Talk on the Opioid Crisis in Blacksburg, VA, March 13, 2018

I will be giving a talk entitled “Opioid Epidemic? What Are the Facts?” for the Lifelong Learning Institute at Virginia Tech on Tuesday, March, 13, 2018, 3:15 – 4:30 PM, at Warm Hearth Village Center in Blacksburg, Virginia. The event is free and open to the public.

If America is facing an “opioid epidemic,” why isn’t evidence-based emergency, urgent, and routine medical care for opioid use disorder available in our town? Ask that question of lawmakers, judges, policymakers, public officials, journalists, treatment professionals, and society at large and watch the spluttering begin. For no other health care condition is belief, opinion, and myth accepted as the standard of care. This presentation focuses on the latest addiction research, with a focus on opioid use disorder, challenging what society has to say about addiction with the available science.

I have compiled my background research for this talk here.

For context, I recommend this article:

And this one, too:

For further reading, I’ve compiled suggestions here.

I gave a talk on opioids for the Montgomery County, Virginia Democratic Party on August 17, 2017. Here is the first half of an expanded version of the talk. The second half is here.

Speaking in Blacksburg, Virginia

Directions to Warm Hearth. As you enter the Warm Hearth complex on Warm Hearth Drive, you will pass Nuthatch Way on your left. Take the next left into the driveway and parking lots for Warm Hearth Village Center.

(LLI requests mail-in registration, but it is not required. Here’s the registration form and here’s a list of all events scheduled for LLI during Spring 2018.)

If you have questions or I can be of service, please feel free to contact me.

Photo: Bonnie Lyons

How to Help a Loved One with Addiction: An Evidence-Informed Approach


Learn what constitutes an evidence-informed treatment plan for the medical condition of substance use disorder, popularly termed “addiction.” Acknowledge that debate rages, even among experts and researchers, about what addiction is and what effectively treats it. Discourse is, of course, necessary, but your loved one needs help now. Learn what the evidence suggests helps most people with substance use disorder, most of the time, better than other treatments, and better than no treatment.

Co-create solutions

Read Unbroken Brain: A Revolutionary New Way of Understanding Addiction, by Maia Szalavitz. If you only have time for two chapters, read Chapters 11 and 12.


Learn enough about addiction to understand what people with the disorder experience, why their actions may not make sense, why abstinence is neither a cure nor a relief, and why they might not want treatment. Understand that substance use disorder occurs with multidimensional complexity and variability. Use terms related to addiction accurately and humanely.

In particular, understand that the neuroscience of addiction suggests that through compromising the brain’s basal ganglia, extended amygdala, and prefrontal cortex, addiction under-sensitizes people to pleasure, over-sensitizes them to pain, automates use of the substance to feel, not necessarily good, but normal, weakens decision-making abilities, magnifies emotional highs and lows and incapacitates the ability to regulate them, interferes with recognizing cause-and-effect relationships, and confounds the ability to make a plan and follow through with it.

“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, Ph.D., 2004

Many people have misinformed beliefs about addiction. Even people with substance use disorder may not fully understand the condition. Misbegotten beliefs can endanger people. Challenge your beliefs through your studies. Try not to say anything about addiction or its treatment for which you can’t cite research.


Be brave.  Beyond the medical condition of addiction which compels use, become aware of, seek, and acknowledge all the possible current conditions, risk factors, and pre-existing conditions – including trauma and mental illness – that might lead your loved one to find use of substances appealing, helpful, or meaningful. If the person initiates the discussion, without judgment, be open to talking about these with your loved one. Approaching difficult subjects, rather than avoiding them, can be painful, difficult work. Get support for yourself so you can support your loved one.

What substances do for a person – including helping with past pain, current distress, and anxious worry about the future – will need to be adequately replaced before a person can do without them.  Expand and deepen your already-present empathy and compassion for these conditions and reasons, and for the person who has them.


Offer love love, not tough love.


If your loved one is in an emergency state, dial 911 or get him or her to an ER.

If not, your loved one may be newly released from the hospital, newly released from treatment, or in need of urgent care.

Having grounded yourself in learning, understanding, compassion, and love, confer with your loved one about what next steps might be helpful. Although the situation might seem dire, co-decide on the smallest step that might make a slight improvement – perhaps finding an answer to a question through a phone call or a Google search – and do that. Don’t try to strategically build trust – be trustworthy.

