A Cohort of 300

I am one among a likely cohort of 300 who developed addiction in Blacksburg, Virginia after the Virginia Tech shootings. I developed an addiction to alcohol.

According to research on the relationship between community violence, trauma, and addiction, of the 40,000+ people living in Blacksburg, Virginia in 2007, research predicts 15% of them would develop post-traumatic stress disorder, PTSD. That would be 6000. Of that 6000, research predicts 5% would develop addiction. That’s 300.

Flag at half mast, Virginia Tech, April 2007

Addiction is defined as continuing to drink, use or do despite negative consequences. The person’s actions don’t make sense, yet he or she persists. It’s irrational. Brain studies now show us rational data to explain that irrationality: the very brain structures and networks needed to recognize cause-and-effect relationships, make decisions, and other executive functions – to stop what we’re doing – have become impaired.

For me, that meant drinking wine at 5:00 PM, falling down the stairs, cracking my bones and skull on the steps, banister, and walls, vowing never to drink again, and shifting my weight to ease my bruised body while I poured the first glass of wine at 5 o’clock, again, the next night.

What was not known in 2007 but is known 10 years later, thanks to the Surgeon General’s report, Facing Addiction in America, is that people with addiction just need to be taken early, at the first signs, to a doctor. No drama, just medical care for the medical condition of addiction. Then to be screened for mental illnesses that may accompany addiction. Like PTSD.

I have disclosed publicly that I developed alcoholism and have experienced first-hand, in the fish bowl of a small town, the stigma of addiction and its heartbreaking consequences. Comments like “All alcoholics should be shot at dawn – and that goes for drug users as well,” abound on the Internet and are unspoken in many minds and hearts. New Virginia laws mandating if and how people with opioid addiction can receive life-saving medication are based on the medieval premise that people with addiction got themselves into this in the first place. The belief is that if they suffer from it, even die from it, they deserve it.

I hope members of my likely cohort of 300 who developed addiction after the Virginia Tech shootings will reach out to me. I will ask them if I can do for them what should have been done for me. I will ask if I can take them to a doctor. And I will never disclose their identities. It’s not safe out there.

Photo: Steve Jacobs, Flag at half mast, Burruss Hall, Virginia Tech, May 5, 2007

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 have the expertise and credentials 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. This is an excellent academic article by Nora Volkow, M.D., and on pages 16-19 in this publication, she offers a more mainstream explanation of the science of addiction.

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 4/27/17

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.