Bill White-RECOVERY RISING EXCERPT: PAIN AND HOPE IN ADDICTION RECOVERY-June 19, 2018

A Rendezvous with Hope (Lessons from an Outreach Worker)

Through my tenure in the addictions field, the question of readiness for treatment and recovery was thought of as a pain quotient. In the earliest years, we believed that people didn’t enter recovery until they had truly “hit bottom.” If a client didn’t fit that criterion of pain-induced readiness, they were often refused admission to treatment (and if we did admit them, we often threw them out shortly afterward). Then we recognized that the reason it took people so long to hit bottom was that they were protected from the painful consequences of their alcohol and other drug use by a class of people we christened “enablers.” So we then set about teaching enablers to stop rescuing and protecting their beloved alcoholics/addicts. Vern Johnson then came along and convinced us we could raise the bottom through a process he called intervention. Intervention removed the safety net of protection and confronted the alcoholic/addict with the consequences of his or her drug use and promised additional consequences if this behavior continued. Staging such interventions within families and the workplace was something of a revolution—and later an industry—that brought large numbers of culturally empowered people into treatment. But all these philosophies and technologies were about the use of pain as a catalyst of addiction recovery. So, I brought this view to my work as an evaluator of Project SAFE.

Client engagement in Project SAFE relied on an extremely assertive approach to community outreach that often involved many visits before a woman entered formal treatment services. I was interviewing one of the outreach workers and could tell she was becoming frustrated with my questions about how clients entered treatment and particularly my attempts to isolate the painful crisis that had propelled the decision to enter treatment. The outreach worker finally turned to me and said the following:

Bill, you’re not getting it! My clients don’t hit bottom; my clients live on the bottom. Their capacities for physical and emotional pain are beyond your comprehension. If we wait for them to hit bottom, they will die! The issue of engaging them is not an absence of pain, it is an absence of HOPE!

The outreach worker went on to describe how the treatment system needed to shift from a pain-based to a hope-based approach to engage the kind of women she was working with. Let’s now explore that approach through the eyes of those who were on the receiving end of these assertive outreach services.

“She followed me into Hell and brought me back.”

As the evaluator of Project SAFE, I had the opportunity to interview women many months and years after they had completed addiction treatment. More specifically, I interviewed women in stable recovery who, at the point of initial contact with Project SAFE, had a poor prognosis for recovery. Initially, they presented with a massive number of severe and complex problems, involvement in toxic relationships, and innumerable other personal and environmental obstacles to recovery. As I faced these amazingly resilient women, I asked each of them to tell me about the sparks that had ignited their recovery journey. Each of them talked about the role their outreach worker had played in their lives. The following comments were typical.

I couldn’t get rid of that woman! She came and just kept coming back—even tried talking to me through the locked door of a crack house. She wore me down. She followed me into Hell and brought me back.

(This woman is describing the first day she went to treatment—after eight weeks of outreach contacts.) It was like a thousand other days. My babies had been taken and I was out there in the life. I’d stopped by my place to pick up some clothes and there was a knock on the door. And here was this crazy lady one more time, looking like she was happy to see me. I looked at her and said, “Don’t say a word; let’s go” (for an assessment at the treatment center). She saw something in me that I didn’t see in myself, so I finally just took her word for it and gave this thing (recovery) a try.

And she kept sending me those mushy notes—you know the kind I’m talking about. (Actually, I had no idea what she was talking about.) You know, the kind that say, “Hope you’re having a good day, I’m thinking about you, hope you are doing well” and all that stuff. I treated her pretty bad the first time she came, but she hung in there and wouldn’t give up on me. I can’t imagine where I would be today if she hadn’t kept coming back. She hung in with me through all the ups and downs of treatment and getting my kids back.

These remarkable women taught me that, for the disempowered, the spark of recovery is a synergy of pain and hope experienced in the context of a catalytic relationship. Life and their addictions had delivered to these women more than enough pain; what was needed was an unrelenting source of hope. That hope was delivered by a cadre of recovering women who lacked much by way of professional credentials and polish, but who brought an inextinguishable and contagious faith in the transformative power of recovery. These outreach workers knew recovery was possible. They were the living proof of that proposition. What these outreach workers were able to achieve stands as testimony that the addiction treatment system needs to move beyond treating those who are ready for treatment to priming recovery motivation in those who are not yet ready. As the outreach worker so eloquently scolded me, “If we wait for them to hit bottom, they will die.”

