Fresh proposals to respond to rising opioid use/addiction/deaths arrive daily, but are striking in their collective silence on the needs of affected others—parents, siblings, intimate partners, children, extended family members, and social network members. Neglect of affected families has deep historical roots within the history of addiction treatment and recovery. Historically, family members were more likely to be viewed by addiction professionals as causative agents of addiction or hostile interlopers in the treatment process than people in need of recovery support services in their own right. Overcoming such attitudes has taken on added urgency due to the rising prevalence, morbidity, and mortality of opioid addiction in the United States and its rippling effects upon families and communities. In this brief communication, we offer some reflections on this issue and how we might use the current social crisis to forge a new chapter in the nation’s response to addiction-affected families and children.
Scientific research on the effects of opioid addiction on children and families is robust and its findings are unequivocal. Opioid addiction of a family member exerts profound consequences on the physical, emotional, and financial health of other family members and the family as a whole. Opioid addiction dramatically alters family roles, rules, rituals, and the family’s internal and external relationships. Its effects are observed across all family subsystems—adult intimacy relationships, parent-child-relationship, sibling relationships, and the relationship between the nuclear family and kinship networks.
The emotional life of opioid-affected families is rife with denial, shock, anger, verbal confrontations, confusion, guilt, humiliation, shame, fear, fleeting glimmers of hope, frustration, anticipatory grief, and feelings of extreme isolation and helplessness. Such feelings are exacerbated in the presence of an addicted family member’s threatening behavior, physical violence, lying, manipulation, failed promises, pleas for money, and damage or theft of property. Affected family members often report role disruption across generations (e.g., grandparents or aunts and uncles raising children of an addicted parent), a restricted social life, financial distress, a reduced standard of living (from the direct effects of opioid addiction, legal expenses, and repeated episodes of addiction treatment), and a progressive, stress-related increase in their own alcohol and other drug use. The presence, severity, and duration of these effects are mediated by multiple factors, such as the type, severity, complexity, and duration of the opioid addiction and the internal and differences in the external resources available to be mobilized to respond to the addiction crisis.
Many reports note the significant increase in the use of opioids and opioid-related deaths, with much of the focus on prescription practices, the specific opioids used, and the epidemiology of overdose in various communities. Yet, each OD death affects many people left behind. The loss of a loved one through death, incarceration or incapacitation causes immeasurable suffering for the family and other concerned people. One of the authors recently attended a Vigil of Hope in which family members honored the memory of a loved one lost to addiction. Over 130 attended this event. Photos of lost family members lined a table, most of them of young adults. The majority of participants lit a candle and made a statement about losing a loved one (a few lit candles to express gratitude that their loved one is in recovery). One little boy said “I light this candle in memory of my dad who died when I was 3 years old.” A man lit a candle in memory of “two brothers and a cousin who died from drug overdoses.” Several couples and families lit candles as a group in memory of their lost loved one. Tears flowed throughout this Vigil as members shared their sadness and grief. We must all remember that there is a person’s story behind every case of addiction. There are also multiple family stories behind each case of addiction. Addiction truly is a family disease affecting us all. Death by overdose and incarceration from criminal behaviors caused by addiction affects us all. And our pain as family members may persist for years after losing our loved one.
Research and our combined clinical experience on the effects of opioid addiction on children (beyond the effects of prenatal opioid exposure) and the effects of parental opioid addiction on the parent-child relationship are equally unequivocal. Children of opioid-addicted parents are at increased risk of developing attachment, mood (including suicide risk), anxiety, conduct, and substance use disorders and experiencing problems in school adjustment and performance. These effects tend to be gender-mediated with female children experiencing greater mood and anxiety disorders and male children experiencing more disruptive and substance use disorders. These risks are exacerbated when the parental intimate relationship is marked by conflict, violence, and cyclical patterns of engagement, abandonment, and reengagement. Studies of the effects of parental opioid addiction on parental effectiveness and the parent-child relationship note cyclical patterns of disengagement, neglect, abandonment, and guilt-induced over-protection, over-control, and over-discipline—combinations that often leave children confused and rebellious.
While the above addiction-related effects on families and children have been extensively documented in the scientific and professional literature, that same body of literature offers surprisingly little data about the prevalence of recovery from opioid addiction and how affected families recover as individuals and as a family unit. The neglect of families effected by opioid addiction ignores the damage such addiction inflicts on the family, but it also fails to convey the very real possibility of long-term recovery, and offers no normative map to guide families into and through the recovery process. Below are examples of what family-oriented care would look like within policy, prevention, treatment, recovery support, and research contexts.
