Bill White – ATTENTIONAL BIAS IN ADDICTION AND RECOVERY-July 6, 2018

People addicted to alcohol and other drugs see the world differently. They SEE the world differently as a result of neurocognitive changes in perception that accelerate in tandem with increased tissue tolerance, increased intensity of cellular hunger (craving), and the resulting obsession with maintaining the drug relationship at all costs. As drug seeking, drug procurement, and drug use rise to the top of one’s motivational priorities, one develops attentional bias toward words, symbols, and images linked to these substances. Perceptual preferences for drug-linked stimuli are an essential element within the neurobiology of addiction. In recovery, this perceptual preference is reframed, giving perceptual priority to words, symbols, and images that reinforce the recovery process.

The journey from addiction to recovery is marked by extreme ambivalence, particularly during the early stages of recovery, and exposure to these contrasting sets of cues can tip the scales toward either addiction recurrence or the transition from recovery initiation to long-term stable recovery. The issue raised in this blog is the ratio of addiction cues versus recovery cues within community environments. The concern is the relative paucity of community-level recovery cues compared to a near-constant bombardment of drug cues.

Recovery folklore is filled with cautions about stimuli (aka “people, places, and things”) that can send a seductive call back to one’s past life in addiction. Imagine the sensory cues a person experiences in their first days of “sobriety sampling” as he or she pursues daily life in the community. Imagine her exposure to alcohol and other drug cues in every communication medium—the product of billions of dollars in alcohol, tobacco, and drug advertising that glamorizes intoxication and links mood-altering products to physical beauty, social popularity, romance, sexual fulfillment, financial success, and freedom from emotional distress. Imagine that even the social and print media she reads that address drug problems are filled with endless images of drug use, drug products, needles, and all manner of other drug paraphernalia. Imagine constant visual encounters with people and places closely linked to her past rituals of drug use. Imagine the sheer volume of drug cues she experiences driving down any U.S. commercial street—encounters with these cues on billboards and in restaurants, gas stations, grocery stores, and recreational venues, as well as through popular movies, magazines, and music.

One of the shared goals of alcohol, tobacco, and drug (ATOD) industries is to increase the physical presence of their products (and their carefully crafted images) within American life. They have been enormously successful over two centuries in achieving that goal. The result is a literal visual assault of drug-inviting words, images, and slogans infused into the very fabric of American life. In contrast, the stigma attached to having experienced problems with these substances has, until quite recently, rendered invisible the people, places, and things associated with addiction recovery. While ATOD icons have been ever-present in American life, words, images, and slogan celebrating the recovery experience have for too long existed only within subterranean subcultures hidden from mainstream community life.

Returning to our topic of attentional bias, one can see the challenge of initiating recovery within a cultural stew saturated with positive drug cues and few if any recovery cues. This imbalance is a personal challenge faced by each person beginning a recovery journey, but it is also a problem at an environmental level. Just as the ATOD industry sought proliferation of their product images, recovery advocates must help forge recovery-friendly communities in which the glamorization of these products are offset by images portraying their risks and by images linked to successful cessation of drug use and the resulting personal and social benefits.

For recovery advocacy organizations, this means two things. First, it means that they must counteract efforts by the alcohol, tobacco, and pharmaceutical industries to glamorize and promote drug consumption, target vulnerable populations, introduce products of ever-heightened potency, create more pleasure-inducing methods of drug administration, and expand the times and places in which the sale or use of such products are acceptable. By serving as a force to inhibit such cues within the community, recovery advocacy organizations can play important roles in ATOD prevention and the promotion of public health, while also reducing the cues people in early recovery are exposed to that could tip the scales toward re-addiction. An example of this is clearly evident in the history of tobacco policy in the U.S. It is far easier for a person to quit smoking today than in the 1960s, in part, because the massive promotion of smoking and the ever-expanding space within which smoking was acceptable has been reversed as a matter of public health policy. Imagine the cues the smoker trying to quit smoking would be exposed to in 1960 compared to today. Our goal as advocates should be to similarly reduce the cues and community spaces within which addiction to other drugs flourishes.

A second strategy of recovery advocacy organizations is to expand the public visibility of people, places, and things (and words, symbols, and images) that cast a recovery beacon within local communities. An ecumenical culture of recovery is rising into the light of community life through new recovery support institutions, recovery education and celebration events, and the increased representation of the recovery experience through art, literature, music, and social media.

Imagine that same young woman in decades to come in her earliest days of recovery. Imagine her ambivalence about addiction and about recovery. Imagine the challenges of attentional bias, but also imagine a community in which drug cues calling her back are counterbalanced by recovery cues calling her forward into a new life. In that new world, she has a much better chance than the chance she has in far too many communities today in which the former are ever-present and the latter are invisible. We must help build a world in which her recovery will be warmly welcomed. Addiction now flourishes on Main Street America; it is time recovery stepped out of the shadows and announced itself on Main Street. Thanks to recovery advocates across the country, that process has now begun.

