Do No Harm to People with Substance Use Disorders

What can you do to help the over 16,000 people in the New River Valley of Virginia with substance use disorders? Here’s an executive brief.

Executive summary:

  1. Do no harm.
  2. Help people get health insurance and medical care.
  3. If they’re open to it, accompany people to their appointments.
  4. Start a SMART Recovery meeting.
  5. Lobby against federal and state restrictions on medications that treat addiction.
  6. Host substance-free gatherings and events, both at home and in the community.
  7. Help people help themselves.
  8. Inform yourself about addiction and addiction treatment in our locale.

An explanation of #1 – Do no harm – follows. The full brief is here.

I will try to help

 1) Do no harm.

What harms people with substance use disorders?

  • Telling them that your personal experience with addiction, or your knowledge of several people’s experiences, will work for them. Addiction treatment needs to be research-backed, evidence-based, recommended by health care professionals, and individualized for each person’s unique case.
  • Telling someone they have to “hit bottom” before they recover. “Hitting bottom” is a state of physical and mental emergency that can result in death.
  • Telling someone to “Just stop” and “Get over it.” That’s like telling someone with Parkinson’s to stop shaking or someone with dementia to “Just remember!” Addiction is a brain disorder. Like people with Parkinson’s, dementia and other chronic brain disorders, people with addiction need medical care.
  • Telling someone your belief or opinion about addiction. If you can’t cite the research on what you’re saying about addiction, don’t say it.

Most of the over 16,000 people with substance use disorders (SUDs) in our area struggle with alcohol, not opioids. Most people with opioid use disorders struggle with use of other substances as well – including alcohol. Most are not receiving care.

“Do not attempt to take away a person’s main means of trying to cope with pain and suffering until you have another effective coping strategy in place.”
Alan Marlatt

What limits people with substance use disorders from receiving evidence-based care in our locale?

  • Continued belief – by lawmakers, health care professionals, treatment professionals, and society at large – despite the vast and extensive data that reports otherwise – that addiction is a moral problem, not a medical one. Addiction is believed to be the individual’s fault and the individual’s responsibility to cure. Lack of improvement is blamed on lack of character and effort.
  • Federal and state restrictions on access to addiction medications.
  • Lack of knowledge among health care providers and treatment professionals on research-backed, evidence-based treatment for addiction, including medications for addiction. Most people with substance use disorders get recommendations in the reverse order from the standard of care: support group attendance, then, if that doesn’t work – which the evidence says it won’t for most people – counseling. Rarely is the first-order, standard of care – medication – considered.
  • Lack of sufficient trickle-down knowledge to society at large about the latest research on addiction. People still believe they know best, even if the data says otherwise.
  • Lack of early treatment. Many people in our locale have acute, advanced cases of addiction from long-term, multi-year lack of evidence-based treatment or from mistreatment. The signature brain impairments of addiction result in behavioral symptoms that can make people with SUDs challenging patients. As with acute, chronic cases of other life-threatening illnesses, premature death may result. Harm reduction or palliative care – not incarceration or multiple rehab stays – may be the most humane and cost-effective option for our citizens with the direst cases.
  • Arguments about what prevents addiction. The only thing that prevents addiction is never having done the thing – no sip of beer snuck from a parent’s beer can, no first cigarette, no first toke, no sex, no porn, no Internet, no gambling, no exciting experimentation of any kind. The vast majority of Americans, about 86%, do not develop addiction. Through a complex set of known and unknown factors, 14% do. Attempting to prevent addiction through limiting supply is attempting to prevent people from being human. It has, and will, fail.

An explanation of #1 – Do no harm – is above. The full brief is here.

The opinions expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends.  This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

What You Can Do to Help People in the NRV with Addiction

An executive brief on what you can do to help the over 16,000 people in the New River Valley of Virginia with substance use disorders.

Executive summary:

  1. Do no harm. 
  2. Help people get health insurance and medical care.
  3. If they’re open to it, accompany people to their appointments.
  4. Start a SMART Recovery meeting.
  5. Lobby against federal and state restrictions on medications that treat addiction.
  6. Host substance-free gatherings and events, both at home and in the community.
  7. Help people help themselves.
  8. Inform yourself about addiction and addiction treatment in our locale.