*Family members affected by opioid addiction are included within policy and service planning discussions to provide family perspectives on service needs.
*Such representation includes a diversity of family experience, e.g., partner, parent, and child perspectives; families who have experienced opioid-related deaths, families experiencing active addiction, and families in recovery from opioid addiction.
*Targeted prevention and/or counseling services are offered to all children/siblings affected by opioid addiction.
*Where possible, assertive linkage to professional and peer-based family support services accompanies all opioid addiction encounters, e.g., emergency services, point of arrest and adjudication, treatment admission, and mutual help contact.
*Families affected by opioid addiction are provided an independent advocate to help them navigate legal and service systems and to reduce the risk of financial exploitation by helping organizations.
*The basic unit of service within addiction treatment programs and recovery community organizations is reconceptualized from the addicted individual to the family unit.
*Family education and support programs are integrated within all organizations offering opioid addiction treatment and recovery support services. Family education includes (at a minimum) information on the neurobiology of opioid addiction, the very real prospects of long-term recovery from opioid addiction, treatment and recovery support options, the diversity of pathways of recovery from opioid addiction, the effects of opioid addiction on the family and family members (including children), and the commonly experienced stages of family recovery.
*Affected family members (adults and children), including those who have experienced addiction-related losses within their families, are provided safe venues to share their stories and experience mutual support with others similarly affected.
*Family-oriented care within treatment programs spans the functions of assessment, treatment and recovery planning, service delivery, and post-treatment monitoring (recovery checkups), support, and, if and when needed, early re-intervention. Periodic recovery check-ups are continued for a minimum of five years following initial recovery stabilization.
*Every family involved in addiction treatment and/or peer-based recovery support services is exposed to individuals and families in long-term recovery from opioid addiction.
*Affected families are given opportunities to use their experiences as vehicles for community education and policy advocacy.
Of the above actions, none is more important than bringing affected family members into policy development and service planning venues and listening–really listening–to their stories and letting the experiences and needs reflected in those stories shape a family-focused policy agenda. Put simply, national and local responses to opioid addiction are most effective when they begin with the lost art of listening—listening to the raw urgency of unmet needs.
Selected References
Daley, D.C., & Ward, J. (2015). The impact of substance use disorders on parents, Part I. Counselor, 16(2), 28-31.
Daley, D.C., & Ward, J. (2015). The impact of substance use disorders on parents, Part II. Counselor, 16(3), 25-28.
Kirby, K.C., Dugosh, K.L., Benishek, L.A., & Harrington, V.M. (2005). The Significant Other Checklist: Measuring the problems experienced by family members of drug users. Addictive Behaviors, 30(1), 29-47.
Lander. L., Howsare, J., & Byrne, M. (2013). The impact of substance use disorders on families and children: From theory to practice. Social Work and Public Health, 28(0), 194-205.
Nunes, E.V., Weissman, M.M., Goldstein, R., McAvay, G., Beckford, C., Seracini, A., Verdeli, H., & Wickramaratne, P. (2000). Psychiatric disorders and impairment in the children of opiate addicts: Prevalences and distribution by ethnicity. The American Journal on Addictions, 9, 232-241.
Velleman, R., Bennett, G., Miller, T., Orford, J., Rigby, & Tod, A. (1993). The families of problem drug users: A study of 50 close relatives. Addiction, 88, 1281-1289.
White, W., & Savage, B. (2005). All in the family: Alcohol and other drug problems, recovery, advocacy. Alcoholism Treatment Quarterly, 23(4), 3-37.

Post Date July 13, 2016 by Bill White


The celebration of multiple pathways and styles of addiction recovery is a central tenet of the new addiction recovery advocacy movement. And yet if one listens carefully to the diversity of recovery stories rising from this movement, there is a striking and shared central thread that forms the connecting tissue across secular, spiritual, and religious frameworks of recovery; across recovery in diverse populations and cultural contexts; and across the mediums of natural recovery, recovery mutual aid, and professionally-assisted recovery initiation. That central thread is a sustained, irrevocable commitment for personal change.