This is subtle, but the goal of helping someone with substance use disorder isn’t to take over the person. The goal is to help the person be himself or herself and move towards health, in the increments that work for him or her. Going slowly enough has to be balanced with going quickly enough to outrun the defining characteristic of addiction, “persistence despite adverse consequences.”

Use the best of your heart, mind, knowledge, experience, wisdom, and presence, all together, all at once. The substance is perceived as needed to survive. The illness of addiction, the symptoms of co-occurring illnesses, and the impact of substances themselves can interfere with a person’s reasoning. Assume the person is often in a state of alarm. Arguing with you, wanting to leave, sitting on the couch while the dishes remain undone – that may be the fight-flight-freeze response.

You will be tempted to make suggestions and offer advice. At the fundamental level, however well-meant, unsolicited advice comes from the advice-giver’s own fear and doubt. The receiver may even agree with the suggestion, but hears the uncertainty from a person they revere. This confirms one of their own deepest fears: “If they don’t think I can do this, maybe I can’t…” Counterintuitively, giving advice to hasten progress actually thwarts it. Talk to a counselor or a friend about your very legitimate fear, but not with your loved one. To your loved one, convey your hope and confidence.

Co-creating solutions with a person under such duress will take the very best of your full humanity.


The primary reason rehabs exist – especially locked facilities – is fear. We’re afraid our person’s experience of the defining trait of addiction – persistence despite adverse consequences – will kill them. Return to use rates after rehab are 70% or higher. Coordinating local treatment may be a more effective option. However, health professionals are reluctant to take substance use disorder cases because health insurance reimbursement rates can range from 0% to 20%. Assume you will have to pay full fees, out-of-pocket for local treatment.

People with illnesses need daily treatment and care. Find the going rate for daily, individual counseling sessions offering evidence-based protocols. Find the going rate for daily 24-7 companion care. Do the numbers. Figure out how much you can pay and/or are willing to pay. Figure out how much volunteer care you can coordinate on your own, perhaps using Doodle for scheduling.

The primary feelings people have about needing treatment are guilt and shame, especially over expenses. You can ease your loved one’s distress and foster his or her autonomy by sharing exactly what funds are available and for how long. “Whatever it takes” may be our wish, but it usually isn’t possible.


Serve as your loved one’s case manager and do what you can to make the components of the treatment plan happen, starting with medical care. Make inquiries and appointments, make phone calls and follow-up phone calls, make copies of all documents, keep originals in a safe place, create a notebook of the copies, provide or find transportation, and accompany your loved one to as many appointments as possible, notebook of copies in hand.


Your loved one has a medical condition needing medical care, but society at large believes it is a moral and criminal problem needing redemption and punishment. Even your loved one may believe he or  she is a good person gone bad. Your natural inclination may be to walk away from care providers who hold these views. Since it’s a position held by the majority, doing so may leave you with no alternatives and no care. Instead, you may need to learn to skillfully and strategically advocate to procure the necessary treatment component from each individual or entity.

Insist on outcome-based treatment. If the treatment providers don’t have data that the treatment works – data that counts all the people who started the treatment, not just the people who finished – ask them for the criteria used to decide which treatment protocols are offered. If a treatment isn’t known or proven to work, why would your loved one be required to do it? People mandated to treatment may have to attempt to make the best of what’s offered. You can convey, however, that you will be overseeing your loved one’s progress.


Acknowledge the on-going alarm and distress 1) of having a loved one with an illness that leads them to say and do things that hurt a person you love – themselves – and you, 2) of living under the constant threat of the defining symptom of addiction – “persistence despite adverse consequences.”

Consider asking a physician for a referral for a trauma assessment. If you have symptoms of Post-Traumatic Stress Disorder (PTSD), seek evidence-based treatment from a qualified health care professional.


Find others with loved ones with substance use disorders and connect with them in ways that are supportive, informative, and empowering. Community Reinforcement and Family Training (CRAFT) is an evidence-backed approach, developed first for alcoholism, and known since the 90s to foster engagement between people with substance use disorders and those who love them towards achieving treatment goals. Even if implementation of a CRAFT program is not possible in your area, finding others who value a CRAFT goal – “Minimize distress and increase positive lifestyles for all family members” – may be encouraging and strengthening.

“Love, evidence & respect.”
– Maia Szalavitz’s answer via Twitter to the question, “What fights addiction?”