References

Cox, W. M., Blount, J. P., & Rozak, A. M. (2000). Alcohol abusers’ and nonabusers’ distraction by alcohol and concern-related stimuli. American Journal of Drug and Alcohol Abuse, 26, 489–495.

Cox, W. M., Hogan, L. M., Kristian, M. R., & Race, J. H. (2002). Alcohol attentional bias as a predictor of alcohol abusers’ treatment outcome. Drug and Alcohol Dependence, 68, 237–243.

Field, M., & Cox, W. M. (2008). Attentional bias in addictive behaviors: A review of its development, causes, and consequences. Drug and Alcohol Dependence, 97, 1–20.

Stormark, K. M., Laberg, J. C., Nordby, H., & Hugdahl, K. (2000). Alcoholics’ selective attention to alcohol stimuli: Automated processing? Journal of Studies on Alcohol and Drugs, 61, 18–23.

Post Date July 6, 2018 by Bill White

Advertisements

Bill White – WHO IS BEST QUALIFIED TO PROVIDE RECOVERY SUPPORT SERVICES?-June 22, 2018

The explosive growth of nonclinical recovery support services (RSS) as an adjunct or alternative to professionally-directed addiction treatment and participation in recovery mutual aid societies raises three related questions: 1) What is the ideal organizational placement for the delivery RSS?, 2) What persons are best qualified to provide RSS?, and 3) Are RSS best provided on a paid or volunteer basis?

At present, non-clinical RSS are being provided through and within a wide variety of organizational settings by people with diverse backgrounds in both paid and volunteer roles. While research to date suggests that such services can enhance recovery initiation and long-term recovery maintenance, no studies have addressed the three questions above or the broader issue of the kinds of evidence that should be considered in answering these questions.

I have repeatedly suggested that these questions should be answered by methodologically-rigorous research evaluating whether recovery outcomes differ by variations in delivery setting, attributes of those providing the services, and the medium (paid vs. volunteer) through which such services are provided. There are, however, considerations beyond such outcomes that ought to be considered and factored into decisions on the design and delivery of RSS.

As for organizational setting, I have heard such arguments as follows:

*RSS should be provided by addiction treatment organizations to assure a high level of integration between treatment and post-treatment continuing care.

*RSS should be provided by criminal justice and child welfare agencies to assure the balance between the goals of recovery support, public/child safety, and family reunification.

*RSS should be provided by hospitals and other primary care facilities to assure effective integration of recovery support and primary health care.

*RSS should be provided through public health authorities to assure the integration of prevention, harm reduction, treatment, recovery support, community-level infection control (e.g., HIV, Hep C), and wellness promotion.

*RSS should be provided by behavioral managed care organizations (or insurance companies) to assure coordination and integration of support across levels of care (and potentially multiple service providers) and the effective stewardship of limited financial resources.

*RSS should be provided by private professional recovery coaches who can coordinate support across multiple systems and across the long-term stages of recovery.

RSS are now being piloted through all of the above arrangements, but I think a strong argument can be made for providing RSS through and beyond all of the above settings under the auspices of authentic recovery community organizations (RCOs). Allocating financial resources to deliver RSS through these organizations and to the community at large has the added advantages of: 1) maintaining long-term personal and family recovery as the primary service mission, 2) drawing upon the experiential knowledge within communities of recovery to inform the provision of RSS, 3) contributing to the growth of local recovery space/landscapes (i.e. community recovery capital), 4) financially strengthening the infrastructure of local RCOs, and 5) proving greater peer support to the workers providing RSS.

Similarly, RSS are now being provided by people from diverse experiential and professional backgrounds. I think there are many RSS functions that can be effectively delivered across this diversity of backgrounds, but I think the delivery of these services by people in recovery who have been specifically training for this role offers a number of distinct advantages. Through the delivery of peer-based recovery support services, people in recovery can uniquely offer: 1) recovery hope and modeling (living proof of the reality of long-term recovery), 2) normative information drawn from personal/collective experience on the stages and styles of addiction recovery, and 3) knowledge of and navigation within local indigenous recovery support resources. Such hope, encouragement, and guidance is grounded in more than 200 years of history in which people in recovery (i.e., wounded healers, recovery carriers) have served as guides for other people seeking recovery from severe AOD problems (See Slaying the Dragon, 2014). It offers the further advantage of expanding helping opportunities for people in recovery—creating benefits for both helpee and helper through the helping process. (See discussion of Riesman’s Helper Principle). Some of these advantages are limited, however, when the knowledge of the RSS specialist is drawn from personal experience within only one recovery pathway—thus the importance of combing experiential knowledge with rigorous training and supervision.

