Health and psychosocial risks associated with COVID-19 fall disproportionately on historically marginalized populations. I recently reviewed published studies on preliminary findings related to COVID-19 among people experiencing or recovering from substance use disorders (SUD).  Major findings from this review are summarized below.

*The COVID-19 pandemic is associated with an increase in substance use, SUD prevalence, and drug-related deaths in the U.S. (Dubey et al., 2020; Wardell et al., 2020)

*Self-medication of emotional distress related to COVID-19 and its socioeconomic effects (e.g., social isolation, loss of employment, and threat of housing instability) are linked to new populations of people experiencing alcohol and other drug problems, exacerbation of the severity of those with pre-COVID SUDs, and destabilizing recovery for some individuals with a past history of SUD (Dubey et al., 2020; Enns et al., 2020).

*Adults with a SUD, when compared to those without a SUD, have a greater likelihood of co-occurring health challenges (cardiovascular disease, type 2 diabetes, cancer, obesity, and diseases of the lung, kidney, and liver) (Wang et al., 2020; Melamed, et al., 2020; Mallet et al., 2020).

*Adults with a lifetime or recent SUD are at increased risk for COVID-19 infection, COVID-19 hospitalization, and COVID-19 death compared to people without a SUD history (Wang et al., 2020; Wei et al., 2020; Jemberie et al., 2020).

*COVID-19 infection, hospitalization, and death risks are particularly enhanced among adult African Americans and for adults with recent opioid use disorder (Wang et al., 2020; Schimmel et al., 2020).

*COVID-19 risks for people with a history of SUD are likely linked to three factors: co-occurring health challenges, specific drug effects, and socioeconomic adversity— including disparities in access to health and social services (Wang et al., 2020).

*While some cautions have been suggested regarding the interactions between medications used in the treatment of opioid addiction and medications used in the treatment of COVID-19 (Mansuri et al., 2020), Wang and colleagues (2020) found no differences in COVID-19 risk based on prescription or nonprescription of methadone, buprenorphine, or naltrexone.

All of the above findings are preliminary and subject to change through future investigations. At present we know nothing about the interactions of SUD and COVID-19 among adolescents and other special demographic and clinical populations, and we do not yet have studies on the specific effects of COVID-19 on people in different stages of recovery compared to people with active SUD or people without a SUD history.

Advocacy Implications

1. Persons entering addiction treatment and recovery support services should be routinely screened and tested for COVID-19 and educated on their increased risk of COVID-19 infection and prevention strategies.
2. Advocacy efforts should begin now to assure that people with a SUD history, as a high COVID-19 risk group, are included among priority populations for a COVID-19 vaccination when it becomes available.
3. The increased COVID-19 risk experienced by people of color (and particularly older African Americans with an opioid use disorder) reinforces the need for advocacy efforts to address both the social ecology of COVID-19 and SUDs as well as racial disparities in access to healthcare.
4. Studies need to be conducted on the effects of SUD recovery status on COVID-19 infection, hospitalization, and death risk.
5. Studies are needed that illuminate the effects of COVID-10 on people involved in addiction treatment and recovery mutual aid organizations as well as the larger effects on these organizations.

There is much to learn on the relationship between COVID-19 and alcohol and other drug problems. We must act on available probationary data and do all we can to protect people impacted by these problems and their families and communities.

Defining people with a SUD history as an at-risk population warranting early access to a COVID-19 vaccination when available will encounter resistance as to whether the SUD population is “morally worthy” of being given priority over people without a history of SUD. That will again provide opportunities for public and professional education about addiction, addiction treatment, and addiction recovery.

References

Dubey, M. J., Ghosh, R., Chatterjee, S., Biswas, P, Chaterjee, S. et al., (2020). COVID-19 and addiction. Journal of Diabetes and Metabolic Syndrome, 14(5), 817-823).

Enns, A., Pinto, A., Venugopal, J., Grywacheski, V., Gheorghe, M., et al. (2020). Substance use and related harms in context of COVID-19: A conceptual model. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice, 40(11-12). Doi: 10.24095/hpcdp.40.11/12.03.

Jemberie, W. B., Williams, J. S., Eriksson, M., Grönlund, A-S., Ng, N. et al, (2020). Substance use disorders and COVID-19: Multi-faceted problems which require multi-pronged solutions. Frontiers in Psychiatry, 11, 714.

