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 npr.com 

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.

http://www.npr.org/sections/health-shots/2017/03/21/520830183/doctors-consider-ethics-of-costly-heart-surgery-for-people-addicted-to-opioids?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20170321

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.

Don't Let the Boogieman Be Your Boss

The regulating bodies for the mental health/chemical dependency field place a huge burden on the professionals in the field and that is never more apparent than when a client dies. You will lose clients. If you stay in the field for any length of time some will die. Some will die of health problems, some from violence, some will take their own lives, some will fall victim to very bad luck, and some will die of unintentional overdose. When this happens one or all of the regulation bodies will descend upon your organization and comb through your treatment notes. They may ask you uncomfortable questions, they may seem like the inquisition. You may feel unduly blamed, you may be unduly blamed and more than likely you will to some degree blame yourself. One of the worst things that can come from this is the professionals involved leave the experience thinking they can never let this happen again.

The worst policy and professional decisions are the ones motivated by fear. They usually take one of two forms, discharging a client who is deemed "too risky" to keep in your program because gods forbid they die on your watch, or putting so many unrealistic requirements on the client that they disengage or are driven away from treatment. While the death of a client under your care will require that you prove you did everything possible to keep the client alive, the death of a client shortly after discharge only requires you tried some type of intervention before the discharge. Threatening the client with discharge if they don't do A, B, and C counts as an intervention, no matter how unrealistic A, B, and C may be counts as an intervention and the regulating bodies will check that you documented the threat and leave confident you did everything you could.

So we can sleep at nigh we tell ourselves the clients brought this on themselves, that the clients failed we did not fail them. We tell ourselves we did it for the client's own good. When that fails us we resort to the Nuremberg defense, we say we didn't have a choice because if we had not discharged, if we don't continue to discharge similar clients, they will take away our licenses. The problems with this are legion so I'll just mention a few.

1) "They" the regulating bodies are not after our licenses. Not only have I never seen a counselors license revoked for continuing to treat a client who is struggling, I have never even heard of it happening. The counselors I've heard who lost their licenses (I don't know any personally) lost them for gross incompetence or unethical behavior like entering into a sexual relationship with a client. The regulating bodies need people doing our jobs so they can keep their jobs. The boogieman isn't real.

2) Even if you are answerable to a regulating body that will revoke a counselor's license for a sound clinical decision, our job is to help people to recover from substance use problems, it is not to protect our license. Usually doing the first doesn't exclude the second but to do this job right may sometimes requires a little courage.

Fear based decisions are almost never good clinical decisions if you let the boogieman be your boss you will hurt the people who need you the most.

Sent from my iPad

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?

 

Why I Would Buy My Daughters Heroin

Why I Would Buy My Daughters Heroin

The views expressed here are my own and are not necessarily shared by any employer or educational institution I may be affiliated with...but who could blame them. This one goes too far.

I have two daughters ten years apart who are similar and different as night and day. I consider myself a pacifist, but I know I would use violence to save them if they were in danger. I might use violence to save them even if there were another non violent way. They are my daughters, and I would not bet that my ideals could withstand a threat to them. But what to do if they were ever a threat to themselves?

I work in a medication assisted recovery center, that's a nice way to say methadone clinic. I work as a chemical dependency counselor, I'm good at it, and though I don't count myself as a believer, this feels like a calling. In the relatively short time I've worked in this field I've worked with several individuals who were unfortunate enough to be born to parents who kicked them out on the street at a young age to fend for themselves. Usually they did this because the child way gay, lesbian, or transgender. I was and still am disgusted by this sort of thing. To abandon a child to what mercy they can find in the world is not only a violation of parenthood, but of our very humanity. While I understand the forces that drive a person to such a barbaric act I have no sympathy for it. I don't care what your parents did to you, what they taught you in school, or what your holy book tells you, you simply need to be better than that. To fall short is unacceptable. But until recently I had some sympathy for the parents of drug addicts who did the same thing. What do you do with a child who continues to use drugs, even after you have sent them to treatment? What do you do when they lie and steal from you to support their habit? What choice do you have if they refuse to go back to treatment after a relapse? Aren't I hurting them more in the long run if continue to enable their behavior?