If we accept the delivery of RSS through recovery community organizations and by people with lived experience of personal/family recovery from addiction, there still remains the question of whether those directly providing RSS should be in paid or volunteer roles. The most prevalent model of delivering RSS is presently through paid roles, with progressively increasing expectations of education, training, and certification—similar to the modern history of addiction counseling. Paying people in recovery to provide RSS has the advantages of expanding employment opportunities for persons in recovery, acknowledging the value and legitimacy of experiential knowledge and expertise, and potentially creating a more stable RSS workforce. That said, the professionalization and commercialization of the RSS role risks undermining the voluntary service ethic within the recovery community, potentially creating an unfortunate future in which people in recovery would expect financial compensation for all service work.

One option is to provide funding to RCOs for the recruitment, orientation, training, and ongoing supervision of RSS, while relying primarily upon trained volunteers to deliver such services. Only time will tell if this option is a viable and sustainable model for the delivery of high quality RSS. If not, great care will need to be taken to avoid the over-professionalization and over-commercialization of recovery support. Questions related to the design and delivery of RSS should be answered primarily through research on RSS-related recovery outcomes, but such research should also examine broader benefits and the potential for inadvertent harm rising from particular models of RSS.

Post Date June 22, 2018 by Bill White

Bill White -QUALITY OF LIFE IN EARLY RECOVERY AND BEYOND-June 15, 2018

Landmark life in recovery surveys have been recently conducted in the United States (Laudet; Kaskutas, Borkman, Laudet, et al.; Witbrodt, Kaskutas, & Grella), Canada (McQuaid, Malik, Moussouini, et al.), Australia (Best & Savic), and the UK (Best, Albertson, Irving, et al.). These surveys provide retrospective confirmation of the improvements in physical/emotional/relational health and quality of life that accrue with duration of addiction recovery. They confirm that increased time in recovery is linked to enhancement of housing stability, improvements in family engagement and support, educational/occupational achievement, debt resolution, and increased community participation and contribution, as well as reductions in domestic disturbance, arrests/imprisonment, and health care costs.
reductions in domestic disturbance, arrests/imprisonment, and health care costs.

A just-published U.S. population study by Kelly, Greene, and Bergman confirm many of these findings, noting that quality of life (e.g., happiness, self-esteem, and recovery capital) increases exponentially over the first five years of recovery and continues to increase in smaller increments in subsequent years. Their study also noted three other findings not captured in earlier studies.

First, quality of life in recovery ratings varied across gender, racial groups, and primary drug choices. Facing lower quality of life ratings in early recovery compared to other groups were women, mixed racial groups, and former opioid and stimulant users.

Second, in their U.S. recovery sample, happiness and self-esteem actually declined in the first six months following problem resolution and was then followed by progressive improvements in these areas. This finding from a community study is consistent with an early clinical study by Dennis, Foss, and Scott noting a peak period of emotional distress (at three-year follow-up) well after the early stage of recovery initiation. The differences in timing of peak negative affect between the two studies may reflect the far greater problem severity in the clinical sample. (Greater problem severity may entail a longer period of disentangling the baggage of addiction before a process of emotional thawing and healing ensues.) What is of great clinical import in both the Kelly and Dennis studies is that the period of greatest negative affect—a condition long-associated with addiction recurrence—appears long after helping professionals have discharged patients and families from active service support.

Third, Kelly and colleagues report that it took a substantial period of time (15 years) for people in recovery to reach the normative quality of life ratings of those persons in the U.S. who had never experienced significant alcohol and other drug (AOD) problems. It is not enough to say that people in recovery have a quality of life better than those actively addicted. The issue is their ability to achieve a quality of life on par with non-affected individuals and families. Providing support to achieve such parity of emotional and relational health would require a sustained recovery support menu far beyond the current range of clinical services offered within addiction treatment programs.

So what does this all mean? I would suggest the following prescriptions for addiction treatment and recovery support organizations.

Educate affected individuals, family members, and service professionals on the long-term stages of recovery and stage-specific recovery management strategies.

Provide written material, videos, and podcasts to all patients and families on the stages of recovery and tips on managing periods of physical/emotional/spiritual distress across the stages of recovery. Bibliotherapy may help normalize stage-specific recovery experiences (particularly for individuals who choose not to be involved in recovery mutual aid groups) and provide a guide for managing periods of heightened vulnerability that is not dependent upon professional care or participation in peer recovery support activities.

Cease the practice of patient “graduation” from addiction treatment—a ritual that conveys that one’s problems have been fixed and one can now expect to live happily ever after.

Provide assertive linkages between addiction treatment and indigenous recovery support resources—both face-to-face and online resources.

Provide intensive post-treatment recovery check-ups and support during the first 90 days following discharge from treatment, with at least quarterly checkups over the first two years and at least annual recovery checkups for the first five years following recovery initiation.