Post Date June 19, 2018 by Bill White

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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 MANAGEMENT AND OLD SCHOOL SOCIAL WORK (BILL WHITE AND MARK SANDERS)-May 25, 2018 By Bill White

Efforts are well underway to shift addiction treatment from models of ever-briefer acute care to models of sustained recovery management (RM) nested within larger recovery-oriented systems of care (ROSC). This shift involves extending the continuum of recovery support services across the stages of long-term recovery, but it also embraces a more activist stance in shaping community environments in which addiction recovery can flourish. RM and ROSC, through their recognition of the ecology of addiction recovery, force a rethinking of drug policy at national and state levels and place clinical interventions within a larger rubric of local cultural and community revitalization. The roots of such perspectives are many, but some can be traced to the early history of social work in the United States.

Social work in recent decades has emphasized clinical interventions into social problems. Early social work, however, was marked by its belief that social problems had social roots and that community and societal level interventions were needed to resolve and prevent the nation’s most intractable social problems. The methods of RM and ROSC are closely aligned with the core values, principles, and methods of early social workers in the U.S. via their:

*activism in drug policy reforms,

*exposure of political, economic, and cultural marginalization as factors in addiction vulnerability,

*challenge to institutional influences (e.g., predatory marketing) that promote and then profit from excessive alcohol and drug (AOD) use and its resulting problems,

*preference for working with people in their natural environments via assertive outreach rather than the clinical consulting room,

*respectful, egalitarian, partnership relationships with those served (i.e., preference for empathy and support rather than judgment and confrontation),

*focus on client/community assets rather than deficits,

*emphasis on the healing power of client voice and choice,

*mobilization of affected people to advocate on their own behalf,

*efforts to forge mutual support groups and “healing sanctuaries” within local communities, and

*warning that short-term quick fixes can result in long-term harm to individuals, families, and communities.

The activist roots of social work declined under the growing influence of psychiatry and psychology. Growing numbers of social workers embraced clinical models of diagnosis and counseling, with many aspiring to a future in clinical private practice as the apex of one’s professional achievement. Interestingly, by the mid-twentieth century social workers were also getting a reputation for ineffectiveness in their clinical work with people who were addicted. The bleeding heart trope emerged that social workers were too soft to work with “hard-core addicts”—that they failed to understand addiction, were too easily manipulated, and too often served as addiction enablers. Anyone familiar with the modern history of addiction treatment is aware that social workers went on to make significant contributions to clinical models of addiction treatment, particularly in services to addiction-affected families and children. Given these achievements, the contributions within the early history of social work that helped shape models of RM and ROSC can be easily overlooked. If RM and ROSC survive as effective organizing paradigms for addressing addiction at personal and systemic levels, and if the history of RM and ROSC is one day written, then the acknowledged pioneers who set the stage for these paradigms should include Jane Addams and other early pioneers within the activist tradition of social work.

The activist roots of social work, with their emphasis on environmental influences on social problems, provide needed balance in what many consider the current over-emphasis on biological models of addiction. For that balance, we owe much to the early history of social work and the current revival of its activist roots.

For more on the activist roots of social work and their infusion into RM & ROSC, see the following:

McKnight, J. (1995). The careless society: Community and its counterfeits. New York: Basic Books.

Specht, H., & Courtney, M. (1994). Unfaithful angels: How social work has failed its mission. New York: The Free Press.

White, W. (2002). A lost vision: Addiction counseling as community organization. Alcoholism Treatment Quarterly, 19(4), 1-32.

White, W. L., & Sanders, M. (2008). Recovery management and people of color: Redesigning addiction treatment for historically disempowered communities. Alcoholism Treatment Quarterly, 26(3), 365-395.

Post Date May 25, 2018 by Bill White

BLOG & NEW POSTINGS May 4, 2018 -Bill White- RECOVERY SUPPORT FOR PEOPLE IN MEDICATION ASSISTED RECOVERY: SUGGESTED STRATEGIES

In the last blog, we explored why people in medication-assisted treatment (MAT) for alcohol or opioid use disorders 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. In my communications with addiction treatment and recovery community organizations, I regularly urge the full integration of psychosocial and medication support options and suggest three broad strategies for increasing medication support for people in MAT within the current dichotomized context of recovery support.

The first strategy is to collaborate with existing recovery mutual aid organizations and local recovery support institutions to increase access to these resources by patients in MAT. This strategy requires a foundational understanding of the history, evolution, and current policies and practices within these groups related to people who are on prescribed medications as part of their treatment for addiction. You will want to know if there are formal or unwritten exclusion policies/practices, any restrictions on membership rights (e.g., ability to speak in meetings, lead meetings, perform service roles) placed on people in MAT, and the degree to which individuals in MAT will be either stigmatized or warmly welcomed within each available group. It is important in this regard to recognize the high variability across meetings within each recovery fellowship and to identify medication-friendly groups with whom you can collaborate. Working within the service structures of these organizations to directly address the needs of people in MAT can help widen doorways of entry and acceptance. Such efforts are enhanced when combined with a sustained campaign of public, professional, and patient/family education on MAT and medication-assisted recovery, the latter enhanced by eliciting stories from individuals and families in long-term recovery whose recoveries were aided by MAT.

