BLOG & NEW POSTINGS October 30, 2015 – Bill White- DR. VINCENT DOLE (1913-2006) ON METHADONE MAINTENANCE TREATMENT

Dr. Dole always regarded methadone as a legitimate medication to normalize aberrant metabolism and thus behavior in the chronic disease of opioid addiction…Dr. Dole was always at the service of patients and advocacy groups to help resolve issues of stigma and misdirected policies…–Herman Joseph and Joycelyn Sue Woods, 2006
In 1964, Dr. Vincent Dole and two colleagues, Dr. Marie Nyswander and Dr. Mary Jeanne Kreek, pioneered methadone maintenance in the treatment of heroin addiction. A half century later, their work stands as a pivotal milestone in the history of addiction treatment. Few subjects within the history of addiction treatment have elicited greater heat and less light than the rhetorical debates that long raged and continue today on methadone maintenance treatment (MMT). I have detailed earlier (see here) my transformation from a rabid critic of MMT (a role I acquired by osmosis during my early years in the field) to a supporter of MMT and other forms of medication-assisted treatment (MAT), even as I sought to elevate the quality of such treatments. The papers and speeches I made on MMT/MAT (see here, here, and here as examples) generated some of the harshest criticisms of my professional career.
As MMT passes the half century mark, I thought it appropriate to revisit some of the original MMT papers authored by Dr. Dole and co-authors. In rereading these early papers and Dr. Dole’s later reflections on the evolution of MMT, I was struck anew by his passionate appeals for science-grounded addiction treatment and by his fierce loyalty to the needs of patients. I recalled that same passion when I interviewed him as part of my research for Slaying the Dragon.
All addiction professionals and recovery support specialists should be knowledgeable of the science and history of MMT. I have highlighted below some excerpts from the papers of Dr. Dole to provide some historical perspective on the evolution of methadone maintenance as practiced in the United States—in Dr. Dole’s own words. I hope to return later to highlight the thought and work of his collaborators, Dr. Nyswander and Dr. Kreek.
On His Initial Introduction to the Addictions Field
“I said what a shame it was that there was none of the scientific thought in the field of addiction that I had encountered in my other researches. It didn’t have recognition as a scientific problem.” (1989)
On Perception of Persons Addicted to Opiates
“. . . the traditional image of the narcotics addict (weak character, hedonistic, unreliable, depraved, dangerous) is totally false. . . .I had an exceptionally gifted teacher, Marie Nyswander, who taught me how to listen to patients rather than rush into their problems with pre-formed judgements. . . .the typical heroin addict is a gentle person, trapped in chemical slavery, pathetically grateful for understanding and effective treatment. In short, a sick person needing treatment.” (1994a)
“. . . it must not be too quickly assumed that these are weak individuals who would fail in society if relieved of the compulsion to obtain drugs. The potential strengths of addicts, like their faults, cannot be judged while the addicts are trapped in the orbit of drug abuse.” (Dole & Nyswander, 1967)
Nature of Opioid Addiction / Rationale for MMT
“It is postulated that the high rate of relapse of addicts after detoxification from heroin is due to persistent derangement of the endogenous ligand-narcotic receptor system and that methadone in adequate daily dose compensates for this defect…methadone maintenance provides a safe and effective way to normalize the function of otherwise intractable narcotics addicts.” (1988)
“The most important principle to recognize is that addiction is a medical disease. And, as a medical disease, it’s the responsibility of the medical profession. . .” (1996)
“It is important to distinguish the causes from the consequences of addiction . . . The rapid disappearance of theft and antisocial behavior in patients on the methadone maintenance program strongly supports the hypothesis that the crimes that they have previously committed as addicts were a consequence of drug hunger, not the expression of some more basic psychopathology.” (Dole & Nyswander, 1967)
On Complexity of Opioid Addiction and MMT
“I urged that physicians should see that the problem was one of rehabilitating people with a very complicated mixture of social problems on top of a specific medical problem. . . The strength of the early [MMT] programs as designed by Marie Nyswander was in their sensitivity to human problems. The stupidity of thinking that just giving methadone will solve a complicated social problem seems to me beyond comprehension. . .” (1989)
On Perception of MMT as “Drug Substitution”
“This medication [methadone] given in fixed dose to tolerant subjects, does not make patients “high” or cause any other narcotic effects. On the contrary it eliminates the abnormal euphoric responses of addicts to narcotic drugs.” (Dole, Nyswander, & Kreek, 1966)
“What was not anticipated at the onset was the nearly universal reaction against substituting one drug for another, even when the second drug enabled the addict to function normally. . . . The analogous long term use of other medications such as insulin and digitalis in medical practice has not been considered relevant.” (Dole & Nyswander, 1976)
On Functioning of MMT Patients
“[MMT] patients are normally alert and functional; they live active lives, hold responsible jobs, succeed in school, care for families, have normal sexual activity and normal children, and have no greater incidence of psychopathology or general medical problems than their drug-free peers.” (1988)
On Importance of Service Relationships within MMT
“Like teachers in a one-room school, we knew each patient personally. The ones in trouble were seen more often, the successful ones, less often; all were followed closely enough for us to know what they were doing.” (1971)
“I made a practice of spending two or three hours almost every day just sitting and talking with the addicts in a somewhat aimless way. I was just trying to get a sense of their way of thinking, their values, their experiences. They educated me about a world that was out of my reach, one that I had never been in and would never enter.” (1989)
“The most that any chemical agent can do for an addict is to relieve his compulsive drive for illicit narcotic. To give him hope and self-respect requires human warmth; to become a productive citizen he needs the effective support of persons who can help him find a job and protect him from discrimination. It is these human qualities that the treatment programs of the past five years have failed.” (Dole & Nyswander, 1976)