Titrate the intensity and duration of post-treatment recovery support services based on degree of problem severity/complexity/chronicity and level of recovery capital, with special attention to those who may be at highest emotional and social vulnerability in early recovery, e.g., women, youth, and those who have experienced the greatest degree of social marginalization.

Offer clinical services as an option across the stages of recovery. The best use of traditional counseling skills may not be during the period of recovery initiation but in the emotional crises that often come far after the “pink cloud” of recovery initiation.

Integrate the clinical care of addiction treatment and long-term recovery support services via expansion of service menus that focus on enhanced quality of personal and family life in long-term recovery.

The bigger issue remains shifting addiction treatment from models of acute care focusing on biopsychosocial stabilization to models of sustained recovery management (RM) nested within larger recovery-oriented systems of care (ROSC). RM models will assure sustained, person/family-focused support across the stages of recovery; ROSC models will assure creating the physical, psychological and social space within local communities in which recovery and quality of personal and family life in recovery can flourish over time. Achieving this shift will require a fundamental reorientation within the addictions field—a process that is now underway in many states and local communities.

Reference

Kelly, J. F., Greene, M. C., & Bergman, B. G. (2018). Beyond abstinence: Changes in indices of quality of life with time in recovery in a nationally representative sample of U.S. adults. Alcoholism: Clinical & Experimental Research, 42(4), 770-780.

Post Date June 15, 2018 by Bill White

RECOVERY SUPPORT FOR PEOPLE IN MEDICATION ASSISTED RECOVERY: THE CONTEXT-April 27, 2018 By Bill White

How can peer addiction recovery supports, including access to medication-friendly mutual aid meetings, be increased for people in medication-assisted treatment (MAT)? That is a question of increasing import to people working in addiction treatment and recovery community organizations.

In this first of a two-part blog, we will briefly explore why people in MAT experience special obstacles to long-term recovery, why individuals using medication support may be in particular need of peer recovery support services, and why some individuals denied access to medication support could benefit from integrated models of medication and psychosocial support.

Participation in secular, spiritual, and religious recovery mutual aid societies and other peer-based recovery support institutions increases rates of substance use disorder remission and enhances global health and social functioning. There are FDA-approved medications that reduce addiction-related morbidity and mortality and enhance health and social functioning. Psychosocial (professional and peer) support and medication support have historically evolved as separate service organizations with their own respective philosophies about the nature of and solutions to severe alcohol and other drug problems. Fully integrating intensive psychosocial support and a full menu of pharmacotherapy choices is historically rare within the addictions field, but interest in such integration is increasing.

There are very few research studies on the experiences of MAT patients seeking participation in mainstream recovery mutual aid societies. Existing studies report high rates of past participation in 12-Step recovery groups and positive self-reports of the effects of such participation, but also note hostile attitudes toward MAT, restrictions on level of participation due to MAT status, and encouragement to progressively lower medication dosage or cease MAT. These studies also note decisions by some MAT patients to not disclose their MAT status to sponsors and fellow group members or to migrate to a fellowship less hostile to MAT (i.e., methadone and buprenorphine maintenance patients seeking support in Alcoholics Anonymous meetings rather than Narcotics Anonymous meetings). Secular and religious alternatives to 12-Step groups exist, but have been historically focused on recovery from alcohol use disorders. Mutual aid groups specifically developed for people in MAT for opioid addiction exist (e.g., Methadone Anonymous), but have been marked by instability, slow growth, and unavailability in many communities.

Similar obstacles are often encountered as MAT patients seek participation in other recovery support institutions (i.e., recovery homes), but some new recovery support institutions have exerted special efforts to extend a warm welcome to those in MAT (e.g., recovery community centers, recovery cafés, etc.). Increased access and warm welcome within mutual aid groups and other indigenous recovery support institutions could significantly elevate long-term recovery outcomes of MAT patients.

The longstanding anti-medication bias within recovery mutual aid societies has resulted in exclusion, discouragement, and second-class status of people seeking support from many of these mainstream mutual aid groups. The stigma attached to medication within these groups is rooted historically in fraudulent claims and iatrogenic effects of many medications prescribed as cures or treatments for addiction during the nineteenth and twentieth centuries. Misconceptions about the nature of medications used in MAT, inadequate dosing policies, high rates of concurrent alcohol and illicit drug use, and low quality of overall care within under-resourced opioid treatment programs has further heightened stigma attached to MAT. This anti-medication bias is slowly decreasing within both addiction treatment and recovery mutual aid settings as a result of improved quality of MAT, research on MAT effectiveness, and increased involvement of current and former MAT patients within the recovery advocacy movement.

