Myths and Realities of Drug Courts: Changing the Narrative Webcast

I’ll be talking about the myths and realities of drug courts with Changing the Narrative Webcast host and journalist Zachary Siegel (@ZachWritesStuff ) on Thursday, July 11, 2019 at 3:00 PM EDT. Click here to listen live.

Changing the Narrative

Listeners are invited to type and submit questions through chat. I would welcome hearing from you. For those who can’t listen in real time, the interview will be posted afterwards on Changing the Narrative Events.

I am honored to be interviewed by journalist Zachary Siegel. When I walked into the hotel lobby in Boston on the September, 2018 morning of what became the founding day of Changing the Narrative, I exchanged a friendly smile with a man with a suitcase. I didn’t know him, but just had a feeling. I asked for a ride. Keith Brown said, “We need to wait for Zach.” I asked, “‘Zach’ as in @ZachWritesStuff?!”

Keith drove, Zach sat shotgun, and I leaned forward from the back seat as we headed towards Northeastern University. My jaw dropped as I began listening to the boldest talk about addiction and recovery I’d ever heard. The clandestine knowledge I had in my own head after reading Maia Szalavitz’s book, the Surgeon General’s report, Facing Addiction in America, and conducting exhaustive literature reviews on the research on addiction was spoken of matter-of-factly in the front seat. I offered a few bits about evidence-based counseling for substance use disorders. Nods, not reprimands! Emboldened, I described constitutional, legal, and humanitarian grounds for opposing drug courts. I was astonished to see the “of course” nods in the front seats.

I got tears in my eyes when I saw this photo of Zach, my CTN co-founder and former co-traveler, who was arrested for recording testimony while doing his work as a reporter. Force can be used, both overtly and covertly, to attempt to silence people who seek facts.

“If you see something, say something.” Thanks to the invitation from Zachary Siegel to speak out, I will say many things – and cite sources – about drug courts.

Here is a summary of my findings.

And here is my full report on drug courts, approximately 4,500 words.

If you find facts altering your beliefs about drug courts, here are some actions you might take:

  • Attend a drug court hearing. Watch for drug court judges giving medical advice without a medical license – including denial of life-saving addiction and mental health medications – giving mental health advice without a counselor’s license, financial advice without financial adviser credentials, and legal sanctions, including jail time, without an attorney present.
  • Go to your state attorney’s office and ask for a copy of the drug court handbook. (In some locales, individuals who have requested copies have been denied them.)
  • Take a copy of the drug court handbook to a medical professional not affiliated with drug court or the administrative/treatment provider and ask if the medical components of the handbook meet medical standards of care for people with substance use disorders and co-occurring mental illnesses.
  • Take a copy of the drug court handbook to an attorney not affiliated with drug court or the administrative/treatment provider and ask which of the policies, if any, violate constitutional, legal, and/or human rights.
  • Take your findings from independent sources to your local government bodies that fund drug courts and ask why this government body is funding a program that violates medical standards of care and/or constitutional, legal, and/or human rights. (Here is the Commonwealth of Virginia’s explanation of the existence and operation of drug courts.)
  • Prepare to hear 1) this rebuttal: “I know it works because I’ve seen it work!” and 2) this threat: “Do you want us to throw the baby out with the bath water? Fine, let’s just dismantle drug court and every criminal addict can go directly to jail. They deserve it anyway.”

That’s as far as I have gotten locally. I cannot get stigmatizing language replaced with factual language (the local use of “addicted babies” is systemic). I cannot get heard the facts about effective addiction treatment or rights violations. I am advised to “go slowly” and “build consensus.” Coercive probation and parole, drug courts, jails and prisons are designed to traumatize. With two-thirds of people with substance use disorder already plagued with trauma symptoms, it’s simply inhumane to exacerbate this condition. One more moment of waiting creates manifold suffering now and into the future.

If you do nothing else, ask your primary care physician to give you an observed urine drug screen. Remember that substance use disorder is a health condition. Use of substances is a symptom of that condition. The presence of substances in your urine would simply be indicative of you continuing to have this health condition.