“. . . with addiction we’re dealing with a disease in which human relationships are integral to rehabilitation. (1989)
On Early Fears about the Future of MMT
“The success of this treatment in rehabilitation of addicts will decline significantly if methadone programs cease to be medical institutions, and instead become instruments of another bureaucracy.” (1971)
On Early MMT Expansion
“The difficulty was not that methadone expanded, or that it did so rapidly, but that it expanded faster than medical competence developed. . . . across the country people who had very little understanding of the pharmacology of methadone, and no comprehension of the wider array of medical and social problems presented by addicts, jumped into the field, feeling that all they had to do was hand out the drug.” (1989)
“. . . abstinence rather than rehabilitation was restored as the goal of treatment; doses were lowered to levels that were frequently inadequate; administrators became punitive and often contemptuous of the patients’ (now called “clients”) termination of maintenance was encouraged despite an 80% relapse rate…Underfunded, crowded, operating in poor quarters, harassed by teams of inspectors who criticized their deficiencies without providing money or political support for improvement, with a negative image fueled by disinformation in the media, the methadone clinics nevertheless survived, thanks to the dedication of their overworked staffs.” (1999)
On Coerced Involvement in MMT
“Is it proper for a judge to force treatment on an addict by sentencing him to a maintenance program? Is it advisable for a physician to accept patients on these terms? I would say definitely no to both of these questions. . . . I would object to the imposition of methadone maintenance treatment just as strongly as I have objected in the past to its unavailability . . .” (1971)
On Withholding or Reducing Methadone Dose for Rule Violations
“The results are generally poor, as might be expected from the fact that limiting or withholding medication that reduces drug hunger increases the need for illicit narcotics.” (1988)
On Regulation of MMT
“Bureaucratic control of methadone programs has given us “slots,” a rule book, and an army of inspectors, but relatively little rehabilitation.” (Dole & Nyswander, 1976)
“True patient-oriented [MMT] treatment guidelines will emerge when the medical profession insists on applying the same standards of chemotherapy in addictions as it applies to chemotherapy in infectious disease, cancer, schizophrenia, depression, and endocrine disorders.” (1992)
“. . . the contempt with which many regulators and program administrators have treated their [MMT] patients seems to be scandalous.” (1996)
On Termination of MMT
“. . . methadone patients are not necessarily committed to a lifelong dependence on the medication. A significant fraction of the abstinent ex-addicts in New York today has previously been stabilized and socially rehabilitated in methadone programs. The key to this result is the realization that the most important objective in treatment of an addict is support of good health and normal function. This may or may not require continuation of maintenance.” (1994)
“The question of whether and when to discontinue methadone therapy can be answered in medical terms if the treatment is judged by the same standards as apply to other chronic diseases.” (1973)
“. . . the possibility of detoxification should be evaluated on an individual basis, taking into account the patient’s own desires in the matter, his progress in rehabilitation, and the potential hazards of relapse.” (Cushman & Dole, 1973)
On Predicting Positive Outcomes Following Termination of MMT
“Available data suggest that the longer a patient continues in a maintenance program that provides adequate doses (e.g., five years or more), the greater his or her probability of permanent abstinence after termination of [MMT] treatment. Apparently, the neurochemical adaptations produced by thousands of heroin injections (with sudden impact on the nervous system and rapid elimination) are capable of gradual repair in some cases under the steady conditions of methadone maintenance.” (1994)
On the Need for Post-MMT Recovery Checkups
“A good physician, experienced in treatment of chronic disease, will weigh these factors before attempting detoxification and will follow his patient for several years afterward, keeping the door open for return to maintenance if indicated.” (1973)
On Patient Advocacy
“. . . I think methadone patient advocacy groups are going to grow in proportion to the numbers of people or programs who abuse their powers over methadone patients.” (1996)
Future View of MMT
“I would say 30 years from now that current attitudes regarding methadone as substituting one drug for another and other negative outlooks on drug addicts in general will seem pretty archaic. What’s happening today seems more like a carryover of medieval attitudes that affected much of the thinking toward mental illness in the last century.” (1996)
“Methadone is very valuable in controlling a specific kind of addiction, namely opioid addiction . . . But the emphasis should be on the fact that you’re controlling the disease; you’re not curing the disease. In time, and with full knowledge of all disturbances to in the neurohormonal systems in the brain, we may find ways to remedy and cure or restore a person to “normal”.” (1996)
On His Involvement with Alcoholics Anonymous
“. . . before accepting the position [non-alcoholic trustee of the Board of A.A], I discussed my research with Executives of the fellowship and raised the question as to whether this appointment might involve a conflict of interest. . . . The insisted that they saw no problem. . . They were right. There never has been a problem in my association with AA, and my admiration for Bill Wilson and the dedicated AA members that I came to know increased over the years.” (1991)
“At the last trustee meeting that we both attended, he [Bill Wilson] spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. . . . He suggested that in my future research I should look for an analogue of methadone, a medicine that would relieve the alcoholic’s sometimes irresistible craving and enable him to continue his progress in AA toward social and emotional recovery, following the Twelve Steps.” (1991)
References
Dole, V.P., & Nyswander, M.E. (1965). A medical treatment for diacetylmorphine (heroin) addiction. Journal of the American Medical Association, 193, 646-650.