A substantial portion of people seeking treatment for alcohol or opioid use disorders in the U.S. are not offered pharmacotherapy as a treatment service. A 2014 study by Volkow and colleagues noted that only 50% of private addiction treatment centers offered medication, with only 34% of patients in centers offering medication support actually receiving medication as part of their treatment. Similarly, less than 5% of U.S. physicians are waivered to prescribe buprenorphine for the treatment of opioid addiction. Among programs that do offer medication support, only a minority offer a full spectrum of addiction pharmacotherapies. A 2018 analysis of data from more than 12,000 addiction treatment centers in the U.S. revealed that only 41.2% of reporting centers offered at least one of three primary medications used in the treatment of opioid addiction (methadone, buprenorphine, and naltrexone), and only 2.7% of facilities offered a choice of all three medications.

Far too many people with alcohol and opioid use disorders are being repeatedly recycled through ever-briefer episodes of traditional abstinence-based treatment without achieving long-term recovery stability. (Forty-seven percent of patients admitted to addiction treatment in 2014 had one or more prior treatment admissions, and 13% had 5 or more prior treatment admissions). The above-noted anti-medication bias, the under-representation of physicians and other medical personnel within the addiction treatment workforce, and limited medication options may well contribute to such recidivism.

Many of the individuals undergoing multiple treatment episodes suffer from substance use disorders that are severe, complex, and chronic, with clinical assessments revealing non-existent or severely eroded family and social recovery supports. These are the patients who are being repeatedly recycled through treatment that does not address the complexity of their needs. It is doubtful that medication alone will alter the trajectory of their problems any more than non-medical treatments alone have, but a fully integrated combination of such approaches combined or sequenced over time across the stages of recovery might well have such potential. It is time that proposition was rigorously tested.

The majority of people admitted to medication-assisted treatment in the U.S., particularly office-based treatment of opioid addiction with prescribed buprenorphine, receive minimal, if any, peer recovery support services or assertive linkage to community-based, recovery mutual aid organizations. There are growing calls for and increased clinical experiments integrating medication support and professionally-delivered or peer-based psychosocial support, particularly in response to the recent surge in opioid addiction and its related death toll.

Substantial populations of people in MAT for alcohol or opioid dependence continue use alcohol, un-prescribed opioids, and other unprescribed drugs while in treatment. Others achieve abstinence from non-prescribed drugs, but fail to achieve larger gains in global health and social functioning. An expanded menu of psychosocial and peer recovery supports could potentially affect improvements in each of these areas.

The majority of people who commence MAT will eventually discontinue medication support, a substantial portion within the first year of medication support. Seen as a whole, the major problem with MAT is not that people remain on it too long as is often argued, but that most patients do not remain on it long enough to obtain stable recovery or sustain recovery following cessation of medication support.

Following cessation of MAT, there is increased risk of addiction recurrence, addiction-related medical disorders, arrest, and drug-related death. Providing peer support throughout the treatment process, providing all patients who are tapering with increased professional and peer supports, and conducting post-treatment monitoring and re-intervention on all MAT patients, regardless of discharge status, could potentially reduce post-treatment morbidity and mortality.

There is also an increased risk of drug-related death for people treated for opioid addiction in abstinence-based programs during the days, weeks, and months following discharge. Intensified post-treatment psychosocial support and, where indicated, combining such supports with medication support, could potentially reduce the prevalence of such deaths.

I have observed people undergoing addiction treatment for more than half a century. It is my view that many people fail in MAT due to a lack of psychosocial supports, and that many fail in traditional abstinence-based programs due to the absence of medication support. It is past time to pilot integration initiatives that rigorously evaluate the extent to which unique combinations or sequences of these interventions can improve recovery outcomes and for which clinical populations such combinations may be most needed and effective.

Treatment of chronic and severe primary health disorders involves a broad spectrum of potential interventions uniquely combined and sequenced to match the unique needs and responses of each patient. The treatment choices available to the cancer patient, for example, may include, surgical interventions, radiation, chemotherapy, pharmacotherapy, hormone therapy, immunotherapy, stem cell transplant, bone marrow transplant, gene therapy, and a minimum of five years of post-treatment monitoring with re-intervention at the earliest signs of cancer recurrence—as well as adjunctive physical therapy, dietary changes, patient and family education and peer support groups. To treat cancer offering a single fixed intervention for all patients or even the same small cluster of treatment activities would be considered professional incompetence and legal malpractice. Why then is offering a single primary intervention or limited cluster of interventions (“the program”) the mainstream of clinical practice in addiction treatment? And why are the treatments used determined not by objective clinical criteria and individual needs but by the randomness of the treatment program one enters and the narrow cannon of clinical beliefs one encounters there?

It is my contention that the future of addiction treatment lies with the expansion of the treatment menu, evaluating the efficacy and effectiveness of individual treatment components, and finding the most potent combinations and sequences of services that can support personal and family recovery across the stages of long-term recovery and across diverse cultural contexts. For some, that will involve integrating medication support and a broad spectrum of psychosocial supports.

