Thursday, April 14, 2016

Breaking Up is Hard to Do

The opinions here are my own and may not reflect those of any organization I may be affiliated with.

The therapeutic relationship is often an intimate one. Clients may feel a profound connection to you their counselor and you may, I dare say will, feel connected to them. This is not a bad thing. As long as healthy and professional boundaries are maintained this connection can help drive the work you do together. Any intimate relationship brings with it a certain amount of vulnerability and this is never more obvious than when that relationship ends. 

I am currently in the process of telling my clients, many of whom I have worked with for almost a year, that I have taken another job and will no longer be their counselor. The responses range from mild disappoint bordering on indifference to feelings of crushing abandonment. As of yet no one has seemed happy about my leaving but in a way that only makes it worse. I love my clients. It's a love that exists within the ethical boundaries of my profession but it is love none the less. I wouldn't do this otherwise. Which brings me to two points that I try to teach my clients when I first start working with them and remind myself at times like these.

1) The therapeutic relationship, no matter how intimate, is not and should not be an exclusive relationship.

This is important. Clients may have theraputic relationships before, during, and after they work with you. Some with have styles that vary greatly from yours. Some may follow a treatment philosophy that is incompatible with yours. That's okay. The progress a client makes with you is not invalidated by the progress they make with another professional. One might argue that a client who moves from you to a successful relationship with another professional is the best indicator that you did your job right.

A client who has made great progress with you and worry that they may not be as successful with another professional. Acknowledge the relationship will likely be different but remind the client the progress goes with them. In the end it's the client's own strength that brings about change.

2) The therapeutic relationship is a temporary one.

If you are lucky you may get to watch a client grow for a long time, but the goal of our work was never to work with them forever. Some clients may become colleagues someday, even friends (but be wary of this) but at some point the theraputic relationship has to end. If not, it transforms into something else which may be a barrier to recovery.


Saturday, April 9, 2016

Wrong Turns

The views expressed hear are mine and are not necessarily shared by my employer or any educational facility I may have some affiliation with. But they should be. Otherwise why would I be writing this?

People are starting to panic about opiate overdose and addiction in the United States. It was bound to happen as things are bad and maybe even getting worse. When people and policy makers panic they seek comfort in what they "know" which is particularly dangerous right now as what they"know" is almost entirely wrong and it will without a doubt cause harm to the people most hurt by this epidemic, and they are legion.

The first wrong turn is a focus on access. It seems we keep making this turn so often we are driving in circles. There is a belief that exposure to a drug is the cause of addiction but if this were true hospitals and doctors offices would be addict factories. Though the data shows that a person who is prescribed opiate pain medication is at a higher risk of developing opiate dependency it also shows us that the vast majority of addicts did not start this way. No one doubts that there has been access to prescription opiate over the past 20 or 30 years, and that may explain why we have a spike in opiate addicts, but why is there an increase in alcohol overdose deaths as well? Is there suddenly more access to alcohol than ever before? People aren't talking about the increase in alcohol overdose because it's not as dramatic of an increase. Why? Because there have always been a large number of alcohol overdose deaths in the country. Yet there is still enough of an increase to be statistically significant even though to my knowledge big alcohol is pushing its products no more than usual and doctors aren't prescribing it. The fact is the role of access in the development of a chemical dependency is far from clear but that doesn't stop self proclaimed experts from claiming it is.

One brand of snake oil being marketed as part of the solution comes in the form of Abuse Deterrent Formulas or ADFs used in prescription opiate. ADFs come in several forms, none of which will stop addiction and may cause additional harm to those addicted to them.

1) Formulas that prevents crushing of the pill for snorting or dissolving it in water for injecting.

Why it won't stop adbuse/addiction 

Humans are very clever. I've heard of one formula that caused the tablet to turn into a gel when crushed, people wishing to snort the drug put the pills in the freezer for an hour and found the could crush them quite easily. But even if the formula worked there is nothing to keep people from simply taking more of them.

Why it might hurt?

People with substance use disorders make mix additional chemicals to the drug to get them to dissolve which may increase the risk of use.

2) Formulas with an added irritant that will cause discomfort if snorted or injected.

Why it won't stop adbuse/addiction

People who are desperate enough will inject or snort them anyway and again there is nothing to stop the person from simply swallowing more pills, which by the way is the most common form of abuse.

Why it might hurt?

These irritants may damage the mucus membrane of the nose and or the veins of the people abusing them. These formulas are not a deterrent for abuse, they are a punishment for those already addicted.

So if ADFs aren't the answer we should just stop using these medications all together right? This is the next wrong turn. Why do I know it won't work? Because it's already failed.

In the 90s and the early part of this century it was relatively easy to get a prescription for opiates. Go to your doctor and point to the 10 on the pain scale and you could walk out with a sizable bottle of pills to get you through the day. If your doctor started asking questions a number of "pill mills" opened up around the country who's job it was to write the prescriptions and supply both addicts and dealers to almost limitless amounts of opiates. The situation was far from ideal but there were some advantages. People knew what they were taking and the pills were so cheap it wasn't cost effective to counterfeit them. Having this largely unregulated stream of opiates supplied to the general public seemed like a bad idea. Clinics were shut down, doctors were arrested, pills became expensive and hard to get. 

But rather than decreasing opiate addiction and overdose deaths, people switch from largely unregulated prescription opiates to entirely unregulated heroin. Opiate overdose deaths are now the highest they have ever been, but we couldn't have known that would happen. It only happened before 100 years ago when opiates were first outlawed.

The CDC is already trying to double down on this wrong turn by releasing guidelines in an attempt to further limit the supply of relatively safe prescription opiates, this will likely result in more heroin use whic will hit the signal for the final and most costly wrong turn, a big law enforcement push.

We can't afford to keep driving in circles. We've been going in circles so long that we've dug ourselves a hole. How much longer can we go before it's too deep to clime out?