Dole, V.P., Nyswander, M.E., & Kreek, M.J. (1966). Narcotic blockade. Archives of Internal Medicine, 118, 304-309.
Dole, V.P., & Nyswander, M.E. (1967). Heroin addiction—a metabolic disease. Archives of Internal Medicine, 120, 19-24.
Dole, V. P. (1971). Methadone maintenance treatment for 25,000 addicts. Journal of the American Medical Association, 215, 1131-1134.
Dole, V.P. (1973). Detoxification of methadone patients and public policy. Journal of the American Medical Association, 226, 780-781.
Cushman, P., & Dole, V.P. (1973). Detoxification of rehabilitated methadone-maintained patients. Journal of the American Medical Association, 226(7), 747-752.
Dole, V.P., & Nyswander, M.E. (1976). Methadone maintenance treatment: A ten year perspective. Journal of the American Medical Association, 235, 2117-2119.
Dole, V. P. & Joseph, H. (1978). Long-term outcome of patients treated with methadone maintenance. Annals of the New York Academy of Science, 311, 173-180.
Dole, V.P. (1988). Implications of methadone maintenance for theories of addiction. The Albert Lasker Medical Awards. Journal of the American Medical Association, 260, 3025-3029.
Dole, V.P. (1989). Interview. In D. Courtwright and J. H. Des Jarlais, Addicts who survived (pp. 331-343). Knoxville, TN: The University of Tennessee Press.
Dole, V.P. (1992). Hazards of process regulation: The example of methadone maintenance. Journal of the American Medical Association, 267, 2234-2235.
Dole, V.P. (1994a). What we have learned from three decades of methadone maintenance treatment. Drug and Alcohol Review, 13, 3-4.
Dole, V.P. (1994b). Addiction as a public health problem. Alcoholism: Clinical and Experimental Research, 15(5), 749-752.
Dole, V.P. (1996). Interview with Dr. Vincent Dole, M.D.: Methadone: The next 30 years? Addiction Treatment Forum, Winter, 1-6.
Dole, V.P. (1997). What is “methadone maintenance treatment”? Journal of Maintenance in the Addictions, 1(1), 7-8.
Dole, V.P. (2002). Conversation with Vincent Dole. In G. Edwards (Ed.), Addiction: Evolution of a specialist field (pp. 3-10). Oxford: Blackwell Science Ltd. (Reprinted from Conversation with Vincent Dole, by Dole, V.P., 1994, Addiction, 89, 23-29).
Joseph, H., & Woods, J. S. (2006). In the service of patients: The legacy of Dr. Dole. Heroin Addiction and Related Clinical Problems, 8(4), 9-28.

BLOG & NEW POSTINGS October 23, 2015 -Bill White – ANONYMITY AND RECOVERY ADVOCACY


The recent surge in social media discussions about anonymity and recovery advocacy (see here and here for examples) have triggered increased email inquiries about my thoughts as a recovery historian on these discussions. Some have pointedly asked which side I am on, as if an anonymity war had been launched forcing one to choose one camp or the other. If there is such an emerging split, I find myself challenging all who frame this issue as a war. I challenge recovery advocates who feel anonymity is a musty, outdated concept that has lost all value in the 21st century, and I challenge those in 12-Step fellowships who suggest that public disclosure of one’s recovery status is a breach of 12-Step Traditions. Here are selected excerpts from what I have written on this topic over the past 15 years.
A.A.’s predecessors had been wounded by leaders and members who either used visibility as a springboard for financial profit or whose public downfall brought discredit to the organization. A.A. avoided both of these pitfalls by declaring that no one with a name (at least a full name) could speak for A.A. Anonymity, while practiced as a spiritual exercise, also protected A.A. as an organization and brought many individuals into recovery who saw in anonymity a shroud of protection from the injury that can result from one’s being linked to a socially stigmatized condition. (2001)
Radical recovery is not an invitation to violate the anonymity traditions of Alcoholics Anonymous, Narcotics Anonymous, and other twelve-step fellowships. It is an invitation for some individuals and family members in twelve-step recovery and those from other pathways of recovery to talk publicly about their recovery status without reference to the means by which that recovery was achieved, e.g., without specific references to AA/NA affiliation at the level of press. It is an invitation for people to become a messenger of recovery apart from their particular identities as members of AA, NA, CA, WFS, WFS, SOS, LSR, or other recovery societies. (2004)
Anonymity served many practical functions in the early decades of AA, and quite animated discussions continue on the extent to which these functions continue or do not need to continue in the twenty-first century. Three such practicalities were most prominent. First, anonymity at the level of press (and the cultural etiquette of not using last names within meetings and admonitions of “who you see here, what you hear here, when you leave here, let it stay here”) helped attract and protect the identities of alcoholics whose affiliation with AA, if publicly known, could cause harm to them or other parties. Second, anonymity at the level of press protected AA from public damage to its reputation that could occur if a publicly identified AA member or leader experienced a resumption of destructive drinking and related mayhem. The principle of anonymity and the practice of leadership rotation also helped AA avoid the organizational pitfalls of charismatic leadership and a centralized hierarchy that publicly personified AA. That function was particularly significant at an organizational level within a fellowship that defined the central problem of its members in terms of “self-centeredness,” “self-will run riot” and “playing God.” An argument could be made that the social stigma attached to alcoholism has declined in recent decades, making the first two functions less vital, although I don’t think this same argument could be made in such 12-Step groups as Narcotics Anonymous, Cocaine Anonymous, Heroin Anonymous, and other 12-Step groups for persons addicted primarily to illicit drugs. (2013)
