Sunday, February 28, 2016

The Drug Holocaust

Drug Addicts Are Human Beings, The Story of Our Billion Dollar Drug Racket! How We Created It and How We Can Wipe it Out by Henery Smith Williams, M.D., B.Sc., LL.D. was published in 1938. I encourage everyone to read it, it can be downloaded at no cost by following the link at the bottom of the page. It isn't an easy read, but it's worth it.

Dr. Williams quotes a U.S. Treasury Department censuses from 1918 which estimates "habitual users of narcotic drugs" to be over one million. What's striking is that 75% of the estimated million were "engaged in gainful industries of wide range and variety" in other word employed, and many of the remaining 25% were housewives, only a small percentage were what could be described as criminals other than the fact that they possessed narcotics that had been effectively outlawed 4 years earlier. Dr. Williams states that many opiate users had no idea they were addicted, since the drugs were cheap and easy to come by they played a very small role in the minds of the users. They would buy their grains of morphine for pennies at the drug store and go about their day.

In 1914 a million  American citizens were transformed almost over night from productive and employed members of society to criminals. Dr. Williams calls the years from 1914 to 1938 "The American Inquisition" though he admits he might have been too kind. The scope of the barbaric and inhumane practices far surpassed anything dreamed of by the Spanish predecessors. His solution is a simple one. Since addiction is time consuming and expensive to treat, with no guarantee of success, far beyond the means of the average person and the drugs were cheap and easy to supply, simply let doctors supply enough of the drug to the affected to remain comfortable and have a normal life. It had worked before, it has worked since, it's working now in methadone clinics across the country but in spite of overwhelming evidence to the contrary the public and political outcry against these programs limits the good they do.

It is not enough it seems for an addict to be healthy and law abiding. It seems the addicts most unforgivable crime is to exist at all.

Johann Hari in his book Chasing the Scream marks 1914 as the beginning of the drug war, and while war accurately describes the policy started in the United States it is a one sided description. It tells the tale of the governments actions but not how those actions affected the people they were aimed to help. The government waged war, the addicted suffered and died. 

1914 was the start of the Drug Holocaust. An estimated 1million people were denied a medication that kept them from becoming terribly ill. The drug was now expensive beyond their means, and difficult to find. Both cost and the time it took to get the drug made it impossible for many to function at a job. Families and communities that were simply low income before became destitute. Legitimate businesses could not be sustained in this environment. The addicts weren't working and what money they did have went to feed their habit. Or they were arrested and made no money at all. Restaurants and shops closed but one business thrived, black market narcotics. The underworld moved in and fought wars with each other,fought wars with the police. The underworld bosses became wealthy beyond their wildest dreams, and the addicts suffered and died.

Soon there were no jobs in these communities. Some addicts sold drugs to support their habits. Since there was little taxable income in these communities, public service suffered, the schools declined, teaching the traumatized children of these areas was difficult, and few could do it, fewer still wanted to.  Soon the black market nacotics draffted the children in these communities as soldiers and sales people. Law enforcement no longer wanted to police these areas. When they did come there arrival was quick and violent. Gun manufacturers became rich supplying all sides with weapons, and the children of addicts suffered and died. 

This was already going on in 1938. Dr. Williams is one of the few voices to speak out against these disastrous policies and while the evidence that he was right was all around the U.S. government not only expanded these policies, they exported them to the world. These policies have destroyed individual addicts, their families, and their communities all over the world. When Michelle Leonhardt was asked for comment on 60,000 Mexican citizen who died in the war on drugs during  her time as head of the US Drug Enforcement Agency she called the deaths "a sign of success." At what point do we say enough? At what point do we say that whatever harm drugs cause this supposed remedy is worse? If we stopped the Drug Holocaust today it may take generations to heal the damage that's been done. Yet somehow we still manage to blame the addicts.

There is hope that we will see an end to the Drug Holocaust in our lifetime. We have one thing that Dr. Williams didn't when he wrote that drug addicts were humans, deserving of compassion and care, Portugal. Portugal rejected U.S. Drug Holocaust practices 15 years ago, when following those practices brought the country to its knees. For 15 years Portugal has been treating their addicts rather than waging war on them, and it's worked. There is still drug use in Portugal, but all the problems associated with it, crime, disease, poverty, is down. Portugal has been healing for 15 years, and even the conservative elements in its government don't want to return to the old way of doing things. Recently Frontline did a two hour report on the heroin crisis an in it highlighted a groundbreaking new program for dealing with addicts.  There is a growing consensus that we aren't going to shoot and arrest our way out of this problem. But in most of the United States, in much of the world, the old policies continue, and addicts, their families, and their communities suffer and die.