I will try to help1) Do no harm.

A full explanation is here.

2) Help people get health insurance and medical care.

Use the Surgeon General’s report on addiction as a guide.

The Surgeon General’s report recommends substance use disorder treatment in this priority order: medications, counseling, and support.

Medications

Help people get health insurance. In the New River Valley of Virginia, help people with severe mental illnesses and low incomes call New River Valley Community Services at 540-961-8300 to make an appointment for help with enrolling in GAP. If they’ve previously paid federal taxes, sit down with someone at a computer and help them navigate healthcare.gov, or call Laura Goorskey at Muneris for help with signing up for insurance through the Affordable Care Act.

Help people make appointments with their primary care physicians (PCPs). While an appointment with a psychiatrist might be optimal, wait lists for appointments in our area are 6 months or more and require a referral from one’s PCP anyway.

Some medications that treat addiction, illogically, are not available in all areas of our locale, are available only through a wait list, or are available for cash only. If your person has an opioid use disorder, you will discover the horror of the double bind in which we place our citizens.

Join with community stakeholders to create attractive packages of positions, salaries, caseloads, housing and Virginia Tech football tickets – whatever it takes – to attract more psychiatrists and medical professionals to our area who are experts in, and federally certified to, treat addiction.

Counseling

Help create and update a list of counselors in our locale who are currently accepting new clients, who are open to taking clients with substance use disorders (many are not or don’t feel qualified to do so), who offer cognitive behavior therapy (CBT), the top recommended therapy for SUD, and who may give discounts to low-income individuals. Dialectical behavior therapy (DBT), is an increasingly evidence-based counseling approach as well.

Counseling does not directly treat addiction, but can assist people with abstinence, drinking or using less problematically, and with co-occurring mental and emotional issues. According to the Surgeon General’s report, individual counseling is the recommended modality, group therapy less so.

Support

The more local support group meetings we have on different days of the week, at different times, in various locations, the more people who need support for the 24-7 condition of addiction can get it.

3) If they’re open to it, accompany people to their appointments.

Study the Treatment section of the Surgeon General’s report, print out several copies, and highlight sections that pertain to your person’s condition. Be ready to point to those relevant section, others as they come up, and to hand over your highlighted copy. (Printouts of very recent research reports can be helpful. For alcohol, try pages 4-24 and 4-25 from the Surgeon General’s report from 2016, and this one from 2107. Although medications for methamphetamine use disorder are still unknown, this report from 2017 is promising. For opioids, this piece of journalism from 2016 is stellar.)

Demand for health care exceeds supply in our locale and many of our health care professionals are saving lives and relieving suffering, not studying the latest research on addiction. Some, unfortunately, offer belief-based treatment, not evidence-based treatment. Help inform them. Advocate if you need to. Keep what happens in the appointment rigidly, absolutely confidential.

4) Start a SMART Recovery meeting.

SMART Recovery does not require meeting facilitators to be in recovery from addiction themselves.That means that any citizen can volunteer to train quickly as a host, and more extensively as a facilitator, and we can, as a community of trained “citizen counselors,” offer therapeutically-based recovery support services to our own community members.

The more citizen volunteers we have hosting local SMART Recovery meetings, the more support we offer and the more stigma-busting we do. I share with permission that to support the launch of our locale’s first open community meeting of SMART Recovery, our town’s mayor, Ron Rordam, attended. If you can go to business, community, educational and religious buildings and see the butcher, the baker, the candlestick maker – and the mayor himself – at a SMART Recovery meeting, well, maybe addiction is just an unfortunate condition for which the whole community backs recovery and wellness.

Mob SMART Recovery Facebook pages like our local one with “Likes.” That explodes the stigma of  “Is she or he ‘one of them’?”and transforms “Us vs. Them” into “We.”

5) Lobby against federal and state restrictions on medications that treat addiction.

Contact your representatives and urge them to work to repeal federal and state laws, and Virginia Board of Medicine policies, that limit access to medications that treat or ameliorate addiction. The logic of the laws is that if people have trouble getting substances, or are punished for using them, they won’t use them. Given human nature – we’re wired for pleasure, excitement and experimentation – and the nature of addiction – addiction’s brain impairments result in persistence no matter what the cost, no matter what happens, and no matter what punishments are levied – this is a position of tragic illogic.

