Bill White -THE TIME IS NOW FOR A RADICAL TRANSFORMATION OF ADDICTION TREATMENT BY WILLIAM WHITE, GARY MENDELL, AND SAMANTHA ARSENAULT-July 20, 2018

Countless people have had their lives positively transformed by addiction treatment. But tragically, this is not the norm.

Despite decades of advancements in science, pharmacology, and technology, the continuum of evidence-based addiction treatment services remains largely unavailable to those in need. The addiction treatment system is hindered by fragmentation, outdated treatment philosophies, and a payment system that perpetuates antiquated care models and discourages the adoption of best practices in the field. The historical rise and development of the current addiction treatment system explains the evolution of a broken system, and sheds light on new solutions.

Today, drug policy leaders, frontline addiction professionals, and affected individuals and families are calling for radical changes in the design and delivery of addiction treatment. It’s time for change. It’s time to protect our families.

THE EARLY DAYS OF AMERICAN ADDICTION TREATMENT
Treatment and recovery support for addiction began in the mid-1800s, with the nation’s first temperance and alcoholism recovery mutual aid movements, which subsequently grew into specialized care. In the mid-to-late nineteenth century, addiction treatment was provided by inebriate homes, inebriate asylums, and private addiction cure institutes; faith-based urban rescue missions and rural inebriate colonies; and by aggressively promoted and often fraudulent “home cures.”
An advertisement for Olin Morphine Cure
The early era of addiction treatment in the U.S was riddled with ideological divisions, ineffective and harmful treatment methods, and exposés of fraud. Not surprisingly, this era of unsubstantiated interventions ended with lost cultural faith in the potential for permanent recovery from addiction.

As specialized care collapsed in the early twentieth century, America embarked on a bold social experiment: Let those currently suffering with addiction die off by benign neglect, and prevent future addiction by legally prohibiting the sale of beverage alcohol and by criminalizing the non-medical distribution and possession of opiates, cocaine, and a succession of other intoxicants. During this time, people addicted to alcohol and other drugs were relegated to the “drunk tanks” of local jails, inebriate penal colonies, the “foul” wards of large city hospitals, the “chronic” wards of psychiatric asylums, and, for the rich and famous, exclusive “drying out” sanitaria.
https://www.shatterproof.org/sites/default/files/styles/max_325x325/public/2018-07/08%20New%20York%20State%20Inebriate%20Asylum.jpg?itok=3lkm7QAQThe New York State Inebriate Asylum
In the mid-twentieth century, sporadic efforts to rebirth specialized addiction treatment accelerated. Alcoholics Anonymous (AA, 1935) and the advent of AA-influenced models of treatment (1940s) elevated cultural optimism about recovery, and rising rates of juvenile narcotic addiction in the 1950s spurred new experiments in addiction treatment and recovery support. This resulted in increased availability of replicable treatment models (e.g., outpatient clinics and inpatient/residential alcoholism treatment programs, therapeutic communities, methadone maintenance clinics).

Driven by the emergence of new treatment methods, decades of medical and legal advocacy, rising alarm about heroin use among American soldiers in Vietnam and youth at home, the U.S. reached a cultural tipping point in the early 1970s.
https://www.shatterproof.org/sites/default/files/styles/max_325x325/public/2018-07/OperationUnderstandingGroupPhoto_5-8-1976.jpg?itok=JKzuNMfHOperation Understanding, 1976
The outcome was landmark legislation (Comprehensive Alcoholism Prevention and Treatment Act of 1970 and the Drug Abuse Treatment Act of 1972), providing federal, state, and local funding for prevention and treatment and expanding insurance coverage for addiction treatment, plus a sustained campaign of public education led by people in recovery from alcoholism.

This stimulated rapid growth of addiction treatment from a fledgling therapeutic movement to a multi-billion (currently more than $35 billion) dollar industry. However, this growth was not tied to improvements in quality: The performance of addiction treatment programs was benchmarked by financial metrics such as occupancy rate and budget, rather than measurements of patient outcomes and wellness.

THE WAR ON DRUGS AND THE OPIOID EPIDEMIC
The 1980s and 90s added additional challenges to treatment quality and barriers to access. An intensified “War on Drugs” further criminalized addiction as a moral failing rather than a medical disease. This resulted in increased penalties for drug-related crimes, diversion of addicted individuals from treatment interventions to jails and prisons, and heightened addiction-related stigma. More restrictive insurance coverage for addiction treatment and an aggressive system of managed care led to the closure of many hospital-based addiction treatment units and private residential treatment programs, as well as progressively shorter durations of addiction treatment.

Since 2000, the opioid epidemic has again shifted the treatment landscape. Legislative and regulatory responses now require insurance coverage of addiction treatment at par with other medical conditions (through the Mental Health Parity and Addiction Equity Act and Affordable Care Act), and have expanded treatment, education, and prevention (through the Comprehensive Addiction Recovery Act and Twenty-First Century Cures Act). However, there has been slow progress to integrate addiction treatment with mainstream healthcare and mandate modern best practices. Instead, addiction treatment is still largely delivered with diverse philosophies and methods stemming from its beginnings as a “folk healing art.”