Next Week: Increasing Recovery Support for People in Medication Assisted Treatment: Suggested Strategies

Post Date April 27, 2018 by Bill White

THE FUTURE OF RECOVERY SUPPORT PART II (BILL WHITE AND MIKE COLLINS) April 6, 2018 By-Bill White

“Disruptive innovation, a term coined by Clayton Christensen, describes a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors.”
The worlds of addiction treatment and recovery mutual aid are on the brink of being radically disrupted and transformed. New recovery support institutions and bold innovations in how, when, and where recovery supports are delivered will pose unprecedented threats and opportunities for established players within the treatment and mutual aid arenas.
In our last blog, we offered five predictions about the future of recovery support in the United States.

1. Transformative innovations in recovery support will encompass high and low tech platforms and a dramatically broadened menu of products, services, and support activities.

2. An ecumenical culture of recovery will spread through new recovery support institutions.

3. Addiction treatment as a professional and business endeavor will face intensified challenges to its legitimacy as a cultural institution, due in great part to its own excesses.

4. Responding to this crisis, addiction treatment institutions will attempt to colonize new recovery support competitors and will pioneer new service menus and new technologies of service delivery.

5. Formal membership in 12-Step groups (as measured by membership surveys) will slowly decline but rate of attrition in groups such as AA will be offset by attraction of new members through non-traditional routes of entrance and the growing secular and religious wings of AA.

Below we will discuss five additional predictions and sample some of the websites, social media accounts, apps, and online mutual aid societies that point to this emerging future.

6. The definition of a valid or sanctioned recovery support “meeting” will be increasingly fuzzy, and the roles of the “meeting” and canonic literature will remain but diminish in their import to recovery initiation, recovery maintenance, and enhancement of quality of life in long-term recovery.

“Meetings” will be extended to a growing catalogue of phone- and internet-based recovery support platforms providing continuous discussions (e.g., continual teleconferences) and social activities that one can enter and exit any day and any time of day. Literature will be transformed to instantaneously-accessible audio and video formats that will provide topical guidance on managing an infinite menu of challenges and opportunities before, during, or after such encounters. This transition could be thought of as the moving from “in the rooms” to “beyond the rooms.”

Historically, recovery mutual aid focused on three delivery mechanisms: 1) “friendly visitors” (recovery sponsorship or mentorship in modern language); 2) scheduled membership meetings for story sharing, problem solving, and recovery celebration; and 3) the written literature of a particular mutual aid society. Tomorrow, such friendly visitors will arrive at one’s wrist and often include people we have never met face-to-face.

It’s not that formal recovery support meetings will cease; it is that such meetings will become a smaller part of a much larger menu of recovery support activities that one can combine and sequence according to personal needs and interests over the course of long-term recovery. A day is rapidly approaching when more people will use telephone and online recovery support than those participating in formal face-to-face (F2F) recovery support meetings. The former will dramatically widen the doorways of entry to recovery for people who cannot access or do not feel comfortable/safe within F2F meetings, e.g., women, youth, high-status professionals, people in communities lacking F2F meetings, people whose physical limitations preclude access to F2F meetings, and people who experience social anxiety, to name a few.

7. Phone-based and web-based information and screening tools will facilitate self-diagnosis of substance-related problems and dramatically expand the pool of people seeking recovery support. Service and support options will increase for people experiencing low to moderate AOD problem severity who are now rarely seen in or retained within specialized addiction treatment institutions or traditional recovery mutual aid meetings.

This population of non-dependent help seekers will spark a parallel growth in models of problem resolution that include support for the moderated resolution of alcohol and other (AOD) problems. The “abstinence only” goal of treatment and recovery support is sustainable only as long as providers of such assistance remain closed ideological systems serving only those with the most severe, complex, and chronic substance use disorders while denying the existence of the much broader spectrum of AOD-related problems. Broader population-based technologies aimed at the full spectrum of AOD problems will allow us to shift beyond clinical interventions with the most severely affected individuals to interventions with whole populations that will reduce the prevalence of this broader spectrum of AOD problems at a cultural level.

8. Geographical boundaries of recovery support, including international boundaries, will progressively dissolve as online addiction treatment and peer recovery supports expand and include simultaneous language translations among people from all over the world.

The beginnings of a global recovery community are already evident. Ironically, this emerging global recovery community may provide the connecting tissue to counter the escalating political, religious, and economic divides that threaten the very future of the world.

9. The exponential growth of recovery support will be fueled by two phenomena: positive network effects and open source recovery support.

Put simply, positive network effects suggest that the more people who use a particular recovery support mechanism, the greater its value and long-term viability as a social institution. For examples, the effects of an online recovery support service increases in tandem with the number of members using such services, the effects of participating in a recovery celebration event increase in tandem with the number of people participating in such events, etc.