The forms of expression of that commitment vary widely. In Twelve-Step programs, it is rooted in the paradox of strength (action) rising from acknowledged limitation (powerlessness) and the experience of surrender—a paradox Kurtz and Ketcham characterized as the spirituality of imperfection, e.g., change emerging from the acceptance of one’s Not-Godness. Faith-based recovery programs such as Celebrate Recovery share a similar focus on powerlessness and the need for connection to resources that transcend the self. In secular recovery frameworks such as SMART Recovery or Secular Organizations for Recovery, the recovery commitment is centered quite differently in “self-empowerment and self-reliance” and a chosen “sobriety priority.” In recovery frameworks rising from historically-oppressed populations, one often finds the recovery commitment expressed through a similar assertion of self, as found in Dr. Jean Kirkpatrick’s (1986, p. 166) discussion of Women for Sobriety’s First Statement of Acceptance (“I have a drinking problem but it no longer has me. I am the master of it and I am the master of myself.”). Such assertion is also evident in recovery ministries rising within African American communities, such as the first “act of resistance” (“I will take control of my life”) in Glide’s Africentric framework of addiction recovery (Williams & Laird,1992). Today’s recovery advocates offer a similar challenge to action: “Recovery by any means necessary, under any circumstances. No matter what, don’t pick up!”
Whether through transcendence of self or assertion of self, a forged and sustained commitment to change is at the center of recovery initiation and maintenance across pathways and styles of addiction recovery. But what is the ultimate source of such commitment to recovery? We know that such commitment can come in a lightning strike (what researchers have called quantum change and transformational change) or in a much slower staged process of change, but what are its essential ingredients? Multiple factors can interact to set a detonation point of recovery initiation. These can take the form of push (avoidance) factors and pull (approach factors) or constitute a process more aptly described as drifting out of addiction and into recovery. Push factors include personal identity issues, family and significant other concerns, health concerns, economic concerns, legal troubles, fear of future consequences, and a progressive erosion of positive drug experiences. Pull factors include exposure to positive recovery role models (recovery carriers), recovery-specific family and social support, windows of opportunity for lifestyle change (e.g., relocation, job change), and emergence of new beliefs (e.g. religious conversion).
I have argued in my earlier writings that recovery involves a process of reaching critical mass in a synergy of push (pain) and pull (hope) factors. Pain in the absence of hope within the context of addiction drives only sustained drug use and further self-destruction. Hope in the absence of pain in the context of addiction fuels only belief in one’s ultimate invulnerability and continued drug use and related excessive behaviors. It is in a uniquely personal ratio between pain and hope that one finds the spark of recovery commitment igniting into a sustainable fire. That recovery alchemy can come early or late in one’s addiction career, with such timing profoundly influenced by one’s family and social environment. The future of recovery lies in a greater understanding of how these interior and exterior environments can be influenced to spark and sustain recovery commitment.
The growing varieties of conditions from which such pain-hope synergies can be elicited are revealed in acts of recovery storytelling within diverse private, professional, and public settings. What they reveal is that recovery stability in the short-term can be challenging, but that the odds are stacked toward long-term success. As we develop a deeper understanding of the natural world, it does become clearer that nature (life) will find a way. So will recovery, if given the opportunity.
Of Potential Interest
Kirkpatrick, J. (1986). Turnabout. New York: Bantam Books.
White, W. (2012). The history of Secular Organizations for Sobriety—Save Our Selves: An interview with James Christopher. Posted at and
White, W., & Chaney, R. (1992). Metaphors of Transformation: Feminine and Masculine. Bloomington, IL: Chestnut Health Systems.
Williams, C. with Laird, R. (1992). No Hiding Place: Empowerment and Recovery for Troubled Communities. New York, NY: Harper San Francisco.

Post Date June 24, 2016 by Bill White


The addiction recovery experience has been sliced and diced in all manner of categories: secular, spiritual, and religious; natural recovery, peer-assisted, and treatment-assisted; and abstinence-based, moderation-based, and medication-assisted, to name just a few. Recovery achieved through any of these frameworks is often referred to as a pathway of recovery. The growing consensus that there are multiple pathways of long-term addiction recovery marks an important public and professional milestone within the alcohol and drug problems arena.
Progress has been made by recovery-focused research scientists on mapping recovery pathways and noting their distinctive and shared qualities. This classification work is important as long as one does not lose sight of the fact that reality is often far messier than such pristine categories would suggest. Or put another way, “the recovery map does not always accurately depict the territory.”
The image of pathways suggests a crossroads with distinct options that call for clear decision-making or voiced guidance from some GPS of addiction recovery. The image conveys that one must choose A, B, or C—with some advocates of each standing at the crossroads claiming they represent the one true path to recovery. There are millions of people living in recovery within these established frameworks of recovery, but there are also innumerable people in long-term recovery who have crafted a style of personal recovery at or beyond the boundaries of these approaches. Their recovery experiences are metaphorically more aptly described as an evolving patchwork, mandala, mosaic, medley, or hodgepodge rather than through the image of the well-marked path. Their recovery experiences are “dynamically evolving” in the sense that critical ingredients are regularly being forged and exchanged without a predetermined map or fixed point of completion. Their recovery experiences are patchworks, mandalas, or mosaics in the sense that this style of recovery may combine unusual and even contradictory elements, the whole of which may resemble no established style of recovery.