Further reading

Recommended reading

Watercolor by Jesi Pace-Berkeley

Last updated 3/22/19

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.

It Cannot Be Concluded That General Group Counseling is Effective for Reducing Substance Use

“Unfortunately, despite decades of research, it cannot be concluded that general group counseling is reliably effective in reducing substance use or related problems.”
– Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, November, 2016, Page 4-26

. . . . .

For research citations on counseling – individual or group – for opioid use disorder, please see On Counseling and Medication-Assisted Treatment.

For more excerpts, quotes, and definitions related to substance use disorder, please see Addiction Recovery: Define Terms and End Conflation.

The views 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.

Open Letter to People Thinking About, or Mandated to, Long-Term Abstinence from Substances

Dear You,

The reality of recovery from addiction is that one has to walk side-by-side with ever-present, unmet, unmeetable longing. Some people experience this more intensely than others; sometimes an individual experiences this more intensely than at other times. For some people, the longing fades like the details of a bad dream. But the mysterious “turn” that happens in the brain from addiction can make that longing elemental, experienced in the heart, mind, body, and spirit.

Hug yourself again and againAnd a person has to do this walk, sometimes limping, without direct help. Other than a few medications for some substance use disorders, no one knows how to make the longing that underpins those “impairments in…voluntary control over substance use”* go away.

When someone is asked to consider abstaining, or is mandated to abstain, that’s the inhumane reality they face. Abstaining risks the anguish, with one’s whole being, of, to quoth Poe’s raven, “Nevermore.”

If you are someone who is thinking about, or mandated to, abstain long-term, here are my simplest, most direct suggestions. They are based on my reviews of the research on addiction, my professional training and experience, and my personal experience developing alcohol use disorder in association with a school shooting occurring in my small, rural, college town.)

(This advice is based on the assumption you are medically stable, have detoxed through medical monitoring, and/or have been medically cleared as having successfully detoxed on your own, and/or are stable on medication treatment. You either have received, or have appointments to receive, medical care for the medical conditions that can accompany addiction.)

Give yourself a big hug. This is sad and hard.

With hope that knowing possibilities may offer you calm and resolve – and with hope that those who love you may understand a little better – these may be true:

  1. How you currently feel, what you feel, and what you think without alcohol and other drugs may last.
  2. The improvement in feeling, thinking, and physical condition – even bliss – that you experienced with substances may not be possible without the substances.
  3. You may always have to hold opposing truths in your mind: “I want” AND “I don’t want.”
  4. Spontaneity may be endangering.
  5. Mandating perfect standards for imperfect humans is cruel, especially when they are ill. Inability to abstain is the primary symptom of the illness of substance use disorder. Abstinence is a cruel standard.

The possibility of these challenges does not preclude the presence of other meaningful and satisfying alternatives. For now, the task is not to try to make these realities go away, but to figure out how to live with them without using or drinking. To abstain, then, we must help ourselves not use or drink.

Ways that might help you not use or drink:

1a. Figure out what alcohol and/or drugs, themselves, did for you originally. Focus on then, not now, on before, not during. (This may be challenging, but try. Use may be essentially automatic now. Given a perfect storm – addiction is actually rare, i.e. only 1 in 10 Americans has it – of pre-existing conditions, and enough use for long enough, if the “turn” happens, it’s a brain thing that no one can figure out.)

1b. Find ways to do manually what alcohol and drugs did automatically. (In vastly oversimplified, general terms, substances help people “Feel better,” “Feel good,” or “Do better,” by adjusting the volume on emotions, focusing or distracting attention, prioritizing thoughts, and/or providing physical stimulation or comfort.) The new ways have to work no matter what happens – however shocking, painful, joyous, or boring.

2a. Figure out what the process, itself, of drinking alcohol and doing drugs did for you.

2b. Accept that nothing will probably ever duplicate what substances did, and anything may only ever be “good enough.” Still, find enough “good enough” replacements, enough of the time, with enough safe people, meaningful enough to you, that meet your needs, that sorta, kinda do what substances did. It will take a bunch of them. One thing might be necessary, but no one thing is likely to be sufficient over the long-term, although, initially, it might feel that way (falling in love, for example, or feeling embraced by a support group).