Become aware of what you feel and think while your genitals are watched during an act of biology – a procedure which can be mandated daily, weekly, and monthly for people with substance use disorder. Don’t ask how much the drug screen costs. You’re responsible for the bill, regardless. Become aware of fighting paruresis – difficulty urinating near others – when you realize that the results of this natural act could cause you to get sent to treatment, fired from your job, lose custody of your children, have you arrested, and, possibly, end up in drug court.

#RecoveryMovement #ChangingTheNarrative

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, 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.

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia.

Last updated 7/10/19

It’s Time to Challenge the Narrative About Drug Courts

“We need more drug courts.”

If that statement were true, then participants in drug courts would 1) achieve a set of desired outcomes better than non-participants, and 2) achieve those outcomes through drug court participation better than they would through other methods.

Changing the NarrativeHowever, as Katharine Celantano reports, “Drug courts, which coerce people into treatment under threat of criminal punishment, continue to expand nationally. But three decades of evidence clearly shows that most drug courts do not reduce imprisonment, do not save money, do not improve public safety and ultimately fail to help people struggling with drug problems.”

Further, the constitutionality, legality, and humanity of drug courts are being challenged at the national level.

Constitutionality, legality, and humanity of drug courts

Among the charges against the criminal justice system are these constitutional, legal, and human rights violations:

  • Violation of Eighth Amendment protections against cruel and unusual punishment. Cruel and unusual punishment is evidenced by: 1) denying individuals with opioid use disorder buprenorphine and/or methadone, 2) denying individuals who have been prescribed methadone and/or buproneorphine by medical professionals the right to take these medications; 3) requiring individuals to prove they “merit” buprenorphine by attending counseling sessions before receiving prescriptions; 4) dissuading individuals with opioid use disorder from taking buprenorphine and methadone.
  • Violation of the Americans with Disabilities Act. Persons recovering from, or receiving supervised treatment for addiction to alcohol or drugs, are considered disabled individuals according to the American with Disabilities Act. Entities that receive federal funds – including drug courts and community treatment providers – may not treat individuals with opioid use disorder differently from other individuals who are allowed to take medications as prescribed.
  • Violation of First Amendment rights. High courts have ruled that 12-step recovery contains sufficient religious content that federally and/or state funded entities mandating participation in 12-step recovery is unconstitutional, whether through mandatory attendance at meetings, or mandatory “working the steps with a sponsor.”
  • Fifth and Fourteenth Amendment violations of due process. In the criminal justice system, individuals are sentenced to jail for returning to use – “relapsing”- by judges for displaying the primary symptom of the illness, often without legal, medical, or clinical representation or expertise present.

In addition, drug courts may be challenged on these grounds:

  • Malfeasance. Drug courts denying drug court participants medications prescribed and recommended to them by licensed medical professionals could be construed as an act of malfeasance, i.e. a willful and intentional act intended to punish and cause suffering.
  • Malpractice. Licensed medical professionals who prescribe according to the policies of drug court may be considered deviating from the recognized “standard of care” and may be subject to malpractice claims.
  • Unauthorized practice of medicine. Drug court handbooks list which medications participants may and may not take, even if the medications are prescribed or recommended to them by a medical professional. Drug court judges without medical licenses dictate which medications participants may and may not take.
  • Layperson involvement with urine drug screens. Urine drug screens for drug court are routinely administered and read by non-medical professionals. False positive results for some substances can reach 20%. A positive urine drug screen is considered presumptive of innocence, not definitive of guilt, without secondary analysis. Within drug courts, reliance on urine drug screens, and layperson misunderstanding of immunoassay methodology and lack of technical expertise, false incarceration can result from false positives.
  • Urine drug screens as presumption of guilt. Without due process and in the absence of an attorney, participants who, according to a layperson’s reading of an unverified, presumptive urine drug screen, test positive for banned or illegal substances, have been deemed to “relapse,” and may receive sanctions or be dismissed from the program and incarcerated.
  • Right to informed consent for treatment. Drug courts can issue strictures about participants’ relationships, employment, and living conditions. No individual, or team of individuals, has expertise on another individual’s life. Drug courts’ decisions about what participants can and cannot do that are not part of a co-created treatment plan may compromise a participant’s right to informed consent.
  • Wrongful death. Lawsuits on behalf of individuals with opioid use disorder who were denied buprenorphine and died of overdose may be filed by their families, the Department of Justice, and the American Civil Liberties Union.
  • Insurance fraud. Entities that bill individuals and referral sources for substance use disorder treatment that includes 12-step content may be committing fraud. Twelve-step content is available for free.
  • Treatment protocol malpractice. Entities that offer 12-step-based content in substance use disorder treatment programs may be committing malpractice. Despite decades of research, 12-step recovery has not been found to be an evidence-based treatment for substance use disorder.
  • Violation of the Emergency Medical Treatment and Active Labor Act (EMTALA). Given that opioid use disorder has been declared a public health emergency, the denial of buprenorphine by entities able to provide it to individuals diagnosed with opioid use disorder may constitute failure to provide emergency care.
  • Violation of laws protecting against sexual violation. Mandated observed urine drug screens constitute an act of sexual violation by non-consensual observation of a person’s genitals during a private act of personal hygiene, with same sex observation recommended but not always required.
  • Transparency. Some drug courts, although they receive funding from taxpayers, refuse to provide copies of drug court handbooks to the public.
  • “Drug courts cut costs.”  NIDA reports, “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. See Wikipedia’s “Criticism and controversies” in “Drug courts in the United States.”
  • “Drug courts offer an alternative to jail.” According to the Prison Policy Initiative (PPI): “Unfortunately, many mental health and drug courts set participants up to fail, and therefore function more as drivers of incarceration than as alternatives to it. For example, the medical gold standard for opioid dependence treatment is medication-assisted treatment. However, half of drug courts do not offer medication-assisted treatment. Furthermore, although the medical community understands that relapse is often a normal part of recovery, many drug courts require abstinence and punish relapse with incarceration. In order to be effective, drug courts and mental health courts must offer evidence-based treatment in line with medical best practices.”

Drug court journalism

Those seeking citation-rich writing on drug courts might find these articles of interest (most recent first):

Drug court participants as sources for journalists

The majority of drug court participants used as sources by journalists are under coercion, especially at drug court “graduations.” “Graduation” is a public formality with participants usually still under the control of the criminal justice system through probation or parole. Participants cannot afford to offend the drug court judge or members of the drug court “team” for fear of further sanctions or delays. At graduation, they need to thank the judge and the team members for “saving my life.” They are required to draw conclusions from a sample size of one: “If not for drug court, I would have _______.”

To elaborate, since participation in drug court is considered “voluntary” – a forced choice of drug court or jail – participants with complaints are reminded that if they don’t “like” the program, they are welcome to leave it and serve their jail time instead. There is a grievance/complaint procedure, but a participant runs the risk of dismissal from the program for appearing “ungrateful” for the “opportunity” provided by drug court.

Even once participants have received documentation that their sentences have been served, most realize they may have a chronic condition and dare not speak out about injustices and privations suffered at the hands of drug court, given the likelihood they may have contact with the criminal justice system again. For their own protection, they need to stroke the egos of all involved in the hopes that the next contact will be mildly paternalistic rather than severely punitive.

Why don’t drug courts “work”? Because health conditions respond to treatment, not punishment. Please see my full report on drug courts.

I am a member of a network of reporters, researchers, academics, and advocates concerned about the way media represents drug use and addiction. The mission of Changing the Narrative, a project of the Health in Justice Action Lab of Northeastern University School of Law, is to help journalists report accurate, humane and scientifically reliable stories about this complex and often misunderstood terrain. Changing the Narrative’s resource site launched June 10, 2019. Here is the press release.

If I can be of assistance, please feel free to contact me.

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia.

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, 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.

To Those Considering Counseling for Substance Use

Try to put aside everything you’ve learned or been told about addiction. Let’s just look at what the latest research has to say.

Whether the substance is legal, illegal, or prescribed, when substance use morphs into difficulty with stopping or inability to stop using, it’s become addiction and a medical condition. In recommended priority order, the treatment for this medical condition is medical care, counseling, and support.