MosaicDoes this mean that individuals may combine a potpourri of ideas and approaches to initiate recovery and that these critical ingredients may change over time? Does this mean that people may initiate recovery within one framework of recovery but migrate to another framework to sustain recovery? Does this mean that some people may simultaneously use two or more frameworks of recovery, e.g., co-attendance at 12-Step meetings and SMART Recovery meetings? Does this mean that some people may initiate recovery without addiction treatment, but later seek professional help to enhance their emotional and relational health? Does this mean that the person using needle exchange services today may in the future be sponsoring others in Narcotics Anonymous? Does this mean that people may concurrently or sequentially combine addiction medications with participation in abstinence-based treatment and mutual aid? Does this mean that one’s secular, spiritual, or religious orientation may change, sometimes quite dramatically, over the course of recovery? YES, it means all of these and far more. As my friend Richard Simonelli suggests, these support options are best conveyed, not as a straight line of menu options, but as resources on the perimeter of the circle of our lives—resources that remain available to us if and when we need to draw on them.
Long-term recovery involves a rebirthing and assertive reconstruction of one’s life across multiple zones: physical, cognitive, emotional, relational, and spiritual health—all unfolding and evolving across the stages of life and within one’s unique personal responsibilities and aspirations. Achieving such reconstruction over time and maintaining balance within and across these zones is for some people far closer to improvisational jazz than to playing scored music written by one’s predecessors.
None of us are in a position to judge how others negotiate this process. We can only share what has worked for us and how what has worked for us has changed over time and circumstances. As a healing community and network of professional helpers and recovery researchers map long-term pathways and styles of recovery, we must not forget those whose recovery experiences do not fit within the boxes we have crafted to depict such varieties of recovery experience. Those outliers are also part of the recovery community, and their idiosyncratic stories must also be heard and celebrated. Many find recovery within a well-trod path, while others find recovery on the road less traveled. Still others will find recovery where no one has traveled before. Such differences do not need to be cast into categories of superiority and inferiority. All progressive movements toward and within recovery are cause for celebration–no matter how different the journey from our own.
A shared experience of addiction is a hollowing out of self, with the resulting sense of extreme emptiness, disconnection, and resulting sense of extreme isolation. How people authentically fill that emptiness and forge new social and intimate connections constitutes the essence of a highly variable healing process. Such varieties are indeed a cause for celebration. As the recovery advocacy movement declares: Recovery by any means necessary under any circumstances.
Post Date June 3, 2016 by Bill White


Recent surges in opioid addiction and opioid overdose deaths in the United States have triggered considerable public and professional alarm, including its emergence as an issue in the 2016 Presidential campaign. Public health responses to the rise in opioid-related problems have focused primarily on: 1) suppression of illicit opioid markets, 2) public education on opioid addiction risks, 3) prescription opioid disposal campaigns, 4) physician training and monitoring, 5) new non-opioid protocols for non-cancer pain management, 6) introduction of abuse-deterrent opioid formulations, 7) increased legal access and distribution of naloxone (Narcan®) for overdose intervention, and 8) efforts to expand access to addiction treatment—particularly medication-assisted treatment.
As long-tenured addiction researchers, the authors have supported these efforts, but have been struck by the scant attention given to the role recovery mutual aid organizations, such as Narcotics Anonymous (NA), are playing and can yet play in the national response to opioid addiction. If NA is mentioned at all in public or policy discussions of opioid addiction, it is as a fleeting reference to its existence as a post-treatment referral option, or, more frequently, in criticism of its alleged hostility toward maintenance medications in the management of opioid addiction. Such neglect, peripheral attention, or narrow coverage is puzzling, given that NA is the one surviving recovery mutual aid organization whose birth in the early 1950s focused almost exclusively on recovery from heroin and other opioid addiction.