A link to a PDF of Addicts Are Human Beings

Watch Chasing Heroin

More reading on the Drug Holocaust

Friday, February 26, 2016

Stop Relapse... Prevention

Stop Relapse... Prevention 

The views expressed here are my own and are not necessarily shared by any employer or educational institution I may be affiliated with...but they definitely should be.

I'm going to go out on a limb here and say every treatment facility in the United States has a class, group, or workshop called "Relapse Prevention." It may be the biggest lie in the the recovery industry. A quick google search of relapse rates after rehab will tell you that something around 60% of graduates from a given treatment facilities will relapse between in the first 1 to 3 years. Of the remaining 40% about half will relapse by the 5 year mark and about half of those survivors will relapse by 10. Though results may very a bit from program to program the numbers hold fairly steady.  I think it's fair to ask just what relapses are being prevented? The answer it seems is none at all. Yet that's what we say we are doing. That's what we tell the fresh faced first timer who looks at us determined he will never set foot in treatment again, that's what we tell the frequent flyer who is determined to do it differently this time and they fill out the work sheets we give them with triggers, coping skills and numbers to call, they write prevention plans and role play scenarios and most of them use again before the year is through. So what are we teaching them if it's not how to prevent a relapse? When we say things like "relapse is part of some people's stories but it doesn't have to be part of yours" what is it we are trying to say? The one overriding lesson of every relapse prevention class, the very purpose of the topic itself is to teach the clients one thing, when you eventually relapse, it's not our fault, it's yours. It's a lesson they learn well. It's a lesson we teach them over and over again.

Not everything taught in a relapse prevention class is useless. How to access sober support, coping skills for triggers, tips to survive the holidays, these are all things a person in recovery may put to good use, they just don't seem to prevent relapse. So what do we do with these people who are desperate for our help? Do you hear a list coming? I hear a list coming.

1) stop pretending relapse is abnormal. Most people enter a treatment facilitiy long before their last use so don't treat the clients as if they are the only one to ever slip up. 

2) Instead of pretending to prevent a relapse teach them how to survive one. In the case of an opiate dependent person make sure they have Narcon and train them how to use it.

3) put aside the idea that recovery begins that day after one's last use. The truth is recovery begins when one decides it's time to change.

4) instead of talking about Relapse Prevention, talk about Abstinence Goals. Abstinence is an important goal of recovery but it is not the goal of recovery. A client who has gone from daily drinking to drinking 3 times a month has made significant progress towards their abstinence goal of no alcohol, but has failed three times to prevent relapse. Which is more likely to motivate them to continue trying? They might be excited to tell you about the proges they have made towards their abstinence goal, and they may be open to your help in continuing the progress.  On the other side, they may be ashamed if they think they have failed and may be more likely to hide it from you and continue using in secret.

Each relapse can be a learning or a shaming experience for the client, which one may depend on how you the professional decides to handle it.

Wednesday, February 24, 2016

My New Problem With Old Words

My New Problem With Old Words

The views expressed here are my own and are not necessarily shared by any employer or educational institution I may be affiliated with...but they probably should be.

There is a movement to change the terms used when talking about addiction both professionally and in the media. I support this movement, I believe its premise to be correct. Words are powerful and positive and negative words have positive and negative effects on my clients and on myself as a person in long term recovery. This is not in my opinion, political correctness out of control. This is about improving outcomes for some of the most vulnerable people in our society. This is treatment on the largest imaginable scale and while all change is difficult and change on this scale is even more so, I find resistance in surprising places.

The most ambitious goal of this movement is to eliminate the words "addiction"  and "addict" from professional vocabulary. In theory this shouldn't be too hard, "addiction" is nether a scientific term nor is it a medical or psychological diagnosis. The main reason for this is there is no agreed upon definition of the word. Calling someone an "addict" never made any sense if you follow the disease model. A person suffers from cancer, a person is not a cancer (outside of the astrological meaning) Someone is never called a cancer due to a medical diagnosis and being called an addict is never a compliment. At this point you may wish to ask "If you think these words are so terrible Ken, then why have you used them in every Grey's Recovery post?"