The second strategy is to expand access to mutual aid groups specifically designed for people in MAT. Such groups as Methadone Anonymous or local MAT support groups operating under various names (e.g., Ability, Inspiration and Motivation, AIM) can provide medication-specific recovery support without the stigma sometimes encountered in other groups related to the use of medications as an adjunctive recovery support. The downside of these groups is they may be less accessible and less stable than mainstream groups, e.g., fewer face-to-face meetings, less meeting stability, and shorter periods of recovery stability of those attending. MAT-specific support groups tend to flourish in communities in which other support groups are hostile towards medication, but weaken as these other groups become more accepting of people in MAT. The challenges of accessing such resources have led many people in MAT to seek support online rather than within their local communities. Such resources include http://www.addictionsurvivors.org/ and https://www.dailystrength.org/group/suboxone-support-group. A related recovery support strategy is to use parallel support groups that may aid recovery, e.g., support groups for people living with HIV/AIDS or Hep C, groups for trauma survivors, etc.

The third strategy involves providing open-ended peer-recovery support services (PRSS) through the auspices of an addiction treatment, recovery community, or other service organization. An example of such an effort is the M.A.R.S. Project, a federally-funded program providing peer recovery support to patients in medication-assisted treatment (MAT) for opioid addiction. (See interview with M.A.R.S. Director Walter Ginter.) M.A.R.S. is a collaborative project of Albert Einstein College of Medicine in New York City, Yeshiva University, and the National Alliance for Medication-Assisted (NAMA) Recovery. Such efforts can exist as independent projects or be integrated into existing organizations. They can serve as permanent alternatives to existing mutual aid groups where such groups are absent or hostile to MAT or serve as a source of transient support until independent and medication-friendly recovery mutual aid groups can be locally established. Treatment organizations could provide such services over time within three phases: 1) an open-ended and professionally-direct continuing care group, 2) a support group led by former MAT patients under the auspices of an alumni association, and 3) spinning the alumni-sponsored group off as an independent member-run recovery mutual aid society. Such phased efforts can provide services on an immediate basis to those in need of such support while at the same time expanding peer-based recovery mutual aid resources that can operate independently from other organizations.

It is my contention that the future of addiction treatment lies with the expansion of the treatment menu, evaluating the efficacy 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 recovery and across diverse cultural contexts. For many, that will involve integrating medication support and a broad spectrum of psychosocial supports.

References

Galanter, M., Seppala, M., & Klein, A. (2016). Medication-assisted treatment for opioid dependence in twelve-step-oriented residential rehabilitation settings, Substance Abuse, 37(3), 381-383.

Gilman, S. M., Galanter, M., & Dermatis, H. (2001). Methadone Anonymous: A 12-Step program for methadone maintained heroin addicts. Substance Abuse, 22(4), 247-256.

Ginter, W. (2012). Methadone Anonymous and mutual support for medication-assisted recovery. Journal of Groups in Addiction & Recovery, 7(2-4), 189-201.

Glickman, L, Galanter, M., Dermatis, H., Dingle, S., & Hall, L. (2005). Pathways to recovery: Adapting 12-step recovery to methadone treatment. Journal of Maintenance in the Addictions, 2(4), 77-90.

Krawczyk, N., Negron, T., Nieto, M., Agus, D. & Fingerhood, M.I. (2018). Overcoming medication stigma in peer recovery: A new paradigm. Substance Abuse, February, DOI: 10.1080/08897077.2018.1439798.

McLellan, A. T., & White, W. L. (2012). Opioid maintenance and Recovery-Oriented Systems of Care: It is time to integrate. Invited commentary on Recovery-oriented drug treatment: An interim report by Professor John Strang, Chair of the Expert Group. (DrugLink, July/August, pp. 12-12). London, England: The National Treatment Agency.

Obuchowsky, M., & Zweben, J. E. (1987). Bridging the gap: The methadone client in 12-Step programs. Journal of Psychoactive Drugs, 19(3), 301-302.

Tonigan, J. S., & Kelly, J. F. (2004). Beliefs about AA and the use of medications: A comparison of three groups of AA-exposed alcohol dependent persons. Alcoholism Treatment Quarterly, 22(2), 67-78.

White, W. L. (2011). Narcotics Anonymous and the pharmacotherapeutic treatment of opioid addiction. Chicago, IL: Great Lakes Addiction Technology Transfer Center and Philadelphia Department of Behavioral Health and Intellectual disAbility Services.