Mansuri, Z., Shah, B., Trivedi, C., Beg, U., et al, (2020). Opioid use disorder treatment and potential interactions with novel COVID-19 medications. The Primary Care Companion for CNS Disorders, 22(4). https://doi.org/10.4088/PCC.20com02703

Mallet, J., Dubertret, C., & Le Strat, Y. (2020). Addictions in the COVID-19 era: Current evidence, future perspectives, a comprehensive review. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 110070. Online ahead of print. Doi: 10.1016/j.pnpbp.2020.110070.

Melamed, O.C., Hauck, T.S., Buckly, L, Selby, P, & Mulsant, B. H. (2020). COVID-19 and persons with substance use disorders: Inequities and mitigation strategies. Substance Abuse, 41(3), 286-291.

Schimmel, J., & Manini, A. F. (2020). Opioid use disorder and COVID-19: Biological plausibility foir worsened outcomes. Substance Use Misuse, 55(11), 1900-1901.

Wang, Q. Q., Kaelber, D. C., Xu, R., & Volkow, N. D. (2020). COVID-19 risk and outcomes in patients with substance use disorders: Analyses from electronic health records in the United States. Molecular Psychiatry, https://doi.org/10.1038/s41380=020-00880-7.

Wardell, J. D., Kempe, T., Rapinda, K. K., Single, A., Bilevicus, E. et al., (2020). Drinking to cope during COVID-19 pandemic: The role of external and internal factors in coping motive pathways to alcohol use, solitary drinking, and alcohol problems. Alcoholism: Clinical & Experimental Research, online ahead of print. Doi: 10.1111/acer.14425.

Wei, Y., & Shah, R. (2020). Substance use disorder in the COVID-19 pandemic: A systematic review of vulnerabilities and complications. Pharmaceuticals, 13(7), 155. Doi: 10.3390/ph13070155.

The problems men and women of the U.S. military experience upon re-entry to civilian life receive considerable research and media attention. Far less common is information on their resilience to and recovery from such challenges. It is in that context that a landmark study has just been published on the prevalence of recovery from alcohol use disorders among U.S. veterans.

Stefanovics and colleagues surveyed more than 1,200 veterans who had experienced an alcohol use disorder during their lifetimes as part of the National Health and Resilience in Veterans Study. This representative sample of U.S. veterans plotted current drinking patterns across three categories: abstinence, subthreshold (not meeting alcohol use disorder diagnostic criteria), or hazardous (currently meeting criteria for an alcohol use disorder). This research marks one of the most rigorous non-clinical studies of the trajectory of alcohol problems among U.S. veterans. Major study findings include the following:

1. More than three-quarters of U.S. veterans surveyed reporting a lifetime alcohol use disorder (AUD) no longer meeting diagnostic criteria for AUD. Twenty-eight percent were abstinent and 48.2 percent reported a drinking pattern below the AUD diagnostic threshold. This represents an AUD remission rate higher than that found in the general population.

2. Nearly a quarter (23.8%) of U.S. veterans with a lifetime AUD reported current drinking at a hazardous level.

3. AUD remission via abstinence was associated with increased age, less education, greater likelihood of having past concurrent PTSD, drug use disorder (including smoking), greater health problems, less socially engaged, and greater religious orientation.

4. AUD remission via subthreshold drinking was associated with higher income, lower concurrence of other drug and tobacco dependence, fewer health challenges, and lower measures of social engagement.

This study has several important implications. First and foremost, findings offer considerable hope for veterans and their families affected by alcohol use disorders. Remission for AUDs is not just possible for veterans; it is the most likely outcome for AUDs.

Second, subthreshold drinking among U.S. veterans with past AUDs is a viable pathway to problem resolution that may be either sustained over time or migrate towards abstinence with increased age. This point suggests the potential for clinical strategies that support choice in treatment goals and the viability of both decelerating drinking and abstinence as pathways to AUD remission. Subthreshold drinking can also be followed by clinical deterioration and sustained AUD-related problems. This finding suggests the need for continued in-treatment and post-treatment monitoring, support, and, when indicated, re-evaluation of treatment goals and methods.

Rather than argue that subthreshold drinking in AUD is impossible, the addictions field would be well served by clearer delineations of those clinical populations that are most and least likely to achieve moderated resolution of AUD and subclinical alcohol problems, e.g., factors such as genetic liability, problem severity, medical/psychiatric co-morbidity, personal/family/community recovery capital, etc.

Hopefully, the Stefanovics’ study marks a shift in veterans research away from a near-singular preoccupation with pathology toward a focus on the prevalence and processes of veteran resilience and recovery.