6) Host substance-free gatherings and events, both at home and in the community.

Brew Do, Fork and Cork, Cocktails and Collaborations…where can an adult go locally to be with other adults not using substances? And how about gatherings of family and friends accompanied by wine, beer, marijuana, or other substances? Research on addiction reports that environmental cues can illicit automatic use or near-use. Many people with substance use disorders simply cannot risk being around substances. Consider declaring or hosting one gathering per quarter as a substance-free event to protect and enhance the lives of citizens and loved ones with addiction.

To help coordinate gatherings and events, consider volunteering to launch a New River Valley recovery community organization (RCO). A .pdf of the recovery community organization toolkit from the Association of Recovery Community Organizations and Faces and Voices of Recovery is here.

(Recovery advocacy and activism is too lonely to be tolerated long-term by one person and, ultimately will be ineffectual. Faces and Voices of Recovery has found, “[R]ecovery voices are marginalized and ineffective when the work is shouldered primarily by lone individuals.” Groups of individuals can make things happen.)

7) Help people help themselves.

Given the scarcity of treatment and medications for addiction in our locale, and given that addiction is a 24-7 condition, most people with addiction will have to provide much of their own care much of the time. Innovative programs like this exist in other areas. Here, we DIY (do-it-yourself). Help people discover what’s helpful to them and to practice evidence-based self-care.

8) Inform yourself about addiction and about addiction treatment in our locale.

To become quickly informed about the science of addiction, I recommend the NIDA site. For further study, consider the Surgeon General’s report (minus the section on TSF, included for legacy reasons, but which is not an evidence-based treatment), and Maia Szalavitz’s comprehensive report on addictions research, the New York Times bestseller Unbroken Brain: A Revolutionary New Way of Understanding Addiction. Maia continues to report on addictions research and a list of her recent articles is here. Laurel Sindewald and I have written a series of brief reports listed here.

To inform yourself about addictions treatment in our locale, the next time you go to a health care appointment, ask your providers what they would do for you if you told them you had a problem with alcohol, opioids or another substance. You’ll learn why it takes 3,000 words to describe how to get addictions treatment in the New River Valley of Virginia.

The opinions expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends.  This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Last updated 4/24/17

Preparing for April 16

From what I’ve learned about community trauma, I know that grief and aftershock may emerge involuntarily. I know that people with substance use disorders can experience bereavement differently from others. Since strong emotions make me ripe for relapse, I am planning for April 16 very carefully.

In honor of the survivors

Things I am not doing: fussing at myself for not being able to get over it; avoiding and minimizing my reality by saying, “I don’t do anniversaries”; stuffing my inner wail into a stages-of-grief spreadsheet that poor Elisabeth never intended to be hafta-dos; giving in to my tendency to withdraw and quake alone; bending to the complex terror welded to my bereavement that blocks me from asking for help; going to Kroger for any purchase whatsoever because I will only see (usually only see) the wine aisle.

What I am doing: I invited friends for breakfast and they are coming, even though it’s Easter Sunday. I asked my 83 year-old dad to go with me to our local, afternoon SMART Recovery meeting and he is going, even though he doesn’t have addiction issues. I am exercising today and Saturday. I am eating simple foods moderately – no chips, no cakes, no cookies. I will take naps.

I have started to feel the first licking flames of what, for me, is horror rather than grief. I am turning towards it, not away. I acknowledge it. “Ah, horror. There you are.”

If Sunday is an ordeal – or the days before or after – I am preparing myself to endure it the best I can. If it’s not, that’s fine. If I don’t attend the candlelight vigil at 7:30 PM, I will light a candle in my mind. In the past, I have feared immolation. I have no idea what the fires of feeling and memory will do to me this time or how long the burns will take to heal. But I make it through these things. Over and over again.

Photo: John H. Rains, IV

Getting Evidence-Based Addiction Treatment in a World of Illogic

If you come to me for help with opioid use disorder, I will tuck your head under my arm like a football and get ready to start slashing like Logan the Wolverine to get you evidence-based care. I have 12 hours before you start going into withdrawal. I will have to use every connection in my network and call in every favor owed. In seeking help for other people in our area, I’ve used up a lot of those favors already. I may have to hire a driver to take you to another state. I don’t have the funds for a plane.