Recent one-hour specials on ABC and CNN and a CBS 60 Minutes segment on prescription opioid and heroin addiction, like numerous other reports, failed to even acknowledge the existence of NA, nor did they mention other recovery mutual aid fellowships devoted specifically to supporting recovery from opioid addiction (e.g., Heroin Anonymous, Methadone Anonymous, Advocates for the Integration of Recovery and Methadone, Mothers on Methadone). Further, brief mentions of “AA and other Twelve-Step programs,” when such references do appear in media and policy discussions, convey the impression of NA as an Alcoholics Anonymous (AA) clone and fail to convey NA’s distinct history, culture, and program of recovery.
The authors have just published a research review and commentary suggesting that this lack of attention stems from a number of misconceptions about NA that are challenged by the scientific research. We contend, based on the available evidence we review, that:
1) NA is NOT a professionally-directed treatment for opioid addiction, but, similar to professional interventions, participation in NA’s community of shared experience and its Twelve-Step program can play a potentially important role in recovery initiation and recovery maintenance.
2) NA meetings and the broader NA program of recovery are increasingly accessible in the United States and in other countries.
3) The strength of the recovery culture within NA (and the average duration of continued abstinence) has progressively increased as NA has matured as a fellowship locally and globally.
4) NA participation enhances recovery outcomes for adolescents and young adults, and safety concerns have not been identified as a contributing factor to NA disengagement among young people.
5) NA effectively serves women, ethnic minorities, and other historically disenfranchised populations.
6) NA does not formally affiliate with any outside enterprise but has established effective service collaborations with addiction treatment programs and correctional institutions through its Hospital and Institutions subcommittees.
7) Though NA is explicitly abstinence-based in its orientation to recovery, it welcomes the participation of peopled in medication-assisted treatment (MAT) who are considering or in the process of sustaining their recovery without MAT support.
8) Taking medications for a mental health condition as prescribed is compatible with NA’s abstinence orientation, and nearly one quarter of NA members report the current use of such medications.
9) The degree to which NA’s perceived religious/spiritual orientation inhibits attraction to NA or contributes to NA drop-out is unclear, but studies have found that people with less religious orientation who participate in Twelve-Step groups experience benefits similar to those with greater religious orientation. Most NA members report a spiritual but not a religious orientation.
10) NA participation by adults has been found to enhance recovery stability, emotional health, quality of life, and community involvement.
11) NA participation has the potential to significantly reduce the social and health-related costs of opioid addiction and does so at no cost to families, governmental agencies, or private insurers.
The NA research upon which these conclusions are drawn is tentative due to the limited number of studies and varying degrees of methodological rigor, but they represent the most credible scientific data available on NA and the effects of NA participation on recovery outcomes.
Media coverage and professional discourse related to opioid-related deaths and devastation heighten awareness and fear, but all too often reveal little if any information on the lived solutions to opioid addiction as experienced within NA and other peer-based recovery support institutions. We believe the reviewed misconceptions about NA contribute to the paucity of such attention. Increased coverage of people in long-term recovery from opioid addiction and the role of NA and other recovery support institutions in such achievements would help move the national conversation on opioid addiction from a focus on the problem to a focus on the lived solutions that now exist in communities across America.
How might the individual, family, and community trajectory of opioid addiction be altered if every naloxone administration, every treatment admission and discharge (regardless of modality or setting), every drug-related visit to a general practitioner or health clinic, and every drug-related HIV or Hepatitis C screening were accompanied by assertive linkage to NA or other recovery mutual aid resources? We believe it is time to test that potential. Forging an assertive, long-term public health response to opioid addiction will require more than a rising sense of urgency; it will require forging partnerships with those individuals and organizations who understand the need for such urgency in its most human terms.
There is a pervasive pessimism about the long-term prospects of recovery from opioid addiction. Tens of thousands of NA members in long-term recovery from opioid addiction stand as a living refutation of such pessimism. That fact is the least told story in the public media and in professional discussions of opioid addiction. Innumerable individuals, families, and communities will be ill-served if we neglect the role NA and other recovery mutual aid organizations can play in supporting long-term recovery from opioid addiction.
NA has distinguished itself for more than 60 years as an organization with the singular goal of supporting addiction recovery. It is time such contributions were more fully appreciated at public and professional levels, more research attention was conducted on NA, and NA resources were more fully integrated within public health responses to rising opioid addiction.
To read the complete review and commentary with all study citations, click HERE. .