It's a fair question. The truth is it bothers me. I can name several reasons for my choice of words, but the biggest and simplest reason is so that people understand what I'm talking about. The term "Substance Use Disorder" is what I use in clinical notes, but nobody knows what I'm talking about outside of the mental health field. Even in my professional life, in individual sessions and groups I use the word "addiction" and refer to people in general and to myself as "addicts." I get tired of constantly educating clients about terminology and getting diverted from what I see as more important topics. Also I don't want to seem judgmental or paternal by constantly correcting clients language.

 The second reason is something of an excuse, but the first is just laziness. I predict this change will be a long time in coming, longer perhaps than similar changes spurred by the civil rights, women's rights and the LGBT rights movements. In those movements it was the marginalized and oppressed population which demanded then drove the chance in terminology. In my experience so far it is the people in recovery from Substance Use Disorders who have been the most resistant to this change. Myself included. I've identified as an alcoholic or addict for eight years, I've found comfort and community in this Identity. But I think it's time now for a new identity. With that I would like to introduce myself. My name is Ken and I am a father, a husband, a chemical dependency counselor, and I am in long term recovery. 

That's enough change for today.

"I freed a thousand slaves I could have freed a thousand more if only they knew they were slaves." Harriet Tubman

Thursday, February 18, 2016

You Can't Test For It! Part IV

You Can't Test For It: Recovery Cannot Be Detected in Urine (part 4 of 4)

The views expressed here are my own and are not necessarily shared by any employer or educational institution I may be affiliated with...but they probably should be.

Two weeks later he was in my office. "Ken, I pissed right before I got here. Can we push the piss test back one day?" I told him no problem and started to make the change in the computer.   Before I could finish he was back in my office sitting in a chair. "Don't" he said, "I used last night." His shoulders began to hunch, his face twitched waiting for my reply.  I asked him "Did you spend more than you could afford? Did you start using again today?" He answered no to both and added "before it would have gone on for weeks." I asked him since he didn't lose anything, didn't hurt anyone, didn't put himself in danger, and didn't fail to meet any obligations, did it really matter that he used a little cocaine? We both sat for a moment. We were both a little stunned this was new territory for both of us. Then I asked him "do you still want to postpone the test?" He paused thoughtfully, "I'll take it today. I did the coke, and I can handle the consequences."

We continued like this. I told him he was welcome to report his cocaine use to me, but that I would not address it as an issue unless he told me it was. For his part he said it was his goal to stop using cocaine, but agreed that it wasn't helping to beat himself up over it. Each week he would stop in. Sometimes more than once. He would check in whether he used or not but he was using almost once a week. Sometimes he would take the drug screening and sometimes he would ask to push it back. I started to get nervous one week when he reported using three times. Was he falling into an addictive spiral? Had I given him permission to do so? But somethings else was happening. His permanent scowl was replaced by a relaxed smile. Where he used to rush in and out of the clinic as fast as possible, now he stopped to chat with nurses, old counselors, and even the management staff. He no longer walked hunched over but stood straight up and walked at an easy pace. He seemed younger.

Eventually the cocaine use stopped. Neither one of us could pinpoint the exact time, but one day he just didn't need it anymore. Even when his life became challenging again he didn't go back to it. 

I would like to claim credit for his success but the truth is he had done a lot of hard work long before he met me. What he learned with me was that just because he hadn't achieve a goal, in this case abstinence, it didn't mean that he wasn't making progress towards it. In his case an imperfect abstinence was part of an amazing recovery. I didn't teach him that. We learned it together.

In my opinion the biggest problem with the use of drug screenings in chemical dependency treatment is that we use them for ourselves and not for the clients. We use them because we want to know if the clients are lying to us. We use them to have proof that we are successful. We use them because it's easy. But is it helpful? Should drug screenings carry the weight they do when deciding whether or not a client is making progress or is even appropriate for a particular setting? Of course not, I wouldn't be writing this if I thought so.

Here is a list of ideas to make screenings less punitive and more therapeutic.