THE DEADLY TOLL OF OUTDATED TREATMENT METHODS
The continued use of outdated treatment methods is harmful to patient health, and, in some cases, it’s even criminal. The treatment system fails to reach people until the latest stages of addiction, and is ill-equipped to provide care for people with low to moderate problem severity. Insurance denials, prior authorization requirements, and admission waiting lists create impossible hurdles. The system is plagued by high early dropout rates (40-60%), high rates of non-completion (more than 50%), and low rates (less than 50%) of successful linkage to long-term recovery support resources.

Families affected by addiction report that they can’t find or judge the quality of treatment services. Gary’s son, Brian, for example, cycled through seven different programs without accessing treatment based on research or attuned to his needs.

THE ONLY PATH FORWARD: A RADICAL TRANSFORMATION
The Surgeon General’s Report on Alcohol, Drugs and Health illuminates how to systemically course-correct the addiction treatment system and improve the quality of care. Shatterproof’s Substance Use Disorder Treatment Task Force, a multi-stakeholder group including leaders in addiction research, treatment, and health policy and payment, is dedicated to making this happen. Drawing upon core concepts from the Report, the Task Force established the National Principles of Care for Substance Use Disorder Treatment, eight core tenants of quality addiction treatment, to guide their work.

Ensuring the addiction treatment system aligns with these principles will take shifts in infrastructure, payment incentives, and treatment philosophies. Shatterproof and the Treatment Task Force are working to create a rating system for addiction treatment programs that will drive these critical changes by bringing new transparency to the quality of care offered at addiction treatment programs. Measuring each program’s use of evidence-based best practices, and making this information available to the public, will allow those seeking treatment to make informed decisions and market forces to incentivize providers to deliver high-quality, evidence-based care.

These steps will not be easy, but they are essential to transforming addiction treatment into a highly-regarded medical specialty, and to ensuring that every American has access to evidence-based medical care.

Gary Mendell is Shatterproof’s founder and CEO. Sam Arsenault is Shatterproof’s Director of National Treatment Quality Initiatives. William White is Emeritus Senior Research Consultant at Chestnut Health Systems and author of “Slaying the Dragon: The History of Addiction Treatment and Recovery in America.”

Photos courtesy of the Illinois Addiction Studies Archives.

Post Date July 20, 2018 by Bill White

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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

Bill White-CHANGING THE WATER-June 29, 2018

On May 21, 2005, David Foster Wallace opened his commencement address at Kenyon College with the following story.

There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says “Morning, boys. How’s the water?” And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes “What the hell is water?”

Each of us swims in a near-invisible cultural stew of words, ideas, attitudes, images, and sounds that constitute the personal stage upon which the actions of our daily lives unfold. These near-invisible contextual elements of our lives are so deeply imbedded that they rarely if ever enter our conscious awareness. Yet, they exert a profound influence on how we view ourselves and our relationship with the world. They bestow or deny personal value, convey our degree of safety and vulnerability, and impregnate us with hope or hopelessness.

The shared “water” that Wallace refers to includes cultural attitudes towards addiction and addiction recovery. Recovery advocates have long known that these cultural waters can nourish or extinguish efforts to prevent or resolve alcohol and other drug problems. When we talk about the role social stigma plays in inhibiting help-seeking and preventing the integration of people in recovery into community life, it is these waters of which we speak.

Those of us who start out helping people resolve these problems at an intrapersonal level often reach an “Ah Ha” moment in which they see the larger challenge before them. In a breakthrough of insight, we face two essential and linked dilemmas. First, there is the awareness of being at the end of an assembly line spewing out broken souls at an ever-increasing pace and the realization that, in spite of our service to individuals, we are doing nothing to slow this machinery of personal destruction. Second is the awareness that people are seeking to initiate and maintain recovery within communities that offer little if any physical, psychological, or cultural space within which recovery can flourish and which, in fact, impede recovery initiation and maintenance efforts. Those of us seeking to heal the broken person are often initially blind to the power arrangements that inflict such wounds and impose such obstacles to healing. The water within which helper and helpee both swim must become visible if a larger healing is to occur.

As David Foster Wallace suggests, “The point of the fish story is merely that the most obvious, important realities are often the ones that are hardest to see and talk about.” As we get inevitably caught up in the daily details of this or that recovery advocacy or support activity, we must not lose sight of the fact that what we are ultimately trying to do is change the nature of the water within which we are all swimming. Today we bind the individual wounds; tomorrow we will transform our communities into sanctuaries in which such wounds become increasingly rare. Within the Wellbriety movement, this transformed community is understood as a “Healing Forest.”

In the Red Road to Wellbriety, the individual, family, and community are not separate; they are one. To injure one it to injure all; to heal one is to heal all. –The Red Road to Wellbriety

That is a vision of community recovery we must not lose.

Post Date June 29, 2018 by Bill White
Categories Articles

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-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

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