References:

Stefanovics, E. A., Gavriel-Fried, B., Potenza, M. N., & Pietrzak, R. H. (2020). Current drinking patterns in US veterans with a lifetime history of alcohol use disorder: Results from the National Health and Resilience in Veterans Study. The American Journal of Drug and Alcohol Abuse, September. DOI: 10.1080/00952990.2020.1803893

For recent studies on moderated resolution of AUDs, see the following:

Tucker, J. A., Cheong, J., James, T., Jung, S., & Chandler, S. D. (2020) Pre-resolution drinking problem severity profiles associated with stable moderation outcomes of natural recovery attempts. Alcoholism: Clinical and Experimental Research, 44(3), 738-748. DOI:10.1111/acer.14287.

Witkiewitz, K., Heather, N., Falk, D. E., Litten, R. Z., Hasin, D. S., et al. (2020). World Health Organization risk drinking level reductions are associated with improved functioning and are sustained among patients with mild, moderate and severe alcohol dependence in clinical trials in the United States and United Kingdom. Addiction, 115(9), 1668-1680. DOI:10.1111/add.15011.

Witkiewitz, K., Pearson, M. R., Hallgren, K. A., Maisto, S. A., Roos, C. R., Kirouac, M.,…Heather, N. (2017). Who achieves low risk drinking during alcohol treatment? An analysis of patients in three alcohol clinical trials. Addiction, 112, 2112–2121. http://dx.doi.org/10.1111/add .13870

Witkiewitz, K., & Tucker, J. A. (2019). Abstinence not required: Expanding the definition of recovery from alcohol use disorder. Alcoholism Clinical and Experimental Research, 44(1), 36-40. DOI: 10.1111/acer.14235

For more than two decades, advocates with lived experience of addiction recovery have tried to shift the conceptual center of the addictions field from a focus on addiction-related pathology and deficit-focused models of assessment and treatment to a focus on resilience and recovery. A less heralded effort has been to extend the intrapersonal focus on recovery to a broader appreciation of the role of family, community, and culture in long-term addiction recovery. Both agendas have consumed much of my attention, and I recently discovered two papers that may also be of interest to my readers. Below are my takeaways from these two important articles.

In 2012, David Harper and Ewen Speed published a paper in Studies in Social Justice entitled “Uncovering Recovery: The Resistible Rise of Recovery and Resilience.” They make several points worthy of reflection, including the following:

*Behavioral health systems focus almost exclusively on changing how distressed service consumers think, feel, and act. The target of service interventions is the individual.

*The intrapersonal focus of behavioral health systems (i.e., the medicalization of emotional distress) obscures structural causes of distress and structural solutions to behavioral health problems.

*Interventions that encourage embrace of a “recovery identity” as a solution to psychological distress inadvertently enable the invisibility of social, economic, and political conditions that contribute to such distress.

*”…it is only when the collective, structural experiences of inequality and injustice are explicitly linked to process of emotional distress that recovery will be possible.”

*The alternative to this either/or focus is to integrate the personal and the political by combining both personal strategies for problem resolution as well as seeking “institutional remedies for institutional harms.” This will require a simultaneous focus on personal and social change, with the latter reversing historical marginalization based on class, ethnicity, gender, and sexuality.

A 2016 essay by Price-Robertson and colleagues in Advances in Mental Health make many of the same points as Harper and Speed. In describing prevailing models of addiction recovery, they suggest that “the onus of recovery is placed on the individual, while the familial, social, material, educational, economic, and political contexts of mental ill-health are largely obscured.” They contend that individualistic philosophies of recovery miss the complex contexts in which addictive disorders both arise and are resolved. The authors conclude that recovery is best understood and promoted when understood within the contexts of cultural systems of oppression and privilege that constitute many of the social determinants of illness and health.

As concerns related to social justice increase in the United States, it seems an ideal time for us to extend this exploration to the cultural contexts of addiction and addiction recovery. In our current focus on the expansion of peer-based recovery support services, we must not forget the activist and advocacy agendas out of which the modern recovery advocacy movement was birthed.

References

Harper, D., & Speed, E. (2012). Uncovering recovery: The resistible rise of recovery and resilience. Studies in Social Justice, 6(1), 9-25.

Price-Robertson, R., Obradovic, A., & Morgan, B. (2016). Relational recovery: Beyond individualism in the recovery approach. Advances in Mental Health, September, 108-120.

