BLOG & NEW POSTINGS May 27, 2016 – Bill White – NA AND RECOVERY FROM OPIOID ADDICTION (WILLIAM WHITE, DR. MARC GALANTER, DR. KEITH HUMPHREYS, AND DR. JOHN KELLY)

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

BLOG & NEW POSTINGS May 20, 2016 -Bill White – LIFTING THE VEIL OF RECOVERY INVISIBILITY

“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

BLOG & NEW POSTINGS May 13, 2016 – Bill White – TIME FOR A RECOVERY CHECKUP?

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

BLOG & NEW POSTINGS May 6, 2016 – Bill White- RECOVERY AS A CULTURAL JOURNEY

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