Sun of Self-KindnessI urge clients to first get addiction-savvy medical care. Then I provide the secondary tier of treatment: counseling. Traditionally, clients are invited to take their time in counseling because having insights and making changes takes time. However, because 1) substance use itself can be endangering, and 2) symptoms of substance use disorder are criminalized, we’re not allowed time.

Paradoxically, the desired treatment outcome for most people – abstinence – takes time to achieve. On day one, however, authorities can demand proof of abstinence by requiring negative urine drug screens. People can lose jobs, custody of their children, scholarships, prescriptions for medications, even their freedom if they don’t abstain. But if people could abstain, they wouldn’t have the defining symptom of this medical illness, i.e. inability to abstain.

Regardless of this injustice, how can a person attempt to achieve and sustain abstinence as quickly and effectively as possible?

According to research by NIDA, people use substances for these main reasons: to 1) feel good, 2) feel better, 3) do better, and 4) feel connected.

These are normal, reasonable, understandable needs and wants. But when substances meet these needs and wants, and the person abstains, then the needs and wants aren’t met. Add the brain automaticity that occurs through addiction and, logically, the person would return to use.

How can we help people get understandable, human needs and wants met by substances without substances? How can we help them 1) feel good, 2) feel better, 3) do better, and 4) feel connected?

Research suggests that there is a finite set of very specific skills – a protocol – people can learn to equip themselves to do for themselves what substances did. It is not necessary for people to “be ready to change,” or “want to feel better about themselves.” They simply need to learn the skills and apply them. In the contest between the power of these skills vs. substance use, the skills simply have to be mastered at a 51% level. A 51% skills level may overpower a 49% brain-based return to substance use.

I’ve been a counselor since 2014 and been able to offer research-informed counseling in private practice since October 1, 2018. My anecdotal data suggests, so far, with deliberate effort and practice, these skills can be learned in about 8 weeks, beginning with 1 week of daily appointments, followed by 3 individual sessions and 1 skills-focused group session (not general group counseling) per week, daily homework, and daily text contact. Less than that simply doesn’t achieve many clients’ ends in mind, i.e. abstinence and negative urine drug screens. It makes sense that the traditional one-hour session of counseling per week would be ineffectual given the condition is present 168 hours per week.

Some all-or-nothing statements are appropriate here: No one wants to have problems with substances. Everyone wishes they didn’t. Almost everyone minimizes the significance of substance use. Hardly anyone wants to quit using substances. Everyone dreads what comes up when they stop using substances. And yet. While some small groups and communities of people tolerate substance use, most laws, policies, and social norms do not. However much we might wish things were different, the reality is that, to protect their freedoms in the U.S. under current conditions, people may need to be free of substances. Health-wise, for many substances, there actually is no safe level of use. Further, the interaction of substances, including medications, unfortunately, can cause injury, even death.

Ideally, people would slowly taper in custom-selected methods that meet their needs and wants while tapering out substances that do the same. Unfortunately, the endangering nature of substances usually doesn’t allow for that time and criminalization doesn’t permit it.

The skills are selected and offered based on the weight of research in their favor, and in an order that respects and recognizes 1) the realities of the reasons a person uses substances, and 2) the realities of the challenges they will face when they stop. Instruction, coaching, and practice with the skills are all offered quickly and efficiently.

And the skills are offered in the context of kindness. At essence, what helps a person with substance use and other issues is an on-going, kind, thoughtful, informed, inner conversation. “Tough love” isn’t really love because it hurts. In our work with ourselves and each other, we do our best to practice love love.

Note that I make no moral commentary. Substance use isn’t good or bad. People who use substances aren’t good or bad. In todays America, substance use endangers one’s freedoms. The offering of skills is simply a practical approach to regaining one’s freedom from substances and their use.

. . . . .

“Sun of Self-Kindness” coloring page by Nichol Brown. Coloring page .pdf opens in another tab here.

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia. She can provide counseling services to residents of Virginia only. 

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.

At the First Counseling Session for Substance Use Issues

As the counselor at a person’s first appointment for substance use issues, I inhale a deep, athletic breath. An urgent, high stakes race has begun.