Never in U.S. history have there existed more choices of support for the resolution of alcohol and other drug (AOD) problems. Today, recovery support groups span secular, spiritual, and religious orientations, with meetings also organized by gender, age, sexual orientation, language preference, profession, and co-occurring conditions, to name just a few. Recent scientific studies and reviews offer a window into these expanding choices and their relative effectiveness.

Individuals who have resolved alcohol and other drug (AOD) problems do so with and without participation in recovery mutual aid groups. Results from the National Recovery Study (Kelly, et al., 2017) found that, of U.S. adults who resolved an AOD problem, 45% did so with the support of a mutual aid organization; 28% did so with the help of professional treatment. Participation in recovery mutual aid and professional treatment is associated with more severe patterns and consequences of substance use.

An updated Cochrane review of the 27 most methodologically rigorous studies of Alcoholics Anonymous and related Twelve-Step Facilitation (TSF) treatment studies concluded:  “AA/TSF interventions produce similar benefits to other treatments on all drinking-related outcomes except for continuous abstinence and remission, where AA/TSF is superior.”

White and colleagues (2020), in their review of 158 NA-related studies, concluded: “NA participation is associated with decreased drug use, increased rates of abstinence, improved global (physical, emotional, spiritual) health, enhanced social functioning, increased involvement with mainstream community institutions, and decreased health care costs—effects amplified by intensity and duration of NA participation.”

Kelly and colleagues (2014) examined the comparative responses to Alcoholics Anonymous and Narcotics Anonymous among 279 young adults undergoing treatment for a non-alcohol drug use disorder. The majority of mutual support meetings attended post-treatment were AA rather than NA meetings (due in part to less availability of NA meetings). There were no significant differences in participation rates or positive outcomes achieved between drug dependent patients attending AA or NA. The research team concluded: “contrary to expectations, young adults who identify cannabis, opiates, or stimulants as their preferred substance may, in general, do as well in AA as NA.”

Zemore and colleagues (2018) compared the comparative effectiveness of participation in Women for Sobriety, LifeRing, SMART Recovery, and Twelve-Step groups among individuals with an alcohol use disorder (AUD). “Results tentatively suggest that WFS, LifeRing, and SMART are as effective as 12-step groups for those with AUDs, and that this population has the best odds of success when committing to lifetime total abstinence.”

Tsutsumi and colleagues (2018) compared group retention and transitions in group affiliation among 647 individuals participation in 12-Step, Women for Sobriety, LifeRing, or SMART Recovery groups. Key findings include:

1) changing groups among participants of 12-Step alternatives is common,

2) the most common pattern of change was from a 12-Step alternative to a 12-Step group,

3) those transitioning to a 12-Step group continued to report disliking some aspects of the 12-Step program,

4) changing groups is often a search for greater support rather than a different philosophy of recovery, and

5) changing groups was most common among younger participants and people of color,

The above studies are reflective of a larger body of scientific literature documenting the viability of alternative pathways of long-term addiction recovery. The expansion of pathway choices is worthy of celebration by everyone concerned about the resolution of AOD problems. Collectively, these studies affirm the role recovery mutual aid participation in long-term addiction recovery and inform the growing varieties of recovery experience.

References

Kelly, J. F., Abry, A., Ferri, M., & Humphreys, K. (2020). Alcoholics Anonymous and 12-Step facilitation treatments for alcohol use disorder: A distillation of a 2020 Cochrane Review for clinicians and policy makers. Alcohol and Alcoholism (Oxford, Oxfordshire), June.

Kelly, J. F., Bergman, B., Hoeppner, B., Vilsaint, C., & White, W. L. (2017) Prevalence, pathways, and predictors of recovery from drug and alcohol problems in the United States Population:  Implications for practice, research, and policy. Drug and Alcohol Dependence, 181, 162-169.

Kelly, J. F., Greene, M. C., & Bergman, B. C. (2014). Do drug-dependent patients attending Alcoholics Anonymous rather than Narcotics Anonymous do as well?  A prospective, lagged, matching analysis. Alcohol and Alcoholism, 49(6), 645-653.

Tsutsumi, S., Timko, C., & Zemore, S. E. (2020). Ambivalent attendees: Transitions in group affiliation among those who choose a 12-step alternative for addiction. Addictive Behaviors, 102, 106143. https://doi.org/10.1016/j.addbeh.2019.106143.