I don't know the answer to the above questions, but I know one thing for certain. No person I have ever worked with has ever been better off for having been kicked out of their home. Drugs may be bad for your child, but the street is worse. Any child is vulnerable on the street, a child addicted to drugs is even more so. There is no shortage of people waiting to take advantage of such children. 

The reason parents abandon their children for drug use is they have been told that continuing to support their child will keep them stuck in addiction or make their addiction worse. The only alternative is to cut ties with the child, cut off all support, and hope the child gets desperate enough to change.

In reality what happens is that parents trade one option that might hurt the child for one that will almost definitely hurt them. A child has precious little to barter for the things they need. If the child is already tortured by shame for being unable stop using drugs, imagine how much worse it is for I child who has had to sell their body, not just for drugs, but for food and shelter, and sometimes they will offer themselves and get nothing in return. Drugs can hurt your child but that kind of trauma can leave scars that from which they may never fully recover. The other option is to prey on others, any child who has to survive on the streets will probably have to do both. I won't do that to my daughters. 

I would sooner buy my daughters heroin and help them inject it before I would kick them out of my home. It wouldn't be my first choice, but if it came down to it that's what I would do. Being a drug addict is not a fate worse than death. I may not be able to protect my children from everything. But I will protect them from everything I can.

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

https://ia801303.us.archive.org/22/items/DrugAddictsAreHumanBeingsTheStoryOfOurBillion-dollarDrugRacketHow_485/1938Williams-DrugAddictsAreHumanBeings.pdf

Watch Chasing Heroin

http://www.pbs.org/wgbh/frontline/film/chasing-heroin/

More reading on the Drug Holocaust 

https://www.thefix.com/content/repairing-damage-war-drugs-will-require-lot-more-legalization

https://www.thefix.com/kofi-annan-war-drugs-more-dangerous-drugs-themselves

http://chasingthescream.com

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.

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.

You Can't Test For It! Part II

You Can't Test For It: Recovery Cannot Be Detected in Urine (part 2 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.

He told me I was a "nice guy," that he could tell that by the way I said hello to him when we passed in the hall. This was the reason, he told me, that he agreed to come to the first session. He said he was a complicated case and while I was probably a fine counselor, he would prefer to return to someone he had worked with before. I disclosed that I knew something of his case and had in fact requested him for my caseload. I told him I'd only been a licensed counselor for a year but that made me more experienced than most of the others with openings on their caseloads. Also I was older than the others. I agreed to transfer him immediately if he still wanted and told him that he could still check in with me if he thought it would help. He seemed surprised, and his face momentarily twisted from his usual grimace, it softened. "Well that changes things" he replied "you got two weeks."

Remembering my own recovery I found the accountability of the random UDS helped me avoid some unnecessary experiments. I had endorsed that any alcohol use would put me at risk, but I wasn't convinced about weed. I didn't care much for weed, and only smoked it little more than one a year but knowing it would be detected helped me put it out of my mind. I didn't like it much anyway so why even bother. Each successful screening was a boost to my confidence, my feelings of self efficacy increased, I began to address other issues that were getting in my way. I imagine this is the case for many in early recovery, at least those who achieve abstinence early on. Even some  that struggle at first seem to find encouragement in the first "clean" urine. One client who struggled for months with abstinence is now almost giddy when required to do a random screen. Each clean urine is like a liquid gold star that month after month marks his progress. 

But what about clients who are not as successful with abstinence goals? We test all the clients with the assumption that some of them are not accurately reporting their use. When the sceenings indicate the clients is using, we the clinicians provide interventions that provide the client with a more realist view of their use which results in greater compliance with the treatment program and more successful outcomes. There are many problems with this theory.