If substance use has evolved into “substance use disorder,” commonly termed “addiction,” the person’s use meets NIDA’s defining criterion of “persistence despite adverse consequences.” This disorder impedes the very brain functions needed to achieve remission from substance use disorder, starting with decision-making and rank ordering of priorities. Further, the brain has overlearned substance use to the point of what’s termed “automaticity.”


Against these odds, can evidence-based protocols for achieving remission be conveyed in a way the client can understand and apply fast enough, for long enough, to slow or eliminate the person’s substance use, all in hopes of decreasing the occurrences of “adverse consequences”? In other words, can we get what works together swiftly enough to outrun the workings of this medical illness, of which the symptoms aren’t a cough and sniffles, but ominous “adverse consequences,” even premature death?

For many people, myself included, substances offer a nearly otherworldly experience of comfort and relief that meaningfully and profoundly meets needs and wants. Who in the world would want to quit that? And adverse consequences don’t happen every time…

That’s the competition.

I have a nifty, bright office where we can spread our work out on a round, white table. I wear nice clothes with a little style – what my mother termed “oomph,” usually from Bonomo’s – that I think the clients might enjoy.

But the clients and I both know, even with my faux tree and fashionable boots, I can’t play. Not against the bliss and oblivion offered by substances. We both go into the session knowing counseling vs. substances is laughable. Sometimes we do laugh, albeit ruefully. Then we give this counseling thing a go.

I urge clients to get medical care, the first line of treatment for substance use disorder. Medical care can directly treat some substance use disorders and provide relief for other accompanying physical and mental conditions that may be stressing the system and increasing the longing for relief through substances.

Then I offer evidence-based counseling protocols for assistance with substance use disorders, including cognitive behavior therapy (CBT), motivational interviewing, and contingency management. For fundamentals of these approaches, I use the umbrella term, “awareness skills.” We train with these skills in the most straightforward, interesting, engaging, and diverse ways I can think of.

We acknowledge the limits of skills. Science is getting closer, but so far can’t pinpoint exactly where and what is happening in the brain, so there are no direct ways to treat addiction. (The exception is opioid-based medications for opioid use disorder, which directly ameliorate the corresponding brain issues.) Counseling cannot accurately, efficiently, and directly treat the brain for addiction.

Risks lurk like beasts by my phony ficus tree: scientific uncertainty, the illness itself, co-occurring trauma and mental illnesses, return to active use, and those salivating “adverse consequences.” For many substances, there is no safe level of use, including the legal substances nicotine and alcohol. If the client is continuing to use substances, even minimally, a steel-toed boot hovers above the whole shebang, ready to drop. Given this scenario, a client simply showing up for an appointment is an act of heroism.

Although I have never had Army Special Forces training, I liken recovery from addiction to what I read and hear about the final survival test. Candidates are dropped into unknown territory, disoriented, with no weapons and no tools. Amidst conflict and instability, they are subjected to deprivations, dangers, and opponents’ unconventional tactics. Only their personal resources and their skills save them.

In a territory made unknown by the limits of science, with the potential for “adverse consequences” around every corner, people with substance use disorders don’t have the luxury of trial-and-error learning. We wrangle up strengths. We learn and immediately execute knife-sharp skills that research reports are effective, including silent, motionless observation. We race to save our lives.

Further reading

Recommended reading

To understand the research on addiction:

To read a work of fiction in which the main character practices skills similar to the ones needed to recover from addiction:

For help with recovering from harm caused by misinformation and ill-treatment from societal norms and the addiction treatment industry:

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia. She can provide counseling services to residents of Virginia only. 

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 3/31/19

Let’s Talk Openly About Substance Use

An elephant in the room when people talk about addiction is the subject of return to substance use after a period of abstinence. People with addiction who are maintaining abstinence may think, “Will I return to use?” or “Can I return to just a little use?” People who care for people with addiction may think, “Will you return to use?” and “How could you possibly return to use after all you’ve put me through?” People who have lost loved ones to addiction often think, “How could I have let them return to use?” and “How could I have been a better parent, partner, sibling, fill-in-the-blank so they wouldn’t have returned to use?”

So many conflicting, understandable thoughts in one room! Such fear with which to empathize!