3. Think hard, ponder, and muse about the research on addiction that says the way the brain functions with love, bonding, and attachment may be the same as the way the brain functions after addiction has developed. Did our ability to connect, bond, attach, and love get shifted to substances? How do I use this information to help myself not use or drink? Is the ever-present ache and longing I feel since the death of _______ or the loss of _______ related to how I feel while abstaining? Is how I keep putting one foot in front of the other after that loss how I can help myself keep going without substances? Might finding other people, things, and ways to connect – even love – help me not use or drink?

4. Be self-kind. If it’s possible – again, stated in grossly oversimplified terms – that love may directly treat the brain for addiction, then it’s practical for me to have empathy, compassion, and love for myself. It also helps me “Feel better,” “Feel good,” and “Do better,” especially when compared with the excruciating experience of self-judgment and self-reprimand.

Give yourself a hug again. And again. I know this is starting out sad and hard for you. But it’s possible that basic humanity and applying the research on addiction may actually help things end up being pretty okay, maybe even pretty soon. Wouldn’t it be something that, after medical care, simply being thoughtful, kind, and caring towards ourselves might help us recover from addiction?

Wishing you the very best,
Anne Giles
Blacksburg, Virginia
January 10, 2018

* “A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use.” Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, 2016, Page 4-1

This post is part of a series. The table of contents, with links, is here.

Photo: “Self-hug” of Casey Sapienza by Mia Sapienza

The views 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.

How to Help Yourself Not Use or Drink: A Kind, Evidence-Informed Guide

How to Help Yourself Not Use or Drink: A Kind, Straightforward, Evidence-Informed,  Do-It-Yourself, Insider’s Guide to Early Recovery from Addiction
by Anne Giles, M.A., M.S.

Dedicated to my clients: You helped write this. For confidentiality reasons, I can’t use your names, but as you read along, you’ll recognize your own – and each other’s – wisdom. Thank you beyond words for sharing the extraordinary beauty of who you are with me.


This guide is intended for people who have already received medical care for the medical condition of addiction. This guide assumes you are medically stable, have detoxed through medical monitoring, and/or have been medically cleared as having successfully detoxed on your own, and/or are stable on medication treatment. You either have received, or have appointments to receive, medical care for the medical conditions that can accompany addiction.

“Use” refers to use of any substance that has caused problems for you, brought into the body in any way.

How to Help Yourself Not Use or Drink Right Now

  1. If the substance is nearby, turn away from it.
  2. Sort your thoughts into “helpful” and “unhelpful” categories. Focus your attention on the helpful thoughts.
  3. Without judging your feelings, or trying to control or change them, simply turn down the “volume” on the intense feelings.
  4. Do what you can to make yourself more physically comfortable.
  5. When thoughts of using or feelings of craving arise – which they will – without judgment, simply shift your attention to a specific item that engages one of your senses. Become curious about your preferences, focusing on what sensory experiences might be helpful to you. Focus your attention on something you see, a sound you hear, the texture of an object you can touch, a scent in the room, a motion you can observe, or the taste of something available.
  6. When a thought arises that begins with, “Yes, but…”, say, “I am trying to help myself not use,” and shift your attention to what is helpful to you.
  7. When a memory from the past emerges, or a worried thought about the future occurs, say, “I am focusing on this right now,” and shift your attention to what is helpful to you.
  8. If nothing else is working, splash cold water on your face. If cold water is not available, place a cool object safely and gently against your face.
  9. Even if you have to do it 100 times a day, even 100 times a minute, kindly, gently, but determinedly return your attention over and over again to what you think would be helpful for you. Not to what someone else might think is “right” or “good.” To what would be helpful. For you.

How to Help Yourself Not Use or Drink Today

  1. Do the items on the “Right Now” list.
  2. Make two lists of all the people in your life under the headings “safe” and “unsafe.”
  3. Find a way to physically be in the presence of the “safe” people.
  4. Stay away from the people on the “unsafe” list. Do not have contact in person, by text, by messaging, or by any means of any kind. Do not listen to, or seek information about them by word-of-mouth, gossip, rumor, Crime Times, or any way of any kind.

How to Help Yourself Not Use or Drink This Week

  1. Keep doing the “Right Now” items. Stay with safe people.
  2. Make a list of all the problems present in your life that substance use solved.
  3. Rank order the problems.
  4. Make a list of everything that’s missing in your life that substances provided.
  5. Rank order what’s missing.
  6. Think strategically.
  7. Ask yourself, “What is one small thing I could do today to help make a small improvement in my top ranked problem?”
  8. Ask yourself, “What is one small thing I could do today to help provide a little bit of the top-ranked thing that’s missing from my life?
  9. Do those small things.
  10. Think about how you have handled the loss of beloved people and beings in the past. You can never be with them again. How have you handled longing and not having? How have you coped with the loss of your loves? The brain circuitry of love and addiction are interrelated. Answering these questions may provide important information about what might help you cope with the loss of substances.