I still see the value of anonymity at the level of press as a protection of all 12-Step programs, and leaders within the new recovery advocacy movement distinguish public disclosure of recovery status (including at the level of press) with disclosure of one’s affiliation with AA or another 12-Step program at the level of press. I think disclosure of recovery status at the level of press without reference to affiliation with AA or another 12-Step program complies with the letter of Traditions Ten & Eleven, but it may not always meet the spirit of the Traditions (Tradition Twelve)….I think the practical justifications for anonymity change and may even be lost as cultural contexts change, but anonymity as “spiritual foundation” comes from a quite different source—not cultural context and the personal or organizational threats such context pose, but from the essential dilemma of individuals seeking recovery within a 12-Step framework. One of the central discoveries within AA was that the alcoholic could not recover using only resources within the self. The alcoholic’s essential problem, whether as a cause or consequence of alcoholism, was, in AA’s view, entrapment within the self. The most cursory scan of AA’s basic text, Alcoholics Anonymous, is informative. AA’s founding generation viewed such things as self-awareness, self-knowledge, self-control, self-discipline, self-assertion, self-reliance, and self-confidence not as virtues but as part of the central pathology of alcoholism (along with other self-hyphenated conditions, e.g., self-justification, self-pity, and self-deception). So what AA constructed via its steps and rituals was a “we program” rather than an “I program” of recovery that allowed the alcoholic to escape entrapment within the self—a program that required nothing less than the “destruction of self-centeredness” (AA, 1939, p. 30). When AA literature speaks of anonymity as a “spiritual principle,” it does so out of a profound understanding of the importance of self-transcendence as the vehicle for sobriety and serenity. You can hear people depicting AA as a “selfish program” to mean that the alcoholic must get sober for self and not for others, but you find a quite different orientation on the issue of anonymity. The “spiritual substance” of anonymity according to AA’s core literature is not selfishness but “sacrifice.” (AA, 1952/1981, p. 184). What is sacrificed in AA (and in acts of heroism) are one’s “natural desires for personal distinction,” which in AA are eschewed in favor of “humility, expressed by anonymity” (AA, 1952/1981, p. 87). Applying this understanding, one could see how an AA or NA member choosing public recovery advocacy could technically meet the letter of Tradition Eleven (not disclosing AA affiliation at the level of press), but violate the pervading spirit of the Traditions (Tradition Twelve). This could occur when advocacy is used as a stage for assertion of self (flowing from ego / narcissism / pride and the desire for personal recognition) rather than as a platform for acts of service, which flow from remorse, gratitude, humility, and a commitment to service. (2013)
There is a purity—perhaps even a nobility—to recovery advocacy when it meets the heroism criteria. There is a zone of service and connection to community within advocacy work, and I think we must do a regular gut check to make sure we remain within that zone and not drift into advocacy as an assertion of ego. The intensity of camera lights, the proffered microphone, and seeing our published words and images can be as intoxicating and destructive as any drug if we allow ourselves to be seduced by them. If we shift our focus from the power of the message to our power as a messenger, we risk, like Icarus of myth, flying towards the sun and our own self-destruction. To avoid that, we have to speak as a community of recovering people and avoid becoming recovery celebrities—even on the smallest of stages. We must stay closely connected to diverse communities of recovery and speak publicly not as an individual or representative of one path of recovery, but on behalf of all people in recovery. The fact that no one is fully qualified to do that helps us maintain a sense of humility even as we embrace the very real importance of the work to be done. The spirit of anonymity—that suppression of self-centeredness—can be respected when we speak by embracing the wonderful varieties of recovery experience rather than as individuals competing for attention and superiority. (2013)

BLOG & NEW POSTINGS October 16, 2015 – Bill White – MEDIA AND RECOVERY: A RARE TIP OF THE HAT


I have argued for years in my publications and speeches that American media outlets contribute to the social stigma that challenges and limits the lives of people in addiction recovery. Media coverage of recovery has historically been rare and tangential—usually conflated with active addiction and addiction treatment. Recovery is portrayed as an exception to the rule, with the media’s prolonged obsession with the mayhem and deaths of addicted celebrities feeding professional and public pessimism about the prospects of successful, long-term addiction recovery. Even when recovery is addressed, it has been most often told from the perspective of the recovery initiate rather than from the perspective of long-term personal and family recovery. But on rare occasions, a media leader gets the story right.
Media and Recovery The Meredith Vieira Show recently aired a follow-up to a piece on Oxford House that Meredith Vieira did for 60 Minutes in 1991. Here’s why this show deserves accolades. It shares the inspiring stories of people in long-term recovery, including those profiled in the original 1991 60 Minutes episode. It includes the faces and voices of women and people of color in long-term recovery. Rather than a few isolated stories, it shows a large segment of the show’s audience standing as people in long-term recovery. It conveys, through the individual stories, the powerful role of community support in long-term recovery. And the show acknowledges the historical emergence of new community support institutions beyond the more typical portrayal of addiction treatment.
To Meredith Vieira and her producers, I extend a tip of the hat for a job well done. Check out the show by clicking here.