Let's talk about the elephants in the room

The American Heritage Dictionary of the English Language defines “ambivalence” as “1. The coexistence of opposing attitudes or feelings, such as love and hate, toward a person, object, or idea,” and “2. Uncertainty or indecisiveness as to which course to follow.”

I posit that the majority of ambivalent feelings and thoughts about addiction are created by belief-based social norms rather than reason and research. This extends to return to use after a period of abstinence, commonly termed “relapse.”

The American Heritage Dictionary defines “relapse” as “1. To return to a former state. 2. a. To become sicker after partial recovery from an illness. b. To recur. Used of an illness. 3. To slip back into bad ways; backslide.”

The third dictionary definition is the one usually applied to people with addiction. When people were abstaining, they were observing “good ways.” When they returned to use, they were “slipping back into bad ways.” This implies that return to use is a matter of morality, a good-bad duality.

For addiction, however, it is the second definition that is confirmed by research. Addiction is defined as a medical illness, not a moral one. Therefore, for some people, return to use may well be “to become sicker after partial recovery from an illness.” Addiction has also been determined to be a brain disorder that causes substance seeking and use, despite negative consequences. Ergo, if a person is “not sicker,” no longer seeks substances, and no longer experiences negative consequences from using them, by research-backed definition, the person is in remission from this medical illness. When substance use is optional and without negative consequence, it is not indicative of medical illness.

Proponents of the moral model of addiction rage at these statements. However, the statements are supported by data. Humans have used substances for at least 12,000 years. The vast majority of people – 70 to 80% for substances in general, 92% for people who use opioids – do not develop addiction from substance use. Of those who do, research indicates that brains are made susceptible to developing addiction from trauma, particularly in early childhood – including the chronic trauma of poverty and economic hardshipchallenges with attention, autism spectrum disorder, and other factors.

[The primary argument against helping people with addiction – even after acknowledging the evidence from brain research that addiction is a medical illness – is that since people “chose” to use the substance in the first place, they deserve what they get.

Let’s check the facts.

  • Nearly 99% of Americans have “chosen” to use some combination of the legal, experience-altering substances alcohol, nicotine, and caffeine.
  • Two out of three Americans have “chosen” to use the substance of food in ways other than maintaining normal body weight, such that complications from obesity cost taxpayers an estimated $190 billion per year.
  • 70,000+ Americans died from “choosing” drug use that ended in overdose in 2017.
  • 300,000+ Americans die annually from “choosing” to use the substances of food and beverages that end in obesity-related complications.
  • 480,000 Americans die annually from “choosing” to smoke tobacco products containing the legal substance nicotine. (Without choice, 41,000 Americans die annually from secondhand smoke exposure.)

Using the logic of “choice” to exclude people from medical care, the debate over universal health care should be tabled since nearly no Americans deserve it due to their “choices.”]

If all elephants were led gently from the room, all debates silenced, and all criminal penalties for having a medical illness removed, a person who has been diagnosed with substance use disorder – the clinical term for what’s commonly called addiction – actually only has one concept to consider: harm. “Would my return to use cause harm to myself or others?” On the surface, that question seems simple. However, for many substances, there is no safe level of use. For example, ethyl alcohol is a neurotoxin, on the list with lead, nitric oxide, and Botox, served by the glass. The decision to return to use requires a complex cost-benefit analysis with rank ordering of risks and priorities.

Before that analysis can begin, the person with substance use disorder who is considering a return to use needs to achieve remission from the illness. Essentially, summarizing this definition and this one, the person needs to be able to live well enough without problematic substances. “Well enough” would be individually defined, not socially defined, or defined as a loved one might wish.

Based on the neuroscience of addiction, the brain without substances to which one has become addicted creates anguish akin to losing air, water, a limb, and one’s beloved, all at once. How to live with anguish is the first task in achieving remission.

This is why research has found that medical care, counseling, and support – in that priority order – are the foundations of achieving remission from substance use disorder. Through specific, comprehensive assessments, medical professionals can find physical and mental sources of anguish and ease them with medical treatment: medications, medical appliances, physical therapy – the list of medical help and support is nearly endless.

