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. (I’ve compiled all 3 handouts as A Brief Guide to Evidence-Based Self-Care for Recovery from Addiction.)

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.

. . . . .

The Fix publishes excerpts from my memoir-in-progress on Fridays. A table of contents is here.

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.

Updated 5/6/17

Ready to Write a Memoir

“…but seven years is long enough and all of us
deserve a visit now and then
to the house where we were born
before everything got written so far wrong”
– Peter Meinke, “Liquid Paper

I am so very fortunate that The Fix accepted my proposal and will publish excerpts from my memoir – as I write it! – as a column on Fridays, beginning 3/24/17.

While I self-publish readily on my blog, for me, selection of my work by others for publication is validation of its merit. The Roanoke Times published my letter to the editor on 9/2/14, technically my first piece of writing related to addictions published by another source, but it’s to The Fix – a publication dedicated for 6 years to reporting exclusively on addictions and recovery – I attribute accepting my first piece of writing that attempts to fully express the reality of what having the condition of addiction is like.

Screenshot from The Fix

First publication with The Fix, 5/16/16

My plan is to complete a memoir over the next 150 days, an average of 500 words per day, then to begin to finalize a 75,000-word manuscript for potential print publication, and then move ahead to what I might have written “before everything got written so far wrong.”

This is going to be messy. I have pieces of my story hither and yon – on this blog in various, vaguely named categories – Memoir and Autobiography, (non-addiction-related posts, not sure why I have both terms), and Recovery Story (addictions-related posts) – on The Fix, on an abandoned TypePad blog, and in thousands of Word documents stored in my Dropbox folder.

I’ve written the first 6 columns. The next one is beginning to emerge and I don’t think Part 7 is going to sequentially follow Part 6. So I’m going to try to keep links to posts in some kind of meaningful order from this page. New content will appear first on The Fix.

On this blog, I’ll publish excerpts from the columns on The Fix and link back to the full column, and post additional pieces that surpass The Fix’s 1,000-1,200-word limit per piece. All of those posts on my blog, and explanatory posts like this one, I’ll keep in a new category entitled “Hopefully.” (Why will become clear after the first column is published by The Fix on 3/25/17). I’ll keep track of non-memoir publications here.

My proposal to The Fix best expresses my intentions:

I would like to contribute weekly, 1000-word excerpts from my addictions memoir – hot off the press as I write them – to The Fix.

I’ve realized that, over the past 4 years, thanks to you [Desiree Bowie, Senior Editor] and The Fix, and through my own personal blog, I have been writing an “addictions memoir” online, one blog post at a time.

I am ready to compose the posts that will comprise my addictions memoir, a 10-year period stretching from the Virginia Tech shootings in 2007 to today, 2017. [Realized since writing this I’ll need to start in 2006.]

Having read dozens of addiction memoirs, I think my story, and how I am writing it, contribute uniquely to the genre.

– I am one among a likely cohort of 300 who developed addiction in Blacksburg, Virginia after the Virginia Tech shootings. (Of the 40,000+ people living in Blacksburg in 2007, research predicts 15% of them would develop PTSD. That would be 6000. Of that 6000, research predicts 5% would be develop addiction. That’s 300.)

– From publicly disclosing that I have alcoholism, I have experienced first-hand, in the fish bowl of a small town, the stigma of addiction and its heartbreaking consequences.

– I am among the growing number of mature women in the U.S. who are developing alcoholism and other addictions later in life.

– I am among the large numbers of people who have experience with, and may appreciate, 12-step recovery for personal growth, but who found participating in the program and working the Steps insufficient to successfully treat addiction and co-occurring disorders.

– I share my personal recovery story in the context of the latest data on what addiction is and what effectively treats it.

– I am a trained counselor, for heaven’s sake, specializing in addictions treatment! How could this have happened?!

– My story does not conclude with a faith healing through religion or spirituality. This is stated too simply, but I am neither religious nor spiritual. In the floating chaos of randomness, I have had to find a way to abstain.