Post Date October 16, 2015 by Bill White

BLOG & NEW POSTINGS October 9, 2015 – Bill White WHERE DO WE GO FROM HERE?


This past weekend thousands of recovery advocates participated in the Unite to Face Addiction rally in Washington D.C. and more than 600 remained to meet with their congressional leaders on issues of importance to people in recovery and their families. The Washington rally was one long dreamed of by the recovery advocates who gathered at the Recovery Summit in 2001 to launch a new addiction recovery advocacy movement. As people return to their homes and reflect on the next steps for themselves and the recovery advocacy movement, it seems a fitting time to revisit thoughts I shared in the closing keynote of the 2001 meeting in St. Paul, Minnesota. Below is a brief excerpt from that closing speech.

“We have selected the seeds for this campaign; it is time that we went home and planted them. When you get home and ask others to join us in this campaign, some will say they can’t help with this movement because they are too old. Remind them that Handsome Lake was 65 years of age in 1799 when he launched a sobriety-based revitalization movement among the Six Nations Iroquois Confederacy. Tell them how this man, who was near death, used his own sustained recovery as a springboard to bring sobriety to thousands of Native Americans.
Some will say they are too young. Remind them of the Reverend Alvin Foltz who entered recovery as a teenager and became known as the “saved drunkard boy” and one of the 19th century’s most articulate and effective temperance organizers. Remind them that at the ignition point of the civil rights movement, it was the youngest, not the oldest, minister asked to lead this movement. Remind them that the young King called to lead this movement changed a nation.
Some women will say that the multiple role demands of their lives leave little room to support such a movement. Remind them of the crucial roles women have played in the history of social movements. Remind them that the name of Martin Luther King, Jr., might have remained unknown if it were not for the courage of Rosa Parks.
Some members of the lesbian, gay, bisexual, and transgender community will say that they are too busy fighting their own stigma issues to participate in the recovery advocacy movement. Remind them of a most remarkable human being (and lesbian woman) who dreamed in 1944 that she could change the way a nation viewed alcoholism and the alcoholic. Tell them how Marty Mann built an organization that opened the doors of treatment and saved hundreds of thousands of lives. Tell them that her legacy is now being threatened.
Some will say their background disqualifies them. Remind them of Jerry McAuley and Malcom X whose religious transformations, recoveries from addiction, and activist visions were born in a jail cell. Tell them how each of these men, separated by a century, went on to lead thousands into lives of sober self-respect and dignity.
Some will say they are ill-suited to put a face and voice on recovery. Remind them that the greatest social movements have been sparked and supported by the most imperfect of people. Remind them that their face and their voice will be part of a choir of thousands who like themselves owe a debt of enormous gratitude.
Some will say that they and their families would be injured if they stepped forward. Acknowledge that stigma is real and that we don’t need everyone in recovery to play this public role. Remind them that there are hundreds of ways they can support this movement outside the view of the camera. We don’t need all individuals and families in recovery for this movement to succeed, but we do need a deeply committed vanguard.
You have been that vanguard and I want to close by honoring your passion and your perseverance. It is time for us to leave here and to go back to our communities. It is time for us to leave here and create the future of recovery in America.”
Excerpted from: White, W. (2006). Let’s Go Make Some History: Chronicles of the New Addiction Recovery Advocacy Movement. Washington, D.C.: Johnson Institute and Faces and Voices of Recovery, pp. 86-90. Photos courtesy of Greg Williams and Aaron Kucharski.

BLOG & NEW POSTINGS October 2, 2015 – Bill White – A DAY IS COMING: VISIONS OF A NEW RECOVERY ADVOCACY MOVEMENT


A day is coming when we will gather at state capitals and in our nation’s capital and you will see recovering people in every direction as far as the eyes can see–all offering themselves as LIVING PROOF that recovery is not just a possibility but a living reality.—October 6, 2001
In October 2001, addiction recovery advocates from around the country assembled in St. Paul, Minnesota to launch a new recovery advocacy movement. Those of us present had no way of envisioning the remarkable events that could and would unfold in the coming years. This weekend, now fourteen years later, recovery advocates from around the country will again assemble in the Unite to Face Addiction rally in Washington, D.C. It seemed appropriate on this historic occasion to revisit the vision that drew many of us to St. Paul in 2001. In my closing keynote at the 2001 Recovery Summit, I challenged those present to personally refine and deliver the address below in communities across the country. Perhaps that day we envisioned in 2001 has arrived.
St. Paul, 2001: It is an honor to be able to share some thoughts with you about the recovery advocacy movement in America. I have had the privilege of working with many of the grassroots organizations that are the backbone and heart of this movement. Recovering people and their families, friends, and professional allies are once again organizing to change the way this country views addiction and the potential for recovery. It is indeed an exciting time within communities of recovery in America.
There Was a Day
I want to begin my remarks by talking about our past. There is much we can learn by sitting at history’s feet. Comedian Lilly Tomlin once observed that, if we listened, maybe history wouldn’t have to keep repeating itself. I have come to recognize the profound wisdom in her words.
There was a day in the late 19th century when an elaborate network of recovery support groups and addiction treatment institutions dotted the American landscape. There were Native American recovery circles, the Washingtonians, the fraternal temperance societies, and the reform clubs. There were recovery-oriented inebriate homes, medically-oriented inebriate asylums, for-profit addiction cure institutes, and religiously-oriented inebriate colonies. In that time, physicians in the American Association for the Cure of Inebriety proclaimed to all the world that addiction was a disease that could be either inherited or acquired and that this disease was one from which people could fully recovery. On that day, recovery activists, alone and in organized groups, offered themselves as living proof that recovery from addiction was possible.