White, W., Galanter, M., Humphreys, K., & Kelly, J. (2020) “We do recover”: Scientific Studies on Narcotics Anonymous. Posted at www.williamwhitepapers.com

Readers who have followed this blog series are aware of my sustained interest in the ecology of recovery, particularly the role of recovery space/landscapes within local communities, and the stages of long-term personal and family recovery. A just-published article by Lena Theodoropoulou in the International Journal of Drug Policy offers some intriguing insights into these topics. Below are notes on what I have drawn from the key ideas in her article.

Addiction recovery is an experience of emotional and social connections that prompts a radical renegotiation of the person-drug relationship.

Addiction recovery is far more than an intrapersonal process of change. Recovery is a series of interacting processes that unfold over time in physical, social, and psychological spaces that protectively incubate or suffocate recovery efforts.

These processes most often unfold in fits and spurts over time. Episodes of recovery testing (sampling) often precede the achievement of recovery stability.

Addiction (desire for the drug) and recovery (desire for change) co-exist, and their relative balance dictates both addiction and recovery experiences. Emotional and social connections constitute the push and pull forces of addiction and recovery–the “tipping points” that dictate the final chapters of one’s personal story.

Addiction recurrence is a temporary or sustained breach in the emotional and social connections that initiate and sustain recovery. Addiction recurrence is “the outcome of the interrupted relationship between a subject and a recovery space.”

Brief treatment episodes offer fragile connections capable of inciting hope for recovery. The question is whether brief treatment episodes result in durable connections that can sustain passage from recovery initiation through the later stages of recovery.

Brief episodes of biopsychosocial stabilization without sustained recovery support can leave one “trapped in repetition and broken connections.” (See HERE for my take on this.)

“All encounters between the service and the user matter” as they “constitute components of an ongoing turning point.” Evaluating treatment effectiveness based on a single brief course of service fails to measure the effects of service relationships and activities on the course of long-term recovery.

“By positioning the focus on the connections that become possible within the recovery space, healing becomes a socio-political rather than an individual process, ‘accomplished less through personal therapeutics and processing of painful memories than through small-scale, tentative restoration of trust and support’.”

Recovery must be viewed within the context of time: “There is using time, harm reduction time, recovery time, and accordingly relapse time, all of them part of the recovery assemblage.” The process of moving through these time zones is not always linear.

Recovery must be viewed in the context of space—a transition from using space to recovery space—a deterritorialisation of active addiction, the avoidance of people, places and things that anchor one to the addiction experience.

Unraveling the chronicity of addiction is a sociopolitical problem, not a medical one.

I hope we hear a great deal more from Lena Theodoropoulou. We can learn a lot from her observations on treatment services in the UK and Greece.

Reference

Theodoropoulou, L. (2020). Connections built and broke: The ontologies of relapse. International Journal of Drug Policy, https://doi.org/10.1016/j.drugpo.2020,102739.

Since the late 1990s, I have advocated a radical redesign of addiction treatment—one that extends the prevailing acute care model of addiction treatment to one of sustained recovery management (RM) nested within larger recovery oriented systems of care (ROSC). (See HERE for a basic primer on RM & ROSC.). RM moves beyond providing brief episodes of biopsychosocial stabilization to assuring sustained recovery support across six stages of long-term recovery: precovery, recovery initiation, recovery maintenance, enhanced quality of personal and family life in long-term recovery, and efforts to break intergenerational cycles of addiction and related problems. RM models differ across many dimensions, including approaches to treatment attraction, access, assessment, engagement, service components, service relationship, involvement of family and community, and the nature and duration of post-treatment recovery support services.

I am often ask the extent to which addiction treatment in the U.S. reflects this RM and ROSC orientation. Answering this question with current data across all RM and ROSC elements is beyond the scope of a short blog, but a just-published study does inform the present status of one critical RM element.

Traditional acute care models of addiction treatment is based on an expert relational model of service delivery. A professional expert screens, assesses, and diagnoses a substance use disorder and any co-occurring conditions present in the patient/client. The expert then formulates and implements a treatment plan and monitors the progress of treatment using measures defined by the expert. The expert also makes the ultimate decision when and under what conditions the service relationship is terminated—all in an ever-briefer time due to current funding constraints. In short, the individual being treated is considered a recipient of the services and expertise of the professional in a relationship not unlike having a broken arm treated by a physician within a hospital emergency room.