The idea of open source, drawn from the history of software development, is that recovery support resources (ideas, information, techniques, helping platforms, literature, art, film, etc.) are a product of peer production: products developed within a community and shared at minimal or no cost. Examples of peer production include all the service activities (e.g., 12-Step calls, sponsorship, literature authorship, and other service work) delivered through recovery mutual aid groups by members without compensation or the free exchange of ideas and materials between recovery advocacy organizations.

Peer production is the antithesis of proprietary, fee-based, profit-driven services and products. Open source recovery resources will grow exponentially in the coming decades and survive the threats of professionalization and commercialization. The very essence of the recovery movement (“You can’t keep it unless you give it away”) is a revolutionary concept when freed beyond the bounds of a particular recovery fellowship and freed through new technologies beyond the limitations of face-to-face contact. The future of recovery support will be marked by accessibility, affordability, convenience, portability, flexibility (to one’s personal needs/values/culture), and inclusiveness. It will also be marked by a balance or shift between an expert relational model and a mutual partnership relational model.

10. New innovations in recovery support will engage both dissatisfied portions of existing recovery support markets as well as open new markets that have not been reached through the dominant systems of service provision.

We are witnessing a detonation point that will forever alter the history of recovery. And what is this defining moment? It is twofold: freeing recovery from the bounds of recovery mutual aid meetings and professionally-directed addiction treatment (via new recovery support institutions) and the extension of recovery support beyond the boundaries of space and time (via the explosion of digital recovery support platforms and content). The recovery revolution is here and we do not yet see and grasp its full implications. As William Gibson—the man who coined the term cyberspace—suggests, “The future is here. It’s just not evenly distributed.”

A small sampling of websites, social media accounts, apps, and online mutual aid societies that point to this brave new future include the following:

https://www.reddit.com/r/stop drinking/ 94,776 readers at press time.

https://www.intherooms.com/ 491,114 members. Ever-expanding menu of online secular, spiritual, and religious recovery support meetings and related services. Total member recovery Time: 2,029,267 YEARS! Year

https://recovery2point0.com/ 250,000 person online recovery community embracing a holistic approach to recovery from addiction.

https://sobermovement.com/ These guys have moved all flavors of recovery to Instagram (https://www.instagram.com/sobermovement/?hl=en) 56,300 followers.

http://www.viralrecovery.com/ Chronicling all types of online recovery websites, social media, and apps.

https://geniusrecovery.com/ Watch for big things from this group.

https://www.facebook.com/groups/AddictionUnscriptedSupport/?ref=br_rs 63,000+ members.

Samples of Recovery Bloggers

http://soberseniorita.com

https://www.miraclesarebrewing.com/the-bloom-club/

https://www.recoveryelevator.com/about/

http://www.hipsobriety.com/

http://sobermoxie.com/

http://www.tiredofthinkingaboutdrinking.com/

http://sherecovers.co/blog/

https://iloverecovery.com/

http://livingwithoutalcohol.blogspot.com/

http://sincerightnow.com/contact

http://guineveregetssober.com/

https://www.hellosundaymorning.org/

https://www.facingaddiction.org/ (Just merged with the the National Council on Alcoholism and Drug Dependence, NCADD).

https://facesandvoicesofrecovery.org/

https://soberworx.com/

http://www.thesobrietycollective.com/link-love/

http://sober.gotop100.com/

http://soberblogs.gotop100.com/

http://annadavid.com/

http://ericaspiegelman.com/

https://thisnakedmind.com/

http://www.iamnotanonymous.org/

http://www.theroomsproject.org/

https://theherrenproject.org/

http://y12sr.com/

http://youngpeopleinrecovery.org/

https://www.facebook.com/groups/friends.billw/

Sample Apps

http://meetnomo.com/index.html

https://www.sobergrid.com/

http://www.sobertool.com/

Post Date April 6, 2018 by Bill White

ADDICTION AS A BRAIN DISEASE (PERSPECTIVES FROM THE ISLAMIC REPUBLIC OF IRAN) -March 9, 2018 -Bill White

The understanding of addiction as a brain disease has been a central organizing principle within the research agendas of the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism. Promotion of the brain disease paradigm stirred controversies over its scientific legitimacy and contentions and counter-contentions over its effects on addiction-related stigma, but it exerted unquestioned influence on public and professional conceptions of addiction and approaches to the treatment of addiction in the United States. Interesting variations in the conceptualization of addiction as a brain disease occurred contemporaneously in other countries. The challenge across cultural contexts has been to integrate recent research on the neurobiology of addiction to create more dynamic biopsychosocial models of treatment and recovery support.

One of the most innovative examples of such integration can be found within the Islamic Republic of Iran’s Congress 60 recovery community. Encompassing more than 57,000 active members across 58 branches in Iran, Congress 60 combines a medication-assisted transition into recovery with an extensive menu of psychosocial supports. The rationale for medication support and the unique scheme of such support (the DST method) has been outlined by Congress 60 Founder Hossein Dezhakam in what he christened the X Theory.