– I want to limit the manuscript to 75,000 words, I write every morning, several thousand words per week, so I expect to complete the manuscript in several months. I can’t guarantee that the manuscript will find a publisher, but I can guarantee that I will meet your content deadlines with fine writing, impeccably researched and cited.

Here we go.

Legislation Restricting Opioid Addiction Treatment Harms Us All

Have you ever been prescribed a medication that didn’t work for you? I have. One formulation of birth control pills made my hair fall out and, ultimately, feel suicidal. When I was quaking with anxiety after the end of my first marriage and was prescribed Xanax, I fell to the floor in a near blackout from the very first dose. In both cases, my physicians expressed compassion and concern, prescribed different medications for the same purposes, the medications worked, I returned to stability, and continued to live my life.

We need open access to addictions treatment medications

If laws had mandated that my physicians were limited to prescribing me only the medications that made me suicidal or caused me to lose consciousness, well, I doubt I’d be here today. It’s a ridiculous concept, isn’t it? Laws mandating what physicians can prescribe for their individual patients with unique needs, case-by-case?

Yet, that is exactly the case. States are passing laws that limit how physicians can prescribe opioid medication for pain patients and for patients with opioid use disorder. In Virginia, bills passed both houses of the General Assembly prohibiting physicians from prescribing buprenorphine (Subutex) to men and non-pregnant women. Physicians must now prescribe buprenorphine with the additive naloxone (Subuxone) instead. As an additive, naloxone has no medical value; its sole purpose is to discourage misuse by injection.

The Virginia bills mean that patients stable on buprenorphine alone in Virginia must now take buprenorphine plus naloxone. Physicians have prescribed buprenorphine alone (Subutex) based on their expertise and their consideration of the patient’s unique needs. Some people can’t take naloxone, whether because of allergy, sensitivity, or other metabolic contraindications unique to that person.

But the bills say that all men and all non-pregnant women, regardless of their unique medical needs, most take buprenorphine with naloxone (Suboxone).

Let’s think this through a minute. Sure, the bills infringe on the individual rights of physicians and patients, and on the physician-patient relationship. Sure, lawmakers are engaging in malpractice by legislating medical treatment. Sure, it’s inhumane to make people take medications that make them ill. Sure, the overt intent of the bills is to discourage buprenorphine misuse by injection,  ostensibly to take action against the opioid addiction crisis that Virginia Governor Terry McAuliffe has declared a public health emergency. Aside from all that, isn’t the primary, unstated intention of the bills to curb health care and criminal justice costs related to opioid misuse? How likely is a buprenorphine control law to do that?

Let’s take a walk in the shoes of someone with opioid use disorder. I’ll go first.

If I were being successfully treated for opioid use disorder, had adverse reactions to the naloxone in Suboxone, and were now stable on Subutex, I would know that science says I may need to take either methadone or buprenorphine indefinitely, perhaps my entire life, to treat my illness. If I learned from my physician that the laws have changed and I now have to switch from Subutex to Suboxone, or to try methadone, let’s check out my options.

Buprenorphine alone is out because of the laws. Methadone is out because, while it’s cheaper than buprenorphine, it’s so highly federally regulated that it must be obtained at a clinic and I don’t live near one in my rural area. Taking buprenorphine with naloxone, Suboxone, makes me ill. Even if I were willing to suffer the additive’s side effects on my own behalf, I’m the primary caregiver for my elderly father and I can’t afford to be sick. I could start to Google for ways others in this situation have tried to solve the problem and would find zero help from credible sources, but some highly suspect ways on message boards for how to hold the Suboxone pill in my mouth to separate out the buprenorphine from the naloxone, then spit out the naloxone… Huh?

I’m backed into a corner. I am no longer allowed to have the medication, Subutex, that kept me well. If I take what makes me ill, Suboxone, I won’t be well enough to care for myself and my father. If I don’t take what makes me ill, Suboxone, and I go off medication-assisted treatment entirely, with relapse rates between 50% and 90% after cessation of buprenorphine, I have a huge chance of that old illness – opioid use disorder – coming back. Counseling won’t make a difference; opioid use disorder could kill me this time. Marijuana might have helped, but it’s not legal in my state.