About the Authors: William White, M.A., is Emeritus Senior Research Consultant at Chestnut Health Systems and the author of Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Marc Galanter, M.D., is Professor of Psychiatry at New York University School of Medicine, the former president of the American Society of Addiction Medicine, the lead author on several NA-related studies, and the author of the recently-released book, What is Alcoholics Anonymous? John Kelly, Ph.D., is the Elizabeth R. Spallin Associate Professor of Psychiatry in Addiction Medicine at Harvard Medical School, the founder and Director of the Recovery Research Institute at the Massachusetts General Hospital (MGH), and a former President of the American Psychological Association (APA) Society of Addiction Psychology. Keith Humphreys, Ph.D., is a Professor in the Department of Psychiatry and Behavioral Sciences at Stanford University, a Senior Research Career Scientist at the VA Health Services Research Center, a former Senior Policy Advisor at the White House Office of National Drug Control Policy, and author of Circles of Recovery. All of the authors have conducted and published studies on addiction recovery mutual aid organizations.

Post Date May 27, 2016 by Bill White


“How does it feel to be a problem…It is a peculiar sensation, this double consciousness, this sense of always looking at one’s self through the eyes of others, of measuring one’s soul by the tape of the world that looks on in amused contempt and pity.” –W.E.B. Du Bois, The Souls of Black Folks
“I am invisible, understand, simply because people refuse to see me. Like the bodiless heads you see sometimes in circus sideshows, it is as though I have been surrounded by mirrors of hard, distorting glass. When they approach me they see only my surroundings, themselves or figments of their imagination, indeed, everything and anything except me.” ― Ralph Ellison, Invisible Man
W.E.B. Du Bois and Ralph Ellison introduced three concepts of considerable import to recovery advocates. Du Bois’ notions of the veil and double consciousness were brilliantly conceived with profound implications for the future of race relations and efforts to escape the personal effects of racism—or similar processes related to people affected by prolonged historical trauma and contemporary social stigma and discrimination.
Du BoisIn the addictions context, the veil is a metaphor for the artificial lens through which people in addiction recovery are socially viewed and through which they simultaneously view the larger social world in which they are nested. As Howard Winant has observed, “The veil not only divides the individual self; it also fissures the community, nation, and society as whole (and ultimately, world society in its entirety.).” The veil contains objectified images and caricatures that distort how one is seen and how one sees oneself and others. Self-talk and communication with others are hampered and distorted through the veil’s influence. The veil creates a deep sense of alienation, disconnection, and utter sense of aloneness. As Richard Wright’s Bigger Thomas declares in Native Son: “Half the time I feel like I’m on the outside of the world peeping in through a knothole in the fence.”
Du Bois double consciousness depicts a related split produced by the introjection of addiction-related social stigma (a stained self) and the resulting defensive projection of a false self. Over time, these processes of double consciousness make claiming one’s “real self” increasingly difficult. As a result of this prolonged mask-making, one’s greatest fear is not that one’s inner evilness will be revealed, but that one’s utter emptiness and status as an imposter will be fully exposed to self and others.
Ralph EllisonEllison’s concept of invisibility suggests a potential threefold loss of self: 1) being seen only as an objectified caricature if one’s recovery identity is revealed, 2) a profound sense of imposterhood as one’s stigmatized status is hidden behind layers of masks, and 3) the inability to feel and hold to one’s own true self. That sense of invisibility-even to oneself–is amplified by the depersonalization experienced in late stages of addiction. Social invisibility, whether buried within a subterranean drug culture or hidden behind a carefully but fragilely crafted mask of normalcy, is an inevitable dimension of the addiction experience.
While addicted, we are invisible until acts of degradation and desperation (or our untimely death) briefly thrusts us into the public spotlight. In recovery, we also remain invisible until we come to see ourselves as a “people” and respond to prophetic call to collectively step from hiding to declare our existence. Other illnesses once bore a moral stain (e.g., tuberculosis, epilepsy, schizophrenia, cancer) and social invisibility, but campaigns to destigmatize some of these disorders (most particularly, cancer) have fundamentally altered their social perception and their professional treatment.
When we all step out of our cloistered sanctuaries and look around, we realize a profound lesson: we are all wounded in some way and all reaching for healing and wholeness. When the veils fall, the need for double consciousness diminishes and invisibility and transparency give way to a new sense of personhood. When the veil is lifted, we can escape entrapment within the label “substance abuser” and emerge as a free person of substance. When the veil of shame is lifted, we will find to our great surprise that what lies beneath is not our personal inferiority, but shared pain, unquenchable hope, and our common humanity—what Ernie Kurtz and Katherine Ketcham christened The Spirituality of Imperfection. It is time the veil, the double consciousness, and the invisibility that pervades addiction recovery were relegated to the dustbin of history. Only a recovery advocacy movement sustained across generations will achieve that goal.

