Saturday, March 25, 2017

The one you hate

The one you hate

"There she was in my group, 40 minutes late but a week early for our scheduled appointment. Group days are always hectic but I fit her into my schedule thirty minutes before lunch because we had a few things to go over before she met with the team doctor and she had  to keep her last scheduled appointment. She hijacked the group immediately giving her peers unasked for advice and complaining about her roommates in treatment until I cut her off and dismissed the group. One on one she complained for 40 minutes about the incompetent care she was receiving adding it was not necessarily my incompetence she was referring to while clearly sending the message that it was. I know this game well so when I was satisfied I had given her a fair say I redirected the conversation to her goal and trying to break them down to manageable objectives. she parried by switching the topic and refusing to commit to any course of action. I confirmed the date of her doctor's appointment and that I would provide transportation before she left.  A week later she didn't answer my calls, didn't show up at the agreed upon meeting place and missed the appointment then showed up the next day at my office angry that she was making no progress."

In close to five years working in the the recovery field most recently as the substance abuse specialist on a community mental health team I am happy about the direction of my life. I wake up in the morning tired but I don't dread going to work, I look forward to it. My favorite part of my job is the face time with clients and as a rule the more I get the less tired I am at the end of the day. But every now and then a client comes in that makes me dread the upcoming appointment and I even wish they wouldn't show up. Sometimes it's because they are negative, sometimes they are just plain mean, and it's hard to see if I'm doing any good at all. At past jobs I had the reputation of being able to manage the "difficult" clients. I'm not certain that reputation has followed me to my current position where the people we work with are often struggling with profound mental illness and the percentage of "difficult" clients is much higher. I can honestly say that while sometimes I do dread an upcoming appointment with a client I have managed not to hate any of my clients. I'm no saint but I've found a few things to keep these challenges from getting me down.

While it's okay to blow off steam it's not okay to be openly disdainful of a client. Even if it's just among friends and colleagues 

A client can be so frustrating that you need to give voice to the complaints burning in your gut to a supervisor or trusted colleague but don't let it go on for too long. Nobody gets paid to do an easy job, a miner doesn't get anywhere by complaining about the stone and I don't get anywhere complaining about the symptoms of disorders who's very existence provided me with employment. While Goodwill Hunting moments of tears and hugs do happen from time to time most of the time change takes hard work an a lot of time for us and even more for the clients.

See past the symptoms to the pain.

The people I work with are suffering. Often the pain isn't physical (though sometimes it is) and it's hard to see. Isn't that what the unpleasant behavior is for, to hide the fact that they are suffering, vulnerable? The behaviors are frustrating to me but to the client they are isolating and as bad as it is to suffer it's worse to suffer alone. When I can see the clients pain my judgement of their symptoms melts away. It can be a powerful experience when this happens and the client can sense it too. When judgment is replaced with acceptance suspicion turns to trust. It can make all the efforts leading up to it worthwhile.

Just because it's hard to see doesn't mean your not doing any good.

I don't believe that some people "just aren't ready to change." At least not the ones who have managed to come to my office.  They may not be ready to change in the way I want them to, they may not understand what is required to change, I may not have what they need to change, but it's not because they don't want or just aren't ready to change. I strongly believe that if a client is truly getting nothing from our contact they will ask for another counselor or stop coming altogether. It might be that my office is the only safe place for them to be unpleasant or at least the only place they don't feel judged for being that way.


Suspending judgment in the face of a barrage of insults and attacks on your competency and character takes energy, if you don't have any you won't be able to do it. Use those vacation days, sick days if you have to, illness doesn't have to come from a virus. I found I need to see a therapist and do so no less than once per month. Our jobs are difficult, sometimes even dangerous and we need to be at our best to do it right. If you find yourself in this field you care about people. Remember you are people.

Wednesday, March 22, 2017

The Drug Holocaust part 2

The Drug Holocaust 2

A year ago I tried to make the argument that the attempts to control the supply of illegal intoxicants led primarily by the U.S. Government for the last 100 years has been incorrectly characterized as a "drug war" and should and perhaps someday will more accurately be characterized as an "addict holocaust." After all doesn't a war require that both sides fight to some extent? The war on drugs while sold as a war on suppliers has been a war on minorities and on the poor. While pictures of sad and unkempt dealers on the news followed by pictures of cellophane wrapped products sitting on a table with uniformed law enforcement standing at attention behind continue to be commonplace we never see videos of captured cops standing next to armed addicts being forced to read a manifesto denouncing their role in the war. It is the government that attacks and the poor who suffer, the poor and addicted who suffer most of all. Sometimes it seems like we are finally ready to try something else. There are programs popping up here and there attempting to replace the ineffective punitive models of the past and present that were effective enough to lead us to what might be the worst addiction epidemic ever. Everyone knows that heroin use has increased dramatically but few know so has alcohol use as has death from alcohol related diseases. Hard to blame that on pain pills. But even as these new encouraging models appear the dehumanizing effects of the old (and current) way are so powerful that progress may be impossible.