White, W., Campbell, M. D., Shea, C., Hoffman, H. A., Crissman, B., & DuPont, R. L. (2013). Co-participation in 12 Step mutual aid groups and methadone maintenance treatment: A survey of 322 patients. Journal of Groups in Addiction & Recovery, 8(4), 294-308.

White, W. L., & Torres, L. (2010). Recovery-oriented methadone maintenance. Chicago, IL: Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health and Mental Retardation Services, and Northeast Addiction Technology Transfer Center.

Post Date May 4, 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 ROLE OF MEDICINE IN ADDICTION TREATMENT-April 19, 2018- By Bill White

Imagine seeking assistance from a health care facility and being told that you have a progressively debilitating and potentially fatal medical disorder (one widely recognized in the research community as a brain disease), but then discovering that no physician or other medical personnel will be involved in the assessment, diagnosis, acute treatment, or continued monitoring of your condition. Imagine that the vast majority of organizations specializing in treatment of your condition have no affiliation with a hospital or other primary healthcare facility. Imagine the existence of FDA-approved medications specifically for treatment of your condition, but that you will not be informed about nor have access to these medications as part of your prescribed treatment. These are precisely the circumstances encountered today by the majority of people entering addiction treatment in the U.S.

There are more than 18,000 facilities in the United States that specialize in the assessment and treatment of substance use disorders. Surveys of these facilities reveal a low complement of physicians on staff, with nearly half having no physician availability. Publicly funded programs that constitute the bulk of addiction treatment services in the U.S. are particularly lacking in physician services and access to pharmacotherapy as a treatment adjunct.

Physicians are critically needed as part of the multidisciplinary teams involved in addiction treatment. Some of the more important functions they perform include:

*Diagnosing the presence, severity, and complexity of substance use disorders, particularly in distinguishing these disorders from other medical and psychiatric conditions which may manifest as, be masked by, or be self-medicated by excessive alcohol and other drug use.

*Diagnosing and treating acute medical and psychiatric conditions that result from or co-occur with substance use disorders—conditions that if left untreated pose a significant burden within the recovery process.

* Assessing and addressing the physical and emotional toll addiction has exacted on family members.

* Participating in, if not leading, development of a personalized plan for acute stabilization and a more comprehensive plan of sustained recovery management for the patient and family.

* Evaluating the role medications could potentially play in detoxification, acute stabilization, and long-term recovery management.

* Providing guidance on the management of chronic primary health care problems and promoting recovery-enhancing wellness activities, e.g., smoking cessation, diet, and exercise.

* Educating patients and families on the addiction and recovery processes.

* Supervising other members of the treatment team.

* Providing regularly scheduled post-treatment recovery check-ups as part of the long-term recovery management plan.

If you or a family member must enter treatment for a substance use disorder in a program that does not have physician services, I recommend the following two steps.

1) Involve your primary care physician (PCP) in the treatment process. Inform your PCP of the following: you are entering addiction treatment, you would like your PCP to be available for consultation regarding that treatment, you will provide your PCP copies of all records related to your treatment, and you would like your recovery status regularly evaluated through all future check-ups. If you do not have a primary care physician, make obtaining a PCP a priority as part of your treatment /recovery plan.

2) Consider engaging a physician trained in addiction medicine to consult in your overall treatment and to provide ongoing guidance following treatment discharge. It is recommended that such a physician be affiliated with the American Society of Addiction Medicine or the American Academy of Addiction Psychiatry. Addiction medicine specialists in your area can be identified by contacting these organizations.

Beyond these two suggestions, it is critical that anyone seeking addiction treatment become an informed consumer. This requires seeking both experiential knowledge and empirical knowledge about addiction and recovery. The former can be obtained by talking to individuals and families who have successfully resolved alcohol and other drug problems. The latter can be obtained by reading the latest research findings about the critical ingredients of addiction treatment and recovery—research findings that have recently been translated for public consumption by the Recovery Research Institute, a nonprofit arm of Massachusetts General Hospital and Harvard Medical School.

Each person in recovery must own his or her own recovery process. A wide variety of professional and peer support services may be helpful along this journey, but it is the person in recovery who must direct this process, assembling diverse consultants who can inform and assist this effort. Physicians and psychiatrists knowledgeable about addiction recovery and experienced in offering guidance through the recovery process can be important and even crucial resources within the recovery process. The challenge for America is to expand the number of physicians and psychiatrists who possess such knowledge and expertise. The challenge for organizations that make up the addiction treatment industry is to assure their staffing patterns match their rhetoric of addiction as a treatable medical disorder.

Post Date April 19, 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