I will try to helpIn my small town in rural Southwest Virginia, I could more easily get you heroin than I could get you treatment for heroin addiction.

In my locale, for people with opioid use disorders, wait lists for people with low incomes are 6 months or more to be assessed for suitability for buprenorphine (one of the top two treatments for opioid use disorder known to cut death rates by half). (By new Virginia law, Suboxone, not Subutex, must be prescribed to all but pregnant women.) To my knowledge, no more than half a dozen local physicians have completed federal certification to prescribe Suboxone. Local private Suboxone clinics have shorter wait lists, but require $500 cash for the first appointment, and $180 cash per month afterwards. The price makes sense given the enormous costs to start and run such an enterprise. Locally, a common therapeutic dose of Suboxone is approximately $100 for a one-month supply.

Scarcity requires stark, either-or choices.

This is what science says to do for people with opioid use disorder and, indeed, for substance use disorders in general: get people to medical professionals to be assessed for medications.

If we, hypothetically, had a budget of $100 to spend per month on each person in our locale with opioid use disorder, as a taxpayer, I want it spent on what science says will benefit most people most of the time. While other supportive services might be helpful, science says that meager $100 is best spent on methadone or buprenorphine, not on rehab, individual or group counseling or support groups.

Getting evidence-based care for addiction should not require action-adventure movie tactics in a fantastical world of illogic, i.e. medications are reasonably priced and plentiful but access to them is denied or limited by the very government that claims the disorder they treat is a national crisis.

The opinions expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, family members or friends.  This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

I Just Didn’t Understand Addiction

I have been abstinent from alcohol for over 4 years. But I am no St. Anne of Recovery.

For me, abstinence is not a moral high ground. I get little from abstinence that I revere or value. I wish I were having glasses of wine with my friends and co-workers again.

My life is not better as a result of developing addiction to alcohol or being in remission from alcohol use disorder. I have nothing in common with rah-rah recovery community members who are “grateful” they developed addiction so they can receive “the promises” of recovery. I experienced professional, financial, relational, social, emotional and mental ruin as a result of developing alcoholism. If my family didn’t support me, my townspeople would have to begrudge me a share of their tax dollars allotted for social services agencies for the indigent. My income is so low, I qualify for subsidized health insurance. I live with an ever-present, mewling whine of parched, hungry, stifled needing-and-not-having. My return to alcohol use which, based on the numbers, is nearly inevitable, will not feel like a mistake to me, but mercy.

What not drinking feels like

When I finished my training as an addictions counselor, prior to developing alcoholism myself, I believed the ladies at the women’s residential treatment center where I served my internship simply needed me, Miss White Bread Do-Gooder – moralistic as only the eldest child of two eldest children parents can be – to enlighten them about their decision-making.

According to my coursework during 2003-2006 for a master’s degree in counseling, addiction was a mental illness. “Alcoholics” and “addicts” simply didn’t understand themselves and how life worked. I could counsel them to recognize unconscious family-of-origin issues through psychodynamic therapy, correct their thoughts through cognitive behavior therapy, instruct them in how to replace their immorality with Kohlberg’s “universal ethical principles,” and lift them up from their “spiritual disease” with 12-step principles. Alcoholics and addicts would see the error of their ways and abstain. Then we would send them out to be productive members of society, Sneetches with “stars on thars,” their addictions arrested.

If the people with addictions weren’t ready enough to “change” in accordance with Prochaska’s and DiClemente’s transtheoretical model, well, we didn’t say this but we were thinking it: the addicts secretly wanted to keep diddling themselves with their substances. Tsk-tsk. I remember a nod being given to the possibility that maybe, maybe something else was going on with the term “dual diagnosis” (now termed co-occurring disorders ) but addictions treatment theory focused primarily on redemption of emotions, cognitions and behaviors. Simply put, the addict had to be better, think better, and do better to get better.

O, polite and patient ladies at the treatment center! I am so sorry. I just didn’t understand.