That day vanished in the opening years of the twentieth century, drowned in a wave of cultural pessimism that closed addiction treatment institutions and sent recovery groups into hiding. The demise of America’s first era of institutional treatment and recovery support groups is a stark reminder that we can take nothing that exists today for granted.
As America’s 19th century institutions and support groups collapsed, a new sunless day emerged. That day, less than a hundred years ago, witnessed addicted people locked away for years in rural penal colonies. Americans, believing that alcoholics and addicts were a “bad seed” that threatened the future of the society and the human race, passed laws providing for their mandatory sterilization. That was a time when people who had yet to achieve recovery filled the “cells” of “foul wards” in large city hospitals, and they were the lucky ones, as most hospitals refused their admission. That was a day when alcoholics and addicts spent their most despairing hours in city drunk tanks. That was a day when those not yet in recovery died in the streets and were swept up like discarded refuse. That was a day when alcoholics and addicts languished in the snake pits of aging state psychiatric hospitals. That was a day when alcoholics and addicts were subjected to brain surgery and shock therapies and every manner of drug insult–all thrust upon them in the name of help. That was a day when family members died a thousand emotional deaths in their desperate, unrelenting search for help for an addicted spouse, parent, sibling, or child. Those days of professional condescension and public contempt were not so long ago.
The remnants of those dark days were present in the earliest years of my own entrance into the worlds of addiction treatment and recovery. In the 1960s, I witnessed alcoholics and addicts languishing in the most cold and callous of institutions. I have no words to convey the feel or smell of such places, places that conveyed in a thousand ways that you were not human, places that sucked the hope out of all condemned to live in them. I have vivid recollections of local community hospitals refusing to admit alcoholics and addicts for treatment of acute trauma: such people were perceived as not morally worthy to fill beds reserved for those who were “really sick.” Working as an outreach and crisis worker, I have nightmarish recollections of the bodies of the addicted hanging from torn sheets in jail cells, and my own desperate attempts to find the words to communicate with families who had long feared a visit such as mine.
The invasive treatments–the shock therapies, the drug insults, the prolonged sequestration–are not ancient tales. I recently interviewed a woman who was hospitalized for acute alcohol poisoning in 1971. She and her family were given two treatment choices: a one-year commitment in a state psychiatric hospital or brain surgery–a lobotomy–that they were told would remove her craving for alcohol. The woman herself thought the surgery a better alternative than being locked up for a year. But a chance encounter between her father and a man in recovery brought a woman from Alcoholics Anonymous to her bedside and the beginning of what has now been more than three decades of sanity, sobriety and service. Her story tells us that we are little more than a generation away from these infamous days. Her story also hints at what happened to open the doors of recovery.
Those Days Ended
Those dark days passed not by accident but because small handfuls of people in communities across the country said, “No More!” and spent their lifetimes destroying drunk tanks and drunk jokes. Those days ended because a desperate stock analyst reached out to a desperate physician and started a fellowship of recovering alcoholics whose influence embraced the world. Those days disappeared because of the vision of Marty Mann, who dared to dream in 1944 that she could change the way a nation viewed alcoholism and the alcoholic. Those days vanished because a senator, in gratitude for his own recovery, challenged a country to create local alcoholism education and treatment centers accessible to all of its citizens. The odds against success were enormous, but these remarkable human beings spent their lives building the world of addiction treatment and recovery that has touched the lives of many of us in this room. The bleakest days for the addicted in America passed because men and women looked beyond their own recoveries to advocate for the needs of others. The foul wards and drunk tanks and brain surgeries gave way to new treatment and recovery resources because real men and women made these changes happen. Consider for a moment what their lives rendered.
Imagine the degree of fulfillment that Dr. Robert Smith and Bill Wilson experienced at the sunset of their own lives as they reflected on the fruits of their work. Imagine what it must have been like for Sister Ignatia, who after working with Dr. Bob detoxifying early AA members, was later asked to address the 25th anniversary convention of AA in 1960. Imagine what this frail, humble woman must have felt as she stood and looked out at 17,000 sober and grateful alcoholics standing before her. Imagine what Marty Mann, after decades of barely acknowledged effort, must have experienced seeing the rise of local alcoholism treatment programs across the country. Imagine the import of such fulfillment in a woman who before her own recovery had repeatedly tried to kill herself. Imagine the fullness of lives that profoundly touched so many people.
The days of shame turned into days of hope because hundreds of unnamed men and women devoted their lives to changing the way a country looked at a disorder and those who suffered from it. The fruits of their work were indeed remarkable. Hundreds of thousands of people rose from the dead to live full lives because of the resources these people created. The national network of prevention and treatment programs are all part of their legacy as are the diversion programs in the criminal justice system and the early intervention programs in the workplaces and schools. By the early 1980s, it looked as if the dreams of these pioneers would be fully realized, but other forces were lurking in the background.
A Shameful Regression
Today, the world they created is being dismantled, and their advances are being threatened. Three ominous changes threaten this progress.