1) Getting the clients to submit to a screening can quickly become a power struggle. Most of the more explosive behaviors from both clients and staff that I have witnessed came as a result of such power struggles.

2) The interventions are often punitive and shaming. Even when the treatment team goes out of their way to be nurturing and supportive the clients who has been reporting abstinence can be devistated when caught in a lie. Rather than improve the clients treatment this may make the client feel isolated.

3) The tests are sometimes wrong. False positives happen. This can put even a high functioning clients at risk.

4) Perhaps the most disturbing aspect of the screenings is the assumption of guilt. Clients that are doing well and clients who try to hide the fact that they are struggling report the same thing. Truth must be proved and proved repeatedly or it doesn't exist. The message we send to clients is that addicts are inherently unworthy of trust, and the clients more than anyone take this to heart. What do we get for this, we learn what we already know, that some clients continue to use while others do not.

I am not arguing that drug screenings have no place in the treatment of chemical dependency. I am challenging chemical dependency professionals to examine the way they use the screenings and to ask themselves how much they are truly being used for the benifit those who come to us for help. 

To be continued...

IT'S AN EPIDEMIC!!! (don't panic)

It's an Epidemic (don't panic)

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.

Epidemic! Such an exciting word! Brings up images from history and horror movies of bodies in the street and society on the brink of collapse. Fingers have been pointing for years to find who to blame. Do we blame the doctors for filling medicine cabinets across the country with oxi and perc 30s? Or do we blame the drug companies who made billions supplying pill mills with unlimited product which then ended up on the streets? Do we blame the war in Afganistan for modernization of heroin production and distribution that has flooded the streets with so much heroin that some days it's cheaper than booze? We could always go back to blaming the addicts, but that thankfully is getting harder and harder to do. Now that heroin has found its way from poor inner city neighborhoods to wealthy suburbs and rural white comminuities it's harder for politicians to slap "other" status on the dealers and consumers of heroin and write it off as "somebody else's problem." Here on the east coast it's hard to find someone who hasn't lost a close friend or family member to heroin overdose, and some have lost more than one. In truth it doesn't matter who we blame. Blame has been as useful to a person fighting this epidemic as an anchor is to a person tryinging to swim the English Channel. It's something best left behind so we can focus on the task at hand.

Yes things are bad, it might even be that we haven't seen the worst of it, but this epidemic is treatable. We already have what we need to handle the situation. We just need to stop panicking. 

The war on drugs has lasted about 100 years. 100 years ago people panicked and decided to turn a small number of functioning addicts into criminals. Panic has driven drug policy since then to increasingly draconian measures on the mistaken belief that the problem is heroin itself or what ever drug du jour we are afraid of. Panic has driven us to wage was on cartels, arrest heads of state, and fill our jails so full that we now imprision more people than any other country in the world. Panic has driven us to treat an epidemic like an invading force rather than a disease and by doing so we've waged war against our fellow citizens. It's time to stop panicking. These panicked attempts to rid the world of heroin have brought us to where we are now. More people addicted to heroin, more people overdosing on heroin, more people dying from heroin than ever before.

We need to stop and take a breath. There are two medications with a proven track record in treating opiate addiction, Methadone and to a lesser extent Suboxone. We need to educate addiction professionals on the effectiveness of these treatments and stop acting as if they are as bad as heroin. We need to stop using prisons as the treatment option of choice for all addicts. We need to open our minds to any treatment modality that helps the addicted person return to the human experience rather than judge them for not recovering the way we want them to. We need to stop trying to punish the afflicted back to health.

For a history of the drug war and the damage its fear based policies have done to the world and to the treatment of addiction I recommend Chasing the Scream: The First and Last Days of the War on Drugs, by Johann Hari.

The author thanks you for taking the time to read Grey's Recovery. Feel free to give feedback on the ideas presented. Feedback on spelling, and grammar is not requested. Those who can't resist commenting on the author's spelling and grammar may be rewarded with a picture of the author's middle finger.