I can speak publicly about addiction because I have had no legal consequences from having developed the illness of addiction. Further, I have no partner, children or career. If I had to keep a judge pleased with me right now? Or a child protective services case worker? Or the parents of my children’s friends so the friends would still be allowed to play at my house? Or my boss, or my partner’s boss, so we can stay on track for a promotion? No way I’d utter a peep. I want to beat stigma with the imaginary length of 2″ x 4″ I keep in my prim purse. But it won’t help. Stigma is a behemoth.

So, what’s a person with addiction to do in 2017? Scrabble for as much evidence-based help as is available.

Then what?

For me, while the intensity waxes and wanes, even after 4 years of abstinence, my longing for a drink is ever-present. Addiction, for me, is 24-7. The Surgeon General’s report on addiction urges a 3-prong treatment approach, in priority order: medications and medical care, counseling, and “recovery support services,” RSS. I do all these and I appreciate them. I welcome help from people who don’t have this and I’ve tried to explain to them that it’s like this and this, but I come away thinking that they – as I did not – just don’t (or won’t) understand.

So when medications are doing what they do, but no more than that, and I’m not in a counseling session, or attending a support group meeting, then what? I’m all I’ve got.

That’s why I wrote “3 Handouts I Wish I Had Been Given on My First 3 Days of Recovery from Addiction.” Here’s Handout 1. (Handout 2  and Handout 3 are forthcoming from The Fix.)

I reflected on the past 4 years of abstinence, about which I publicly tried to be brave, but which were privately wretched (the research explains why), and wished better for myself. I studied Maia’s book and Vivek’s report and countless research articles and learned the difference between what we know is true in 2017 and what I believed was true in 2006. I imagined using Hermione Granger’s Time-Turner and traveling back in time to be of help to my newly abstinent self.

There I am, waking up on December 28, 2012, intent on that being the first day, forever, that I do not have a glass of wine at 5:00 PM, and then another and another until I’ve had a whole bottle and start falling down the stairs. Look how determined and resolute I am!

My poor self! I have no idea what’s in store for me: the meanness of withdrawal and unrelenting anhedonia; self-meanness from shame and humiliation at believing I am no longer myself, but am an “alcoholic,” a person who meant well but went bad anyway; meanness from the “tough love” recovery community; mean-feeling, arms-length treatment from the medical community; the meanness of mental illness, sedated by alcohol, awakening to scorch and twist me; the meanness of addiction itself that destroys the minds, hearts and lives of those I meet and come to love; the meanness of treatment professionals who say, “Addicts lie. That’s what they do”; the meanness of a society that can ask my friend of half a century, “How’s your alcoholic friend?” and post comments on the Internet like, “All alcoholics should be shot at dawn – and that goes for drug users as well.”

If I could go back in time, my 2017 self would give my 2012 self such a hug! “It’s not you, honey!” I would say. “It’s a brain condition! Nothing more, nothing less.” Then I would hold myself as I began to cry with such grief and regret.

“It’s going to be okay,” I would say. “Look, we don’t know much that directly treats the brain for addiction, but we do know some things that can help with abstinence – or with harm reduction if that’s the plan. You are such a serious, hard-working girl, but I know that you don’t feel well at all right now, so I’ve made you some simple handouts. They synthesize and distill what the research says might be helpful for you. I am so sorry you are suffering.” I would hug and hug my 2012 self. And my 2012 self might even laugh shakily a bit at feeling so loved and cared for, so seen, known and understood.

And my handouts are kind, not mean. And maybe that would have made all the difference.

. . . . .

I have started writing a memoir. The Fix has accepted excerpts on a trial basis and the series is entitled The Last Addictions Memoir (Hopefully): An Evidence-Based Recovery Story.

I’ve explained here how I’m writing the memoir, I’m keeping track of its components here, and I’m keeping memoir-related posts in this category.

This blog post, “I Just Didn’t Understand Addiction,” is an example of one of the pieces I’ll self-publish on my blog because it’s longer than The Fix’s 1,000-word limit, or feels too urgent, or seems to be part of the introduction or afterword rather than the memoir itself. It may or may not end up in the final manuscript in this form or an edited version. I’m learning and discovering as I go. We’ll just have to see.

The opinions expressed here are mine alone and do not necessarily reflect the positions of my employers, co-workers, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.