First, America is again restigmatizing those addicted to alcohol and other drugs. The positive images of long-term recovery (e.g., First Lady Betty Ford) are being replaced by what the public perceives as spoiled celebrities using “rehab” to escape the consequences of their latest indiscretion. Treatment and recovery are degraded through such images. The portrayal of addiction as a medical disorder suffered by sons and daughters, mothers and fathers, and brothers and sisters was replaced in the 1980s and 1990s by the worst racial and class stereotypes—stereotypes that linked addiction with crime, violence, and insanity. Alcoholics and addicts became not people deserving of compassion and help, but people to be feared and who were deserving of punishment. Thousands of celebrities will celebrate recovery anniversaries today and one will be arrested for possession of heroin. Which story do you think will fill the television screens this evening?
Second, after working for decades to place alcohol and other drug problems in the medical and public health arenas, we are now removing them from these very categories. Health care coverage to pay for addiction treatment continues to erode. Many, if not most, of the hospital treatment units have closed. The management of addiction is moving to non-medical settings and toward a focus on control of the addict and addiction-related costs rather than personal recovery.
Third, alcoholics and addicts are filling our courts, jails, and prisons in unprecedented numbers. There are now more than one and one half million drug-related arrests per year in the U.S., up more than 1 million since 1980. The number of drug offenders in state correctional facilities has risen from 38,900 in 1985 to more than 227,000 in 1997 and drug offenders in Federal prisons have risen from 9,482 in 1985 to more than 55,000 in 1996. I would be remiss if I did not talk about the racial disparity buried within these numbers. African Americans constitute only 15% of illicit drug consumers, but they make up 37% of those arrested for drug violations, 42% of drug offenders in federal prison and 60% of felony drug offenders in state prisons. A recently released Human Rights Watch report revealed that in states like Illinois, a young African American male is more than 50 times more likely to go to jail for a drug offense than is his Caucasian counterpart arrested for the same offense. The rise in addiction-related stigma and the transfer of alcoholics and addicts from treatment centers to correctional centers are deeply entwined with issues of gender, social class, and race. We can’t expose the former without confronting the latter.
A Day is Coming
So where does that leave us? What should recovering people, impacted families, and the friends of recovery do about this bleak situation? What should all people of good will concerned about this problem do? They should do that which is so uniquely American: Organize and change it! And that is precisely what is happening.
We are reaching a critical milestone in the history of recovery in America. We are approaching a crossroads that will dictate the fate of hundreds of thousands of individuals and families and thousands of communities. Recovering people know the deep truth in the adage that it is darkest just before the dawn. That darkened horizon is clearly evident across America today, but there IS a dawn arising. Emerging from that dawn are not government agencies or treatment professionals but a new generation of wounded healers. Recovering people and their families and friends are once again on the move–once again coming together not just for mutual support, but to widen the doors of entry into recovery through education and advocacy. A New Recovery Advocacy Movement is being born in this country. From Wall Street to Bourbon Street, from South Carolina to South Central, from Indian Country to the barrio to the wealthiest suburb, people are coming together to challenge the restigmatization, demedicalization and recriminalization of addiction in America. They are coming together to publicly reaffirm the hope for recovery from addiction.
In 1976, 52 prominent Americans publicly proclaimed their recovery from alcoholism in a landmark event sponsored by the National Council on Alcoholism called Operation Understanding. A day is coming when that number will swell to 5,000 and 50,000 and then to 500,000–all offering testimony about the transformative power of recovery. A day is coming when we will gather at state capitals and in our nation’s capital and you will see recovering people in every direction as far as the eyes can see–all offering themselves as LIVING PROOF that recovery is not just a possibility but a living reality. On that day, young people with a month of hard-earned sobriety will march beside men and women with 50 years of sobriety. On that day, families will walk to honor their survival as a family and to celebrate their own personal recoveries. On that day, those who have lost a loved one to this disease will walk to save others. On that day, AA and NA members will walk beside SOS and WFS members. Those in supported recovery will walk beside those in solo recovery. Those from therapeutic communities will walk beside those in methadone-assisted recovery. On that day, we will set aside our differences and march arm-in-arm as a multi-hued network of local communities of recovery.
In 1893 an addiction mutual aid society organized itself under a banner that read: “The Law Must Recognize a Leading Fact: Medical Not Penal Treatment Reforms the Drunkard.” A day is coming more than a century later when we will protest outside jails and prisons to proclaim that same message. A day is coming when addicted people who fill those prisons will organize their own recovery advocacy organizations. In embracing recovery, they will go on strike–withdrawing the bodies and souls that feed the economies of these institutions.
A day is coming when recovery from addiction will be viewed not as a curse to be masked and hidden, but as a cause for celebration and a gift to be shared with the world. A day is coming when, for one moment in the history of this country, recovering people will stand together and offer themselves as living proof of the fulfilled promises of recovery. To those around us, we will offer our gratitude for your forbearance and forgiveness. To those still suffering, we will proclaim: You represent our past just as we represent a future that could be yours. You have been part of the problem; add your voice to ours and become part of the solution.
Before That Day
We have work to do before that day can arrive. Movements that have created the most dramatic and enduring social change often began with an alteration of personal consciousness. The message from these movements is that we must change ourselves before we can change the world. We cannot confront stigma in the outside world until we discover how stigma works within us, and our relationships with the world. The internal consequences of such stigma must be excised before one experiences the worthiness and the power to confront its external source. We must excise that stigma so that we can move beyond our own healing to find our indignation, our outrage, and our sorrow that people who could be recovering are instead dying. We have to move beyond our own serenity and retrieve the fading memories of our own days of pain and desperation. Before that day, we need leaders who will jar us from our complacency and challenge us to hear the cry of the still suffering. Stigma is real, but we need to confront the fact that our own silence has contributed to that stigma. Listen to the words of Senator Harold Hughes who before he died proclaimed:
By hiding our recovery we have sustained the most harmful myth about addiction disease–that it is hopeless. And without the example of recovering people it is easy for the public to continue to think that victims of addiction disease are moral degenerates–that those who recover are the morally enlightened exceptions….We are the lucky ones, the ones who got well. And it is our responsibility to change the terms of the debate for the sake of those who still suffer.