Post Date May 20, 2016 by Bill White


The extension of acute care (AC) models of addiction treatment to models of sustained recovery management (RM) models of sustained recovery management (RM) for people with severe, complex, and chronic substance use disorders requires a fundamental redesign of what we have known as the continuum of care. A newly conceived continuum of care would span the stages ofprerocovery, recovery initiation and stabilization, recovery maintenance, enhanced quality of personal and family life in long-term recovery, and efforts to break intergenerational cycles of alcohol- and other drug-related problems. A striking hole within that continuum of care at present is what happens to individuals and families following discharge from addiction treatment. Aftercare remains an afterthought despite rhetoric to the contrary, and the cost of such neglect is the repeated recycling of people through acute care models of addiction treatment, with the accompanying demoralization of patients, families, and caregivers, to say nothing of the related costs. One of the promising innovations in post-treatment recovery management is that of recovery management checkups. recovery management checkups.
For more than a decade, Dr. Christy Scott, Dr. Michael Dennis, and their colleagues have refined a model of recovery management checkups (RMC) aimed at enhancing long-term addiction recovery process and influencing tandem behavioral risks (e.g., illegal activity and HIV risk behavior). The RMC model includes regular post-treatment monitoring, recovery encouragement, assertive linkage to treatment other recovery support resources as needed (including transportation for re-assessment), and an HIV risk reduction intervention. In a 2013 summary of three RMC clinical trials, Scott and colleagues summarized the study outcomes and implications as follows.
“RMC (recovery management checkups) clinical trials provide evidence that ongoing monitoring, feedback, and early reintervention can be effective methods of managing recovery over time. Ideally, such services would be paid for and become a requirement for treatment program licensure, accreditation, and funding. Those requirements would be best linked to a larger strategy of reorienting addiction treatment from a predominantly acute care model of intervention to a service model that provides services ranging from a brief intervention to long-term recovery management. However, the implications of shifting to a chronic care model are significant. That shift will require a radical redefinition of the continuum of care, new service philosophies, new service delivery technologies, and a fundamental rethinking of systems of reimbursement for addiction treatment and recovery support services…. Experience to date also suggests the need for a substantial investment in articulating the ethics and etiquette of conducting RMC across diverse clinical populations and cultural contexts.” (p. 272)
Questions remain on key dimensions of the RMC model. What roles and organizational settings are best suited to conduct RMCs, e.g., the treatment organization, a recovery community organization, a research team, and managed care organization? Do RMC outcomes vary by key characteristics of the person performing the RMC, e.g., education, level of training and supervision, gender or ethnicity matches, recovery status, paid versus volunteer? Does RMC effectiveness vary by clinical subpopulation or by cultural context? What is the ideal duration of RMCs following recovery initiation? Could current patient-focused RMC formats be modified to focus on the recovery process of the whole family?
What is not in question is the need for continued systems of recovery support for those with severe substance use disorders and the potential value of the RMC as an integral component of such assertive continuing care. Are RMCs being utilized within your local treatment programs and recovery support organizations? If not, why not?
Recent RMC Studies/Reviews
Dennis, M.L., Scott, C.K. & Laudet, A. (2014). Beyond bricks and mortar: Recent research on substance use disorder recovery management. Current Psychiatry Reports, 16, 442.
Garner, B. R., Godley, M. D., Passetti, L. L., Funk, R. R., & White, W. L. (2014). Recovery Support for adolescents with substance use disorders: The impact of recovery support telephone calls provided by pre-professional volunteers. Journal of Substance Abuse and Alcoholism. 2(2), 1010.
McCollister, K.E., French, M.T., Freitas, D.M., Dennis, M.L., Scott, C.K., & Funk, R.R. (2013). Cost-Effectiveness analysis of Recovery Management Checkups (RMC) for adults with chronic substance use disorders: evidence from a four-year randomized trial, Addiction, 108, 2166-2174.
Scott, C.K., Dennis, M.L., Willis, B., & Nicholson, L. (2013). A decade of research on recovery management checkups. In: Interventions for addiction: Comprehensive addictive behaviors and disorders. Elsevier Inc., San Diego: Academic Press, pp. 267–273.

Post Date May 13, 2016 by Bill White


Addiction recovery is a highly intrapersonal process, but it also can and often does involve a journey between two physical and cultural worlds. Some years ago, I explored the implications of this suggestion in the book, Pathways from the Culture of Addiction to the Culture of Recovery. Here are some key points from that book.