Consider this headline from 

Doctors Consider Ethics Of Costly Heart Surgery For People Addicted To Opioids

You may have to cut and paste the link to read the article and if that doesn't work there's a link to it on the Grey's Recovery Facebook page.

The article is not as terrible as the headline makes it sound. The ethical guidelines discussed are more about connecting a patient with drug treatment than leaving them to die because they continue to shoot heroin.

"Daly says that the guidelines are not some kind of moral test. Instead, they are meant to help doctors connect patients with a primary care physician or set them up with addiction counseling."

"This is not the patient proving to the medical team that they are worthy of a new valve, that they are worthy of the surgery," Daly says. "We wanted to make sure that that could not happen."

But it could happen. It does happen, it will continue to happen. For those of you working in the field ask your clients what their last emergency room visit was like. If you work in a traditional abstinence based program the treatment your clients receive will shock you. If you work in a methadone clinic you will be appalled. See you can't wage a war on a substance. A substance can't be your enemy. You can only wage a war on the people who use that substance and the enemy in any war must be less than human.

Why isn't the answer to the question "How many times should you replace the same heart valve?" as simple as saying "as many times as you can"? Why isn't a cheaper more effective solution to the problem even discussed? The cardiac problems of IV opiate users aren't caused by the drug they are caused by the "war" on the drug. Impure products and dirty needles cause the infections mentioned in the article. A cheap solution that would be more effective than any surgery would be to make needles free and easily accessible and to provide a safe supply of opiates.

The new administration has made it clear that not only do they plan to continue the failure of the drug Holocaust and plan to make matters worse by resuming the prosecution of cannabis users. I expect minimal resistance by those affected with the addiction disorder as the sit in the recovery group I run and argue for even harsher drug policy. The holocaust has not only devastated individuals, families, and communities across the globe, it has produced Hitler's willing executed and the end no longer appears to be in sight.

Wednesday, February 15, 2017

What about Moderation Management?


Popular wisdom tells us to be moderate in all things…except abstinence.



He came to see me on his own with minimal outside pressure. He very candidly shared his history with alcohol, cocaine, and heroin and his success at recovery. He was very high functioning for the population I serve. He worked almost full time and had never had a long stretch of unemployment. He worked low paying food service jobs but tended to keep them for years meaning he could show up on time for work and was productive. He paid his own rent and lived in a boarding house with “a bunch of Cambodian teenagers” who were in actuality all in their 20s. “They’re kind of like my kids.” An impressive attitude for a white man from his generation with little education who is barely scraping by. 

“Eight years of nothing and I was happy about it.” He had started drinking again after a manager he liked quit and his replacement an authoritarian type who often called him a “retard” increased his work stress. Most nights he drank a six pack after work but not every day but two blackouts in the last month had scared him and he had requested to meet with me individually feeling uncomfortable in groups. “It doesn’t look like things are too out of control” I told him. “The things that kept you sober for 8 years will likely help you now. What kind of support do you think you need to reach your abstinence goal? Assuming you want to be abstinent.” He paused. “Sometimes I have a beer in the summer on a hot day. Just the one. I sure would hate to give that up.” I asked him if his goal was to quit all drinking or did he want to try controlling his drinking. “Is that even possible?” he asked surprised. My answer  “I really have no idea.”

If you want to see a group of eyes roll walk into any 12 Step or SMART Recovery meeting and tell them you’re practicing Moderation Management. MM is considered pure nonsense by most people in the USA with any involvement in substance use disorders and the recovery from them. “Once an addict always an addict” the saying goes and it is accepted as fact from the highly educated doctors to the newest recovery coach. People struggling with substance use believe this because no one bothers to dispute it. Research doesn’t support this. Now I’m not going to site sources so you’re going to have to trust me on this. I looked very hard six years ago for information on how many people achieved moderation after being diagnosed and there isn’t much. What I could find was not reliable not using a random sample or control group and relying mostly on self-report. People who are problem drinkers and manage to moderate after treatment don’t come back to tell their counselors of their success. Why would they? They obviously don’t need our help and are like to be told what they have achieve is impossible. What little I could find on the subject put the success rate between 3% and 45%. In other words we have no idea. 

So it might work and it might not work so why was I who argues for research based treatment (at least in the professional setting) printing out drinking diaries and frantically reading the MM website after a session. MM is an unknown but abstinence is proven to work. Here’s a list of reasons I chose to make my first Moderation Management treatment plan as a professional.