RM relies on a partnership relational model in which the person seeking recovery guides their own recovery process with professionals, family members, and peers in recovery serving as recovery consultants who offer guidance as needed and requested. The client role in co-creating and directing their own recovery processes involves an  active role in problem definition and problem resolution with acknowledgement of many pathways and styles of long-term personal and family recovery that differ considerably across clinical populations and cultural contexts. This philosophy of choice is central to the RM approach to treatment and counseling. In mainstream medicine, this personalized model of service delivery is widely advocated as “patient-centered care.”

Park and colleagues have just published an analysis of 2017 data on the degree to which U.S. addiction treatment providers practice patient-centered care. Based on a national sample of 730 addiction treatment programs, only 23% of programs involved clients within clinical decision-making processes. Clinics treating a majority of clients with alcohol or opioid use disorders were most likely to offer a standard, minimally personalized treatment protocol and least likely to involve clients in clinical decision-making.

In a recent blog, Bill Stauffer and I offered a renewed call for the inclusion of people seeking and in recovery into the decision-making venues that affect their lives. Such ideal representation surely includes the active involvement in clinical decision-making of patients undergoing addiction treatment. Based on the Park study, the addiction treatment field has a long way to go in achieving the involvement of its most important constituents. It is long past time for that to change.

Reference

Park, S., Grogan, C. M., Mosley, J. E., Humphreys, K., Pollack, H. A., & Friedmann, P. (2020). Correlates of patient-centered care practices at U.S. Substance use disorder clinics. Psychiatric Services, 71(1), January.

White, W. L. (2008b). Recovery management and recovery-oriented systems of care:  Scientific rationale and promising practices. Pittsburgh, PA:  Northeast Addiction Technology Transfer Center, Chicago, IL: Great Lakes Addiction Technology Transfer Center, Philadelphia, PA: Philadelphia Department of Behavioral Health & Mental Retardation Services.

In 2005, my colleagues Christy Scott, Michael Dennis, Michael Boyle, and I co-authored an article entitled It’s Time to Stop Kicking People out of Addiction Treatment. At that time, 18% (or 288,000) of people admitted to specialized addiction treatment in the U.S. were “administratively discharged” (“kicked out”) prior to treatment completion. Such expulsions most often resulted from alcohol or other drug use, violation of program rules (e.g., missed appointments, refusal to follow staff directives, “fraternization” with other patients, etc.), or failure to pay service fees. We drew the following conclusions in the 2005 review.

1. Administratively discharging clients from addiction treatment for AOD use is illogical and unprecedented in the health care system.
2. Administratively discharging clients from treatment for AOD use reflects a fundamental misunderstanding of the role of volition in addiction and recovery.
3. Administrative discharge casts the role of the treatment agency as one of persecutor, and misjudges the meaning and consequences of administrative discharge (AD) to the client.
4. Administratively discharging clients from treatment for rule violations is often the endgame in a process of escalating negative countertransference.
5. Administratively discharging clients often involves behaviors that are unrelated to, or have only a weak connection to, the prospects or processes of recovery or safety issues within the treatment milieu.
6. Administratively discharging clients from treatment projects casts the blame for treatment failure on the client and prevents treatment programs from evaluating and refining clinical practices.
7. Administratively discharging clients from a publicly funded addiction treatment program for failure to pay service fees constitutes clinical abandonment and is a breach of professional ethical principles and (potentially) legal and regulatory standards.

We then outlined 12 policy alternatives to administrative discharge and 6 clinical strategies to reduce such premature treatment discharges.

The 2004 paper contended that expelling a client from addiction treatment for AOD use–a process that often involves thrusting the client back into drug-saturated social environments without provision for alternate care–makes as little sense as suspending adolescents from high school as a punishment for truancy. The strategy, we suggested, should not be to destroy the last connecting tissue between the individual and pro-recovery social networks, but to further disengage the person from the culture of addiction and to work through the physiological, emotional, behavioral, and characterological obstacles to recovery initiation and recovery maintenance.

The 2004 paper was followed by blogs in 2014 and 2015 (See HERE and HERE) that updated AD data and added to these early suggestions. New data at that time suggested that AD decisions inordinately target African Americans and persons of low socioeconomic standing, as well as those persons in greatest need of treatment—those with highest problem severity, complexity, and chronicity, and the lowest recovery capital.

The present blog draws on three additional studies, a study of premature treatment termination in an inpatient addiction treatment unit, a study of discharges for “behavioral transgressions” among patients in methadone treatment, and a paper addressing AD for patient “fraternization.”