Elaborate cultures–with their own tribal organization, roles, rules, core daily activities, relationship etiquette, language, values, symbols, rituals, music, literature, and art–have evolved to provide sanctuary for people with severe and prolonged alcohol and other drug problems. Such cultures can play important roles in the initiation and maintenance of addiction, and they can constitute a major obstacle to successful addiction recovery. People can become as addicted to a culture of addiction as they are to the central sacraments of that culture. The wide range of needs met within that culture can be as powerful a pull back to addiction as the brain’s adaptation to the presence (euphoria, self-comfort) or absence (craving, anxiety) of drugs.
Recovery involves radically altering the person-drug relationship, but it also involves changes in one’s relationship to the culture (people, places, and things) that has supported the person-drug relationship. The addiction experience varies to the extent one is isolated from the culture of addiction (acultural style), is involved in both the mainstream and addiction cultures (bicultural style), or lives one’s life almost exclusively within the culture of addiction (enmeshed style). For those with significant involvement within the culture of addiction, recovery requires discovery of new ways to meet a vast array of needs once met within the culture of addiction. Failing that, addiction recurrence is as much a return to the culture of addiction as a return to the drug.
People who have escaped the addiction experience have organized parallel cultures of recovery to serve as havens for those with these shared experiences and aspirations. The culture of recovery also has its own tribal organization, roles, rules, core daily activities, relationship etiquette, language, values, symbols, rituals, music, literature, and art. This culture offers an alternative set of people, places, and things that support recovery initiation, recovery maintenance, and enhanced quality of personal and family life in long-term recovery. The recovery experience varies to the extent one is isolated from the culture of recovery (acultural style), is involved in both the mainstream and recovery cultures (bicultural style), or lives one’s life almost exclusively within the culture of recovery (enmeshed style). As with addiction, these styles of cultural affiliation can vary across the stages of recovery.
People with enmeshed styles of addiction may need a period of decompression and parallel enmeshment within a culture of recovery to achieve successful recovery stabilization and maintenance. They may need guides to assist them on this journey, e.g., the peer assistance found within recovery mutual aid societies, culturally competent addiction professionals, or within new recovery support roles (e.g., recovery coaches). What has changed since first writing Pathways is the exponential development of the culture of recovery in the United States. Recent history has witnessed the growth and diversification of the culture of recovery via the growth of secular, spiritual, and religious recovery mutual aid societies; a new addiction recovery advocacy movement culturally and politically mobilizing people in recovery and their allies; new recovery support institutions (recovery community centers, homes, schools, industries, ministries, cafes, and sports venues); development of new recovery-focused language, art, music, literature, theatre, and film; and the growth of technology-based recovery support via the Internet. The culture of recovery in the U.S. has never been more fully evolved, diverse, family-inclusive, geographically accessible, and financially affordable.
In an era that continues to be dominated by acute care models of addiction treatment, treatment that focuses almost exclusively on neurobiological stabilization (e.g., short-term detoxification, medication with minimal if any sustained psychosocial support), and treatment that views recovery as a primarily physical and psychological process, it is helpful to again remind ourselves of the role of culture in the processes of addiction and recovery. If recovery is for many a journey between two worlds, then there is a need for a fully developed culture of recovery available across geographical and cultural contexts. That development is one of the major stories of recent decades. Also needed are roles filled by persons with a profound depth of knowledge of the cultures of addiction and recovery to serve as guides in this transcultural process. That has yet to be achieved, and the rise of new services and support roles aimed at speeding recovery initiation (shortening addiction careers) and supporting long-term personal and family recovery is in part an attempt to fill this void.
In writing Pathways from the Culture of Addiction to the Culture of Recovery, I tried to provide a travel guide through which addiction professionals and recovery support specialists could serve as effective guides in this cultural journey from addiction to recovery. Since then, both cultures have undergone profound changes. I hope others will carry forward this work of cultural exploration and its service and recovery support implications. Addiction treatment and peer recovery support outcomes may be determined as much by the presence and vitality of healing communities (cultures of recovery) as by the vulnerabilities and assets of individuals in need of such healing. Many have written eloquently about the role of culture and community in recovery, but perhaps none more eloquently than that found in the words of Joseph Campbell.
“We have not even to risk the adventure alone; for the heroes of all time have gone before us; the labyrinth is thoroughly known; we have only to follow the thread of the hero-path. And where we had thought to find an abomination, we shall find god; where we had thought to slay another, we shall slay ourselves; where we had thought to travel outward, we shall come to the center of our existence; where we had thought to be alone, we shall be with all the world.” –from The Hero with a Thousand Faces
Post Date May 6, 2016 by Bill White