1) Let the clients choose. There are those, myself included, who report the accountability provided by regular screenings was helpful in early recovery. A common factor between those of us who report this is we were fairly successful early on at achieving sustainable abstinence. To us the screenings were not accompanied by anxiety and shame, they were just another way to mark our success. So ask the client "do you think this will be helpful?" and accept it if the answer is no. In the end it's not important for us to know if the client is reporting honestly or not, only the client needs to know if they are using, and they already know.*

2) They don't need to be random. Let the clients know when the tests are coming, how often they are coming and what to expect from the results. Two concerns that immediately come to mind are that the clients may bring sombody else's urine or that they may time their use so that it won't be detected on the day of the screening.

I'm going to put the next sentence in bold letters because it is very important. Clients almost never bring in someone else's urine. It happens, but so rarely that it should be a nonissue! How much urine are you carrying on your person right now? Now go to a friend or family member who doesn't use drugs and ask them to pee in a cup for you. Don't tell them why you need it or better yet tell them you need it to fake a drug test. Please share the reaction you get on YouTube. Your clients are not lying machines. The vast majority of them if not all are with you to get better. They don't want to hide their use from you, they want to stop using. If you have a problem with clients lying about their use ask yourself, have you made your treatment program a safe place to be honest?

Clients trying to sneak a little use in during the safety window where it will avoid detection is much more common. In all honesty any client may be doing this at any time, but this is an important piece of information. Clients who can manage this are not using every day. That is huge. Don't worry about clients who are getting away with something. Clients who have a serious substance use disorder are very bad at managing this sort of thing so for what it's worth it's eventually going to show up on the screening. Better yet, if you are not judgmental, and you are supportive they will tell you they after they use. If possible Don't focus on the use  at all. Focus on what they are doing right on the days they don't use and see if they can do more of it. If use doesn't show up on the screenings there will be other symptoms. If not, is a disease/disorder with no symptoms really a problem? Lastly, if a client requests a screening just so they can see a "clean" result, given them one, and when it comes back tell them "good job."

3) Measure progress in other ways.  Abstinence is only one leg of recovery, and recovery is a many legged beast. When deciding if a client is making progress look at their attendance and engagement in groups. In my experience this has been the best indicator that a client will achieve some sort a of recovery and even abstinence, even if they continue to using at the time. Ask them how they are getting along with their families, ask them how work is going, ask them how they feel. Do they look better than when they walked in the door? For our clients progress in any of these areas will probably require progress in their abstinence goals, but not necessarily perfect sustained abstinence. At least not early on. Is it not the goal of recovery to have good relationships, stable employment, and to feel good about yourself?  If they could have these things while using would we even care that they were on drugs?

One last point before I close. Observed urines, or the practice of watching a client provided the sample to make sure it's valid has almost no place in a therapeutic setting. It is dehumanizing, humiliating, and possibly traumatic to clients who have suffered sexual abuse.  The actual and potential damage done by this practice far outweighs anything the client might gain.

*One exception to clients knowing when the use drugs can be benzodiazepines like Xanax and Valium. These can cause amnesia where the client forgets taking the drug.

Wednesday, February 17, 2016

Opinion: America Needs Heroin-Assisted Treatment | The Fix

Mainainence medications like Methadone and Suboxone have their advantages when used to stabilize a person's life but any opiate could be used, morphine, oxi, and even heroin.

Opinion: America Needs Heroin-Assisted Treatment | The Fix: Switzerland has been widely criticized for its liberal drug policy but perhaps there's a lesson to be learned from the Swiss drug model.

Monday, February 15, 2016

You Can't Test For It! Part III

You Can't Test For It: Recovery Cannot Be Detected in Urine (part3 of 4)

The views expressed here are my own and are not necessarily shared by any employer or educational institution I may be affiliated with...but they probably should be.

I made it through my two week trial period without any trouble. I was confident all he needed was to refocus his energy from other peoples behavior to things he had control over. Once he did so I assumed he would progress quickly and for a time it seemed to be working. He was very open to the idea and it supported the 12 Step work he had done in the past. But then he started skipping sessions. When I did see him the angry scowl that was his only expression seemed to intensify. His shoulders hunched even more so that he walked like a man twice my age, though he was 12 years younger. Final reports of behavior issue began to reach me from other parts of the clinic, and when I addressed them in session he became angry and defensive. I wanted to blame him, to believe he wasn't tryinging hard enough, but the truth was he'd done all I asked. Something was missing. He had worked too hard for too long to be getting so little from his recovery. 