A just-published (2020) study by Syan and colleagues explored the characteristics of patients who failed to complete residential addiction treatment. Those failing to complete treatment via AD or leaving against medical advice were distinguished by high severity of illicit drug use and high psychiatric severity (particularly PTSD). This study confirmed anew that those most likely to experience a premature termination of treatment are precisely those in greatest need of such treatment. Syan and colleagues called for assertive efforts to identify and offer specialized support for those at highest risk of premature treatment termination.

A recent (2019) study by David Potik and colleagues explored the prevalence of psychopathy among methadone maintenance patients exhibiting continued drug use and other “behavioral transgressions” (e.g., verbal/physical aggression, selling drugs to other patients, failure to return empty take home medicine bottles, etc.) during the course of their treatment. Both drug use and other behavioral transgressions during treatment were associated with high psychopathy scores.

This study confirmed two important findings. First, as in the Syan study, continued drug use and “behavioral transgressions” in addiction treatment are often indicators of high addiction severity and co-occurring psychiatric disorders (including personality disorders). Second, evidence suggests it is possible to address these issues within the context of treatment over an extended course of treatment without patient drop out or administrative discharge from treatment.

In light of this study, administratively discharging an MMT patient for drug use and behavioral transgressions may involve punishing the patient for exhibiting symptoms of the very disorders for which treatment is indicated. For other chronic health care problems, symptom manifestation during treatment confirms or disconfirms the working diagnosis and provides feedback on the degree of effectiveness of the treatment methods. In marked contrast, symptom manifestation in the addictions field too often results in blaming and expelling the patient. It is contradictory to argue that addiction (with or without co-occurring psychiatric illness) is a primary health care problem involving loss of volitional control over drug use and its consequences while continuing to treat its primary symptoms as bad behavior warranting termination of the service relationship.

A second study by Hafford-Letchfield and Nelson concludes that the addictions treatment field pathologizes and suppresses sexual desire of patients in ways that go far beyond promoting physical/sexual/emotional safety within the treatment milieu and avoiding romantic/sexual acting out as an escape from the treatment experience. Such pathologization is most evident in bans on patient “fraternization” and kicking patients out of treatment for becoming romantically involved during their time in treatment.

Patients entering addiction treatment bring all manner of complex sexual histories—histories that may include sexual victimization or predation, sexual dysfunctions, and self-destructive patterns related to past sexual relationships. It is inevitable that these issues rise within milieu-oriented treatment and require clinical attention. Failing to address such issues can lead to concerns related to patient safety, patients using romantic/sexual attraction as a diversion from treatment, or patients leaving treatment prematurely to pursue their relationship. Such concerns are clinical issues to be addressed within the counseling process. But is the expression of sexual desire or mutually (and voluntarily) acting out that desire grounds alone for discharging patients from addiction treatment? Would treatment of any other medical condition be suddenly and prematurely terminated due to sexual involvement between two patients who met within the treatment milieu? Are there no clinical management strategies that would prove more effective in promoting long-term recovery outcomes?  Administrative discharges are often characterized as “therapeutic discharge,” but there is no scientific evidence that kicking a person out of addiction treatment has any positive therapeutic effects.

These new studies point out several shared elements. One, it is the patients who are most in need of treatment and prolonged recovery support that are most likely to be subjected to disciplinary expulsion from addiction treatment. Two, the behaviors most likely to be the justification or expulsion are symptoms of the very problems for which treatment is indicated. In short, too many patients entering addition treatment are arbitrarily discharged for confirming their diagnoses. Third, race, ethnicity, and class interact with problem severity and complexity to predict those patients at greatest risk of expulsion from treatment. Fourth, there are clinical alternatives to management of these behaviors that can enhance long-term recovery outcomes.

We could do much better with these patients and we must.

References

Hafford-Letchfield, T., & Nelson, A. (2008). Closeness equals pathology: Working with issues of sexual desire and intimacy within the substance misuse field. Diversity in Health and Social Care, 5, 215-24.

Potik, D., Abramsohn, Y., Schreiber, S., Adelson, M., & Peles, E. (2019). Drug abuse and behavioral transgressions during methadone maintenance treatment (MMT) are related to high psychopathy levels. Substance Use & Misuse, https://doiorg/10.1080/10826084.2019.1685546.

Syan, S. K., Minhas, M., Oshri, A, Costello, J., et al., (2020) Predictors of premature treatment termination in a large residential addiction medicine program. Journal of Substance Abuse Treatment, 117, 108077.

White, W., Scott, C., Dennis, M. & Boyle, M. (2005) It’s time to stop kicking people out of addiction treatment.  Counselor, 6(2), 12-25.