How to Help Yourself Not Use or Drink This Year

The only way to not use substances long-term is to find enough things to do, enough of the time, that meet enough of your needs, connected to enough people, in ways that touch your heart enough, make enough meaning for your mind – all of this stable enough but with room for change and growth – that, together, are “good enough” replacements for substances.

Nothing is likely to ever do for you what substances did. Their chemical nature gives them an other-worldly ability to offer extreme comfort, excitement, joy and relief. Managing attention, feelings, thoughts, physical sensations, and behavior during the days ahead will only work so long while holding still. The insights you gain from learning what substances did for you are necessary, but likely are not sufficient, to prevent yourself from returning to use.

Hopelessness and despair are considered to be among the root causes of addiction. You need to develop a way of thinking that helps you feel hopeful and confident. This is where religious and spiritual beliefs, and philosophical and scientific understandings might be helpful. Figuring out the values that drive your decisions can inspire a sense of strength as well. Finding even a few people with whom you feel a sense of belonging, and continuing to add people to that circle as time passes, will be crucial.

If in doubt, Google it. Knowledge and information offer power and freedom. Before drawing conclusions from the results of Internet searches, check the authority of the source. Reliable sources link to primary sources, secondary sources that report on multiple primary sources, and informed commentary.

And then there’s the money.

If you’ve had substance use issues for awhile, you probably have financial challenges. More money would increase stability. But people with substance use disorders usually can’t work more hours to make more money. Working more hours increases stress. Stress is a top predictor of return to use. Stress comes from the usual suspects – finances, relationships, and health issues among them. But boredom is a stressor. Lack of purpose is a stressor. Frustration is a stressor. So people with substance use disorder have to figure out how to make more money per hour in ways that are meaningful to them. That usually requires education and training. You may need to learn to read, to get a GED, learn a trade, or take entrance exams to go to college or grad school.

You need an it’s-who-you-know network of people to help guide you to the right information, mentor you as you go, and introduce you to people who might be able to help you. You’ll soon be a member of the “it’s-who-you-know” network. You’ll be able to help someone else who started just where you’re starting.

  1. Acknowledge realities. Note what’s unlikely to be possible in the future based on physical or other limits. For example, if you want to move to a place with more jobs but have a suspended license, you’ll need to find a city with public transportation.
  2. Inventory your strengths. What do you have going for you, in spite of everything that’s gone down?
  3. Make a list of possibilities. Given current realities, but also given your strengths, what might be possible for you to do, that you might like to do, that would give you a sense of being meaningfully engaged with your life?
  4. Rank order the list of possibilities. Which of the possibilities do you think would sustain your interest the longest and be most likely to make the most money, or result in the most satisfying volunteer work?
  5. Find someone who has made things happen in his or her own life to talk with about your top three possibilities.
  6. Think strategically.
  7. What small, first steps could you take to move yourself a tiny bit closer to setting yourself up to have meaningful things going in your life – even if they’re only ever “good enough” – to help you not use?
  8. What people in your it’s-who-you-know-network can you contact to help you with these first steps?

. . . . .

I wish I could write a guide that anticipates all the problems that might arise for you and offers solutions to them! But you are a unique, complex individual, and addiction is a complex condition. You are the guide to you.

If you would like to read more about evidence-informed, self-care for recovery from addiction, this guide’s current table of contents, with links, is here.

If you like handouts and worksheets, here is my current list of printable, evidence-informed addiction recovery worksheets.

An earlier version of this post is here.

This guide is a work-in-progress.

These words, just over 1,500 in number, are a summary of what research on addiction suggests helps most people, most of the time, better than other ways, and better than nothing, to help themselves not use substances that have become problematic for them. As you know, I use these ways, too. I am hoping with all my heart and mind that they will be helpful to you.

With the sincerest of best wishes,

Blacksburg, Virginia
January 4, 2018

“Love, evidence & respect.”
Maia Szalavitz, in response to the question, “What treats addiction?”

Photo: “Self-hug” of Casey Sapienza by Mia Sapienza

The views 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.