Together we reviewed his time in treatment. His screenings showed reactive for cocaine every 3 to 6 months, but illicit opiate use hadn't shown up for years. His case notes told the story of a man who survived a life threatening accident that left him disabled, but who still managed to be a good husband and father and had recently returned to work. When I ask how he felt about his success he replied "I see what you mean, I can understand it when you say it, but I still feel like a failure." When I asked him why he thought that, he disclosed to me that he never really stopped using cocaine, and the it was eating him up. 

This didn't make sense, he had said he was saving money, there were new shoes on his daughter's feet, his car was paid for, he was working full time, and most of his drug screenings didn't show cocaine. How was he managing this? He explained to me that he wasn't using every day. He tried to make each use his last. He told me he could often hold out for weeks, and never less than a few days. He explained the amount he used was never more than one or two lines, so the money was negligible, and often he payed nothing at all. But he felt tormented.

I proposed to him that we treat his cocaine use like any unhealthy behavior. He could report his use to me but I would give the use no more significance than cigarette smoking. If a random drug screening came up after a recent use he could report the use to me and I would document it in his case notes. He would have the choice of taking the screening or rescheduling for a later date. 

The physical change in him was immeate and dramatic. His eyes opened all the way, his face relaxed and his shoulders unhunched for the first time since I'd know him. "Can't you get fired for this?" He asked. I told him not to worry, but I honestly didn't know.

When should a random UDS be a part of a client's treatment?

1) When it's needed for safety:

One might argue this is the reason for almost every drug test in a treatment setting but I would argue the test rarely increase a client's safety. One exception may be in Medication Assisted Treatment. Some drugs react dangerously with maintenance medications and arguably the risk is too high to count on the client's report. Even so mainainence clinics rarely test more than once per month so the UDS only provides a small window into the client's substance use. 

It could be argued that illicit use in any setting is dangerous, and to some extent this is true, but does the test really make the client more safe? In my experience the tests drive clients away from treatment. Clients who know they won't pass a screening may not show up at all, and clients who do show up may be kicked out of a program. A client who is in treatment is much less likely to die from an overdose, but clients who are kicked out of a program die at the same rate as those who get no treatment at all. Better to create an environment where the client can safely report their use without fear of being discharged or forced into a level of care they aren't ready for.

2) Because it is legally mandated:

Sometimes due to state regulations the facility you work in will be required to give regular random screenings. As a counselor you have little to no control over these policies but you will invariably be the face of them and you may be able to lessen the shame these screening may cause. When the results of these screenings contradict what the client has told you don't use that information aggressively. Don't use the information as an honesty test to see if the patient will lie to you. Tell them in a nonjudgmental way the results of the screening and use it as an opportunity to ask the client what more you can do to support them. If the client has reported something inconsistent with the results there is no need to address the lie unless the client brings it up. This is an opportunity for the clinician to demonstrate that it is safe for the client to report their use honestly. Remember, the two most common reasons clients lie to you are 1) they are afraid if the tell you the truth you will judge and reject them. (so don't) and 2) because the want desperately for what they are saying to be the truth. (So help them make it so)

Sometimes a client may be mandated for random screenings as a condition of probation or parole. As a counselor it is important to remember that even though you are providing this service for law enforcement, you are not working for law enforcement, you are working for the client. While the client likely signed a release that give the P.O. access to the results of these screenings it is the counelor's ethical responsibility to advocate for what is best for the client no matter what the results. Continued reactivity may put a client at risk for being locked up, but so long as you have a comprehensive release for the P.O. there is no reason to send only the UDS results. Provide the results but also provide  context. Does the client show up every day? Are they engaged in groups and individual sessions? Did the client recently suffer a loss that makes sustained abstinence difficult? Even if the client is less than perfect in all areas include your clinical opinion as to why incarnation is will not support the client's recovery because it almost never will. 

I can't say it enough, if you must make random screenings a part of a client's treatment let them be informative, but never punitive. If it were possible to punish a person out of addiction the U.S. Prison system would be the most effective chemical dependency treatment in the world, but sadly it is not. So as clinicians there is no reason for us to borrow their tactics.

To be continued...

As always the author invites anyone to comment on the ideas presented here, but asks that you keep comments on spelling and grammar to yourself.