I recently had the opportunity to interview Mr. Dezhakam about the X Theory and the DST method and how they are integrated within the larger culture of support within the Congress 60 recovery community. This interview is highly recommended for those exploring such integration in diverse cultural settings, including in the United States, and for those interested in variations in the clinical application of the brain disease model of addiction in non-Western countries.

For decades in the U.S., addiction treatments, with and without medication support, have existed as warring factions fueled by debates producing far more heat than light. Such either/or polarization defies the fact that many people in medication-assisted treatment could greatly benefit from an expanded menu of long-term recovery support services and that recovery outcomes within traditional “abstinence-based” programs could be elevated by recognition of the potential role medications can play for some patients in recovery initiation and/or maintenance. Congress 60 provides a template of how medication support and psychosocial support can be fully integrated within a vibrant recovery culture.

Post Date March 9, 2018 by Bill White

THE SECULAR WING OF AA- March 2, 2018 -Bill White-

A.A. is so decentralized that in a very real sense, there really is no such single entity as “Alcoholics Anonymous”—only A.A. members and local A.A. groups that reflect a broad and ever increasing variety of A.A. experience. To suggest that Alcoholics Anonymous represents a “one size fits all approach” to alcoholism recovery, as some critics are prone to do, ignores the actual rich diversity of A.A. experience in local A.A. groups and the diverse cultural, religious, and political contexts in which A.A. is flourishing internationally. (Kurtz & White, 2015)

All are self-identified alcoholics and go by many other names: agnostics, atheists, nonbelievers, skeptics, cynics, rebels, freethinkers, humanists, secularists, and rationalists. What they share in common beyond the experience of alcoholism is need for a personal program of recovery not dependent upon belief in any religious deity. Such needs have propelled the growth of secular alternatives to Alcoholics Anonymous (AA) and a growing secular wing within AA. The existence of the latter challenges AA critics who argue that those without religious faith cannot find a home within AA.

The growth of a secular wing of AA is evident in many quarters. The number of registered secular AA meetings in the U.S. has grown from a few dozen in the early 2000s to more than 400, and two international conventions of atheist and agnostic AA members have been held to date. Online secular recovery support resources for AA members (such as Secular AA, AA Agnostica, and AA Beyond Belief) have grown in tandem with the increase in face-to-face meetings. An October 2016 special issue of the AA Grapevine was dedicated to “Atheist and Agnostic Members,” and there is a planned Grapevine book containing previously published stories of atheist and agnostic AA members. Also of note are the increased number of books on secular recovery within AA (see below) and the increased national media coverage of secular AA meetings.

Chronology of Secular AA & Related Recovery Literature

1991 Martha Cleveland and Arlys G. The Alternative 12 Steps: A Secular Guide to Recovery

2010 My Name is Lillian and I am and Alcoholic (And an Atheist)

2011 Marya Hornbacher Waiting: A Non-Believerʼs Higher Power

2011 Vince Hawkins An Atheists Unofficial Guide to A.A.

2012 Joe C. Beyond Belief: Agnostic Musings for 12 Step Life

2013 Archer Voxx The Five Keys: 12 Step Recovery Without A God

2013 Roger C. The Little Book: A Collection of Alternative 12 Steps

2014 John Lauritsen A Freethinker in Alcoholics Anonymous

2015 Adam N. Common Sense Recovery: An Atheist’s Guide to Alcoholics Anonymous

2015 Roger C. Do Tell: Stories by Atheists and Agnostics in AA

2017 Thomas B. Each Breath a Gift: A Story of Continuing Recovery

Two recent books by Roger C. provide a fascinating window into the world of secular AA. Published in 2014, Don’t Tell: Stories and Essays by Agnostics and Atheists in AA is a potpourri of secular recovery stories, alternative wordings and interpretations of AA’s 12 Steps, book reviews, snippets from the early history of atheists and agnostics in AA, description of a secular AA convention, and discussions of some of the controversies triggered by the growth of secular AA. Published in 2017, A History of Agnostics in AA provides engaging accounts of early secular groups within AA in the U.S. and Canada. Together, these books provide insight into the challenges and triumphs of achieving recovery without religiosity within AA. They are above all a celebration of the “multiple pathways of recovery” mantra that has gained such prominence in recent years.

Anyone wishing to learn more about the secular wing of AA and secular styles of recovery may do so be exploring the rich collection of stories, articles, and other publications posted at AA Agnostica and related websites or by reviewing the growing body of secular AA literature.

The secular wing of AA and the growth of secular recovery mutual aid groups beyond 12-Step groups are both cause for celebration. As the new mantra goes, “Recovery by any means necessary under any circumstances.”

Post Date March 2, 2018 by Bill White