I’m stable and I’m no more a burden to the health care and criminal justice systems than any other citizen. These new laws now destabilize me and increase the likelihood that I might become very costly indeed.

Which would you choose?

What if we simply stride out of the buprenorphine control, no-win corner and straight out the door into the vista of financial data from the National Institute on Drug Abuse, NIDA: “According to several conservative estimates, every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft. When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1.”

Laws controlling buprenorphine limit addictions treatment. Limiting addictions treatment increases costs. Therefore, laws controlling buprenorphine increase costs.

Are lawmakers thinking citizens would rather pay $12 in health care and criminal justice system costs rather than $1 for treatment?

And citizens can certainly read the data on how other countries have solved their overdose crises. They loosen, not tighten, access to addictions treatment medications.

If not for humanitarian reasons, then for fiscally sound ones, lawmakers, please, legislate the end of restrictions on addictions treatment and let the people with opioid use disorder have the medications they need and let their physicians prescribe them.

Image: iStock

Disclosure and disclaimer: 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.

Last revised 3/1/17

What It’s Like to Have Alcoholism

Imagine standing at your kitchen counter, pouring crisp, pale, chilled sauvignon blanc into a glass measuring cup to the one cup mark, then pouring that amount into a wine glass. You have resolved to limit your drinking to federal guidelines: 3 drinks tonight, no more than a total of 7 drinks this week. You’re healthy, at home, and not driving, so you’ve allowed yourself a generous 8 ounces, 3 ounces beyond the 5-ounce measure of a standard glass of wine.

Standard measure for wine is 5 ounces

Note your awareness of the need to drink this amount and no more. Sense your willingness to make responsible choices and to be accountable for them by tangible measures.

Bring the wine glass to your lips, take a sip, hold the coolness in your mouth, then swallow. Tilt your head back in near ecstasy at the first hint of alcohol’s initial euphoric effect. Chop vegetables for stir fry, continuing to sip.

Let’s say each sip measures about a tablespoon. In 16 sips, about 1 sip every 2 minutes, that cupful of wine is done in a half hour. You’ve only just finished the food prep. You measure and pour another cupful of wine, cook various combinations of foods with various spices and sauces, and find this second glass gone. You arrange your meal on a plate, measure and pour the third glass of wine, fill a glass with water, and place all three at your seat for dinner.

Alcohol’s initial euphoric effect has passed and you feel its warm, sedative glow. You may or may not be aware of the uncertainty it has brought to your decision-making. You’re not sure how long you’ve been eating, but the third glass of wine is gone and you still have part of your meal left. You dutifully switch to water and pair sips of it with the rest of your meal, sensing with disappointment water’s dulling effect on flavor.

Clear the table and view the kitchen. Pots, dishes, utensils, peels and spills everywhere. And on the counter is the rest of the bottle of wine by its glass measuring cup – intentionally glass instead of metal in case pouring the wine first into metal might interfere with its taste.

Pick up your wine glass, walk over to the counter, and place it by the measuring cup. Look at the wine left in the wine bottle, the measuring cup, and the empty wine glass.

Know with the entirety of your mind, heart and body that you are not going to pour wine into the measuring cup and that you are not going to pour that measure into the wine glass. Feel the power of who you are and what you can do rise within you. Remember your credentials and successes, envision the faces of everyone you love and who loves – even admires – you. Revel in the power of your intelligence, knowledge and experience to guide and lead you, and in your willpower to make choices in your best interests. Feel your heart swell with compassion for yourself and all beings everywhere. Lift your shoulders and shift your weight to feel the strength and health of your body.

Pour the rest of the wine directly into the wine glass.

Feel the horror of knowing you are no longer who you were.

Bring the wine glass to your lips.

Image: iStock

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