Developing addiction requires continued use over time. Addiction creates in the brain what’s termed “automaticity,” i.e. learned action such that conscious thought is not needed and does not occur, like brushing one’s teeth in the morning, or braking while driving. Prior to developing the automaticity of addiction, people first used substances for reasons. They continued to use substances for reasons. Once addiction occurs, addiction adds automaticity to continued use. But harkening back to the reasons for first use, then for continued use, offers clues to what needs and wants the substances met. Finding alternative ways to meet those needs and wants – beginning with medical care for this medical illness – is the second task in achieving remission.

(Automaticity explains why “Just say no” is cruel advice as a care strategy for the complex medical illness of addiction. “Just saying no” to automatically braking while I’m driving would take a lot of time and training on my part to recreate thought before action. And from you, I would need to see proof with my own eyes that your alternative strategy for saving myself from crashing works. Treatment outcome data for rehabs certainly does not support abstinence as a safe alternative to use.  If I go to rehab, I only have a 30% chance of not crashing?! If I have opioid use disorder and stop using opioids, I have only a 20% chance of not crashing?!)

Emotion regulation is the ability to become aware of the onset of strong feelings states that can become destabilizing, then to be able to simply adjust one’s inner “volume” to a more stable range. Lack of skill with emotion regulation – termed “emotion dysregulation” – is characterized by a sharp onset of strong feelings, a quick spike, continued intensity, and difficulty returning one’s inner state to a stable range. This is experienced as distress beyond bearing. Emotion dysregulation is a challenge common to people with substance use disorders and the conditions that can accompany them, such as trauma symptoms and mental illness. Substances can be used to effectively regulate emotions. Some substances are used as medications for this purpose. Illegal substances can do this work as well.

The more skill people have with regulation of emotions, the less likely they will be to seek and use substances to ease an emotionally dysregulated state. This is why cognitive behavior therapy, motivational interviewing, and contingency management are the top evidence-based methods for helping people with substance use disorders. Through various mechanisms, all of these assist with acquiring skillful emotion regulation, the third task of achieving remission from substance use disorders.

If I’m able to respond to medical care, can co-exist with what might remain an ever-present longing for the experience substances gave me, replace what substances did for me with alternatives, and learn skills to effectively regulate my emotions without illegal or non-prescribed substances, I might achieve remission from substance use disorder. Half of people achieve remission on their own, without treatment. Further, I may be able to return to use without experiencing negative consequences.

In consultation with medical and health care professionals, I might reconsider and expand the initial questions: “Would a return to use harm me or others? Use of what substances, in what amounts, with what regularity would reduce the risk of harm? What do I learn from doing a pros-cons, cost-benefit analysis with rank ordering?” Personally, I consider the possibility of return to use with simple I-statements: “If I want it or need it, I can’t have it.” A close second is, “If I think I deserve it or think I have earned it? I can’t have it.”

If I’m thinking something like, “I can’t take this anymore,” or “Only this substance will help,” or any version of “Blankety-blank this blank,” I reach out immediately for help. I’ve done my best to regulate my emotions but whatever I’m feeling and thinking as a result of what’s happening within or without has overwhelmed my skills. I can’t use substances in a state of stress or distress, not because using is morally wrong, but because the opposite of automaticity is consciousness. Brain science tells me that emotions can trump thoughts. As a person in remission from substance use disorder, I can’t risk automaticity kicking in again. It’s simply practical to require myself to be in a stable state to use substances, likewise to do almost anything that risks harm to me or others.

I reach out to others because social support is an evidence-based protocol for helping people with substance use disorders. The kind sound of others’ voices helps hum me and my brain back to a stable range.

If, after deep and probing conversations with myself and health care professionals, in my individual case, I/we determine that the potential benefits of returning to use outweigh the potential costs, I would create a safer use plan (again, for many substances, there is no level of use considered safe) and a post-use monitoring plan. I would also run these plans by health care professionals.

Tragically, medical illnesses cause misery to the people who have them and to those who love them. This is the human condition. Self-blame, other-blame, and second-guessing are no more merited for addiction than for any other medical illness.

Let’s free the elephants in the room. Let’s keep talking openly, directly, and factually about substance use.

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Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia. She can provide counseling services to residents of Virginia only. 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.

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