How can addicted people experience hope when the legions of recovering people in this culture are not seen or heard? Where is the proof that permanent recovery from addiction is possible? We need a vanguard of recovering people to send an unequivocal message to those still drug-enslaved that they can be free. We need a vanguard willing to stand as the LIVING PROOF of that proposition.
Before that day, we will need to find ways to link those from all kinds of recovery backgrounds into a community of recovery. This is not an AA or Al-Anon movement or a NA movement or a WFS movement or an addiction ministry movement. It is a RECOVERY movement. The failure of various recovery groups and individuals in solo recovery to see themselves in terms of “we” is the most significant obstacle to fully realizing the potential of the New Recovery Advocacy Movement. We must get to know each other not as AA or Al-Anon members or NA members or SOS members, but as members of a recovery nation, each of whom contributes to its diversity and vitality. It is only by constructing our own identity as people in recovery and transcending the categories that separate us that we can transform our personal experiences into a new recovery advocacy movement. It is time we celebrated this coat of many colors that the recovery community has become. Our goal must not be to speak with one voice, but to share a recovery identity out of which we will speak with thousands of voices that achieve harmony on one issue: the potential for transforming and enduring recovery from addiction.
Before that day comes, we will need to find the systemic roots of stigma. We will need to confront the fact that addicted people have become the raw materials that run whole professional and community economies. Some of these institutions operate, not to help the addict, but to protect and extend their own institutional influence. Stigma provides the ideological justification for the perpetuation of these institutional economies. We need to either transform these institutions (shift them to a focus on care and recovery rather than control and profit) or advocate their closure. Confronting these systemic forces will be more about power and influence than about changing attitudes.
We must also find the personal roots of stigma. There are whole professions whose members share an extremely pessimistic view of recovery because they repeatedly see only those who fail to recover. The success stories are not visible in their daily professional lives. We need to re-introduce ourselves to the police who arrested us, the attorneys who prosecuted and defended us, the judges who sentenced us, the probation officers who monitored us, the physicians and nurses who cared for us, the teachers and social workers who cared for the problems of our children, the job supervisors who threatened to fire us. We need to find a way to express our gratitude at their efforts to help us, no matter how ill-timed, ill-informed, and inept such interventions may have been. We need to find a way to tell all of them that today we are sane and sober and that we have taken responsibility for our own lives. We need to tell them to be hopeful, that RECOVERY LIVES! Americans see the devastating consequences of addiction every day; it is time they witnessed close up the regenerative power of recovery.
It is not enough to come together and advocate for our own needs–to focus on the needs of those already in different stages of recovery. This movement must keep its eyes on ways the doorway of entry to recovery can be widened for those still suffering. And perhaps in the end it is not even enough to widen this door. Perhaps there is a larger agenda lurking in the background–the agenda of creating a better community and a better world–to take some of what has been learned in recovery and infuse that into the civilian community. To America, we say:
You can help save us, but we can also help save you. We are the ones who courted, yet cheated, the grave. In our darkest hours, we discovered some things of value that through us you can rediscover.
Some of you don’t know it yet, but you were born to play a role in this movement. To those with long-tenured recovery, we need your wisdom, your stability, your hard-earned serenity. To those new in recovery, we need the freshness of your pain and the fervor of your passion. To those family members who have lived through the devastation of addiction and the demands of recovery, we need your love and patience and invite you as equal partners into the leadership of this movement. To the children who have lived in the shadow of parental addiction, we need your courage to break the intergenerational transmission of these problems. To those who have lost someone to addiction, we call on you to give that lost life meaning by wrapping it within your own story and passing it on to others. To professional helpers and other friends of recovery, we invite your involvement and challenge you to help us create recovery-oriented systems of care within local communities across the country.
I know some of you will see yourselves as unfit for this calling. You will identify an endless list of frailties and inadequacies that disqualify you from serving this movement. But if there is anything that history tells us, including the history of recovery, it is that the most perfect message can be delivered by the most imperfect of messengers. We have freed ourselves; it is time we freed our neighbors and our communities. There is much that we have yet to learn, but as a people we do know something about deliverance and liberation. A day is coming when we will help free America with the truth of our stories.
When will that day arrive? The dawn of that day is here but we must seize it! I invite you and challenge you to become part of this new recovery advocacy movement by supporting local recovery advocacy organizations with your time, your talents, and your money. I invite you to find opportunities to tell your stories to those who know little about addiction or recovery. And I invite you to become an activist in advocating pro-recovery policies in every venue of influence you can reach. As Senator Hughes suggested, our own salvation as individuals and families bestows upon us a debt of obligation and an opportunity for service. When a vanguard of recovering people and their families step forward to pay this debt and accept this mantle of service, that new day will have arrived.
In White, W. (2006). Let’s Go Make Some History: Chronicles of the New Addiction Recovery Advocacy Movement. Washington, D.C.
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