Introduction (Bill White)

 The international recovery advocacy (and peer recovery support) movement is marked by the proliferation of grassroots recovery community organizations that are distinct from traditional addiction treatment organizations and recovery mutual aid societies. As these new organizations emerge across geographical and cultural contexts, one of the critical needs is the creation of a networking process through which such organizations can share their experiences, forge a common vision  and shared goals, and exchange new technologies of recovery advocacy and recovery support.

The following brief report from David Best and colleagues offers a quite promising update on such an effort in the UK. I have closely followed the progress of the UK recovery advocacy movement since my visits there in the 2000s. I find these current efforts quite inspiring and suggest their emulation by other countries.

Connecting the connectors: Creating space to develop evidence-based innovation in Lived Experience Recovery Organisations

By David Best, Ed Day, Stuart Green, Dave Higham, Michaela Jones, Tim Leighton, Tim Sampey, Jardine Simpson, Dot Smith, & Stephen Youdell

The UK now possesses a rich and diverse range of Lived Experience Recovery Organisations (LEROs) whose models and methods are driven by mutual support, community engagement and enhancement and a commitment to individual, group and local community wellbeing. This is often driven by a person of lived experience (POLE) who is often championing a gap between specialist treatment on the one hand and the mutual aid fellowships on the other, in order to meet local needs.

Yet the problem for LEROs is one of fragmentation. There are no professional or membership bodies in the UK or in most other countries, no governance or inspection frameworks and not even any annual events or forums that would allow for the sharing and exchange of good practice of innovation. Partly for these reasons, LEROs remain marginalised in the funding and planning of addiction services and systems, and this marginalisation helps to perpetuate our ‘orphan’ status, and are often perceived by treatment organisations and commissioners as bedevilled by in-fighting and lacking in consistent standards.

Recovery Connectors

Early in 2020, in response to the pandemic and the changing face of recovery support services in the UK as elsewhere in the world, a group of recovery leaders and advocates came together with four primary objectives:

1: To identify and champion innovation in LEROs and provide a supporting evidence base

2: To provide connections and support for recovery leadership

3: To champion good practice in LEROs and to develop standards

4: To act as a voice for LEROs and a hub of evidence and knowledge

The catalyst for convening the group was around the emergence of some incredible innovative and flexible practices around both online transitions following lockdown (in response to the COVID crisis) and some continuing and evolving community work to support clients, their families and the broader communities deal with the hardships that the pandemic had generated.

So what does the group do?

The initial aim for the group was to test shared ideas and shared vision but above all to generate a radius of trust where participants felt confident that they would be heard and respected, and where they could be open and honest without concerns about confidentiality and integrity. Much of the first few discussions (which are held weekly by Zoom) were around what we mean by recovery and recovery-oriented approaches leading to agreement that the appropriate language of inclusion was to focus on Lived Experience Recovery Organisations, where Lived Experience referred to marginalisation and adversity rather than necessitating substance use or misuse. The aim here was to promote inclusivity and compassion.

The initial group membership was opportunistic, based on shared working experiences, yet a number of participants did not know each other, and one of the key successes in the early stages has been that there have been no drop-outs and no additions – in other words, the group has been able to develop its own identity and norms.

With that shared vision and understanding in place, the group is now moving to a process of external engagement and will work towards using these solid foundations to build validity in its communication and thoughts with the wider treatment and recovery landscape.

We are now starting a weekly peer supervision component where the final 30 minutes of the session are to be dedicated to addressing key challenges faced by one of the recovery group leaders. The first one of these addressed the question of maintaining personal recovery values while competing in a professional arena that is often inimical to those values. This process has created strong bonds of commitment and empathy within the group.

While we are still very much in our infancy, there is a clear need for members to explore how to deal with complex issues of leadership and management in organisations that have strong ethical and inclusive principles and values. We are still learning and continue to strive to find the most empathic, humane and empowering ways to deal with people with lived experience.

Defining a LERO: principles, values and standards

Our initial definition of a LERO is: “an organisation of lived experience committed to recovery with a focus on autonomy” while we are deliberately being broad and inclusive in our consideration of lived experience as “Lived experience is defined as personal knowledge about the world gained through direct, first-hand involvement in everyday events rather than through representations constructed by other people“.

From this starting point our aim is to promote principles and values of:

• Human rights
• Strengths-based approaches
• Active engagement with lived communities
• Promoting positive human connection

Through these principles our aim is to promote and champion the emerging evidence base for recovery-