drug in Suboxone) helps us stay “clean.” Ditch the old drug for the new drug and we stop shooting, snorting, stealing, doctor-shopping, tricking.

. . .

If my “Sub doc” had believed—as so many doctors do—that somebody like me could never be drug-free, I’d without a doubt still be on drugs today. Hell, which of us inside active addiction believes we can do without drugs? I’d also be experiencing nasty side-effects for which people who read my addiction-and-recovery blog write in asking for help.

For me, what’s so important about her voice is that she’s one addict speaking directly to other addicts around the chorus of experts chanting, “research shows that maintenance treatments are the most effective treatments we have.” She’s offering hope that other addicts don’t have to limit themselves to the definition of success that these experts offer (reduced death, disease and drug use).

She’s also become a collector of stories about the lived experience of people who have tried Suboxone and found it to be incompatible with full recovery and very difficult to discontinue.

Just like doctors who can’t detox their patients off painkillers, most doctors who prescribe Suboxone don’t know how to help their patients quit. So the patients wind up asking me to be their doctor. One woman recently begged me to manage her detox in exchange for payment. I declined, but I was left shocked at the desperation of some folks out there to live a drug-free life, so much so that they will contact a total stranger and offer cash for an amateur detox. This speaks to the sorry state of treatment (not to mention the general health-care system) in this country.

These folks read my blog, they know I got off drugs including Suboxone, and they can see I’m living a productive drug-free life. I write them back, but I can’t be their doctor. The best I can do is keep writing stories like these, and letting policymakers, researchers, and practitioners know that they need to open their minds about how well most addicts can live, how much we can heal.

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Recovery capital and capital

blindjusticeartFrom the UK Advisory Council on the Misuse of Drugs second report of the recovery committee [emphasis mine]:

…our optimism about recovery should be tempered. Evidence suggests that different groups are more or less likely to achieve recovery outcomes. For some people, with high levels of recovery capital (e.g. good education, secure positive relationships, a job), recovery may be easier. For others, with little recovery capital or dependent on some types of drugs (especially heroin), recovery can be much more difficult and many will not be able to achieve substantial recovery outcomes.

It’s great that people are discussing recovery and looking at outcomes, but I have a few important concerns.

At what point does recovery capital become a proxy for class?

I’m increasingly concerned that recovery capital is becoming a proxy for social class. Whenever I discuss health professional outcomes, the typical response is something like, “Yeah, well, they have a lot more recovery capital than most opiate addicts.” The implication is that health professionals (and people like them) are capable of achieving drug-free full recovery while other opiate addicts are not. This is particularly troubling as maintenance becomes the de facto treatment for opiate addiction and significant financial resources become more important for accessing drug-free treatment of adequate duration and intensity. (Like health professionals get.)

This question brings John Rawls and his “original position” to mind.

In the original position, the parties select principles that will determine the basic structure of the society they will live in. This choice is made from behind a veil of ignorance, which would deprive participants of information about their particular characteristics: his or her ethnicity, social status, gender and, crucially, Conception of the Good (an individual’s idea of how to lead a good life). This forces participants to select principles impartially and rationally.

We have a situation where the experts provide one kind of treatment to their peers and another kind of treatment to the rest of their patients. If these experts had to assume the original position and operate from behind the veil of ignorance–if they were to be reborn an addict of unknown class, race, gender, economic status, etc–what would they want the de facto treatment to be?

If it’s not maintenance, then we have a social justice problem.

Evidence for what?

The other important question concerns the evidence. I have several questions about discussions about evidence.

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NY Times / Suboxone redux

English: Suboxone tablet - both sides.

English: Suboxone tablet – both sides. (Photo credit: Wikipedia)

 

I thought I was done, but here are a couple more smart takes. Both support maintenance but appreciate the article raising awareness of important problems.

 

From The Institute Blog:

 

And as the articles (and the comment section) demonstrate, the use of buprenorphine to treat addiction and prevent substance use-related harms is messy.  Interlacing text and video, the NYT pieces illustrate those complexities skillfully.  Here are three points to keep in mind as you read:

1) Medication-assisted treatment reduces overdose deaths.

2) It is necessary and good that buprenorphine treatment is investigated and reported on.

3) Drugs are double edged.

 

From RecoverySI:

 

To sum it up briefly: Some really bad research was used to convince docs that there was an ‘emergency’ need for more potent opioids to treat chronic pain, and that when used properly, these new, more potent opioids presented little or no danger that the user would become addicted.

That turned out to be BS. Surprise.

The result: We’re in a drug epidemic with no South American cartels or Afghan drug lords to vilify. And with some elements in Big Pharma, and some docs, figuring how to get rich off it.

Right– that’s the same combo that got us here.

It’s my belief that many physicians, even the uncommonly brilliant and passionate ones, can have a major blind spot when it comes to the meds they prescribe. Somehow, they convince themselves that a medication is safe if they prescribe it.

 

It’s worth pointing out that they, also, are not making recovery arguments for maintenance.

 

 

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a spectrum of apples, oranges, lemons, plums?

DSM_5_2Howard Wetsman picks apart the spectrum approach of the DSM5

Making a spectrum out of the illnesses that have been put in the substance use category of DSM IV is like making a spectrum out of an apple, an orange, a lemon, a lime, a blue fruit (if there was one) and a plum. You’d have the colors but your mixing different things. Sometimes a metaphor can be taken too far.

First there is the assumption that the substance use disorders actually hold together and are separate from other disorders in the DSM. It is an assumption and not one that is supported by the evidence of recent studies. DSM is concerned with behavior, not with biology. Illness is biology from which behavior can manifest, but it’s the biology that comes first. So before we look at the substance use disorders and say they can be made into a spectrum we have to see if they are separate from other things that look like addiction (overeating, compulsive sex, compulsive gambling, etc.) and are the same as each other (that substance abuse is the same as addiction, only less of a problem).

The evidence I’ve seen suggests that it can’t be done. Biologically, addiction to opioids and addiction to sugar binging have more in common than addiction to opioids and abuse of opioids. There are a lot of reasons that people with normal brains choose to do stupid things with drugs, but there’s a real commonality about why people with addiction use. That commonality extends beyond drugs to anything that makes the reward system go “Bam.” When we try to put people with normal brains who abuse substances in addiction treatment they don’t understand what we’re talking about. When we try to put addicts in treatment with people with normal brains they get confused and try to “use like a normal person.”

Read the rest of the post here.

 

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