1) Abstinence doesn’t always work: 
You quit and you stay quit until you learn to like it. What could be simpler than that? The problem is it’s not at all simple. The majority of people attempting an abstinence plan don’t make it a year, fewer still make it 3 years. If you look at the pattern of people who use while trying to abstain is it that different from people attempting to moderate? What’s worse is that each use can be seen as a failure you can almost see the weight of it on people who have attempted multiple treatments and find themselves back again. Being unable to moderate may not hold the same sense of shame and may increase the client’s motivation to change down the road. It might even work.

2) Many of the skills are the same:
People who try to moderate need the same skills as people. They need to learn to cope with their uncomfortable emotions, they need to overcome social anxiety, they need to address family issues, and they need to like themselves again. Above all they need to change their relationship with alcohol. Abstinence gives us a nice clear cut line moderation is a little blurry. We know a person is abstinent and when they are not but how do we know if they’re moderating? I suggest you look at something besides the tox screen to figure that out. Are they practicing the skills you teach? What about police interaction or ER visits? The world is rarely black and white and a moderation plan will require us to wade around in the grey and don’t forget, it might even work.

3) It doesn’t matter if it works:
If a client’s goal is to moderate I recommend the counselor begin with the assumption that moderation is possible. It could be the client will never be able to moderate even a little but think of the relationship you can build exploring that together. Supporting a client’s goal to moderate shows that you are respecting the client’s autonomy. The therapeutic relationship works best when it operates as two adults making choices together. The alternative is usually the counselor plays the role of a parent, the client a child and children rebel. Successful counseling is about connection and respecting a client’s choice to attempt moderation provides an opportunity to connect before the client is ready to attempt abstinence and that connection can be used to help the client with positive change whatever the level of success. Abstinence will always be there if moderation doesn’t work.

Stanton Peel has made the point that we have an “abstinence fetish” in the United States and it’s something we’ve successfully exported to much of the world. The problem is by focusing on abstinence we invariably become drawn into a moral judgement where using is a sin and the user a sinner. This judgement is poison to the therapeutic relationship and it closes our minds to new ideas. It may be that research will someday prove that moderation is impossible past some  point and on that day I will gladly retract all I have written today. However, if you find yourself drawn to treating people struggling with addiction you are entering  a field that is just coming  out of a dark age of mysticism and faith healing mascaraing as medicine and it will behoove you to keep an open mind. 

Monday, January 2, 2017

Heroin Has an Image Problem

Heroin has an image problem 

The most significant factor in the epidemic of opiates related overdose deaths has nothing to do how strong it is. Yes strong dope can kill you especially when it's laced with one of the many horror show opiates being manufactured overseas and shipped here but opiate overdose is survivable. Even if you don't have a Narcon kit (and if you don't shame on you) a person who overdosed can be kept alive a free from significant brain damage with simple rescue breathing. With Narcon you can have a person up and talking to you within minutes and there is more Narcon on the streets and people trained to administer it yet the bodies continue to pile up. The news feeds us more nonsense on how strong the new synthetic on the streets is and we all gasp and tut tut every now and then someone floats some asinine idea like forcing opiates addicted people into detox and possibly rehab. 

An idea which is almost certain to increase the number of overdose deaths yet people both in and out of the recovery field jump on board screaming "it's about time" completely ignoring the fact that there is no evidence this will work. I can't blame them really. It's an outcry of people who are watching friends, loved ones, and clients die who desperately want to regain control but it is an illusion of control. Forcing people into a 72 hour detox will undoubtedly raise the body count. Opiate tolerance drops dramatically in three days and a daily heroine user freed after three days despairing for some relief is at very high risk of taking too much. But again it's less about how much the individual takes and more about where the person takes it. Not wanting to disappoint family or risk another 3 day incarceration the individual will likely shoot up alone. Opiate overdose happens quietly and the person will likely appear to have fallen asleep. In the dark no one will notice that the person has stopped breathing, that their lips are turning blue, not until it's too late. Narcon doesn't do a thing when it's in your sock drawer and your son or daughter is dying in an alley. There is a solution. Have them shoot up in your home where you can see them. If that's too much for you we can build clinics for safe injection and even supply the heroin so we know it's safe. This isn't a liberal pipe dream it's been and is being done and the success of such places would drive a call for legalization and implementation of these programs if not for one thing. Heroin has an image problem.

Most other drugs have an iconic image attached to them that is in part or completely positive. Marijuana has the harmless hippy or the cool Rastafarian, cocaine has the driven business man, and booze which kills more people and has always killed more people than heroin and is an epidemic all it's own with deaths from alcohol related diseases rising over 30 percent from 2003 to 2014, booze we tell each other to drink a glass at dinner because "it's good for you." But heroin and people who use it must be stopped. Heroin is so bad we are telling our doctors to stop treating pain and forcing people into programs that increase their risk of death because just sharing a world where people use heroin is simply unacceptable. It probably has something to do with the needles, the needles creep people out, but it probably has more to do with the question of who we think does heroin. The answer is of course "other people" and as long as we continue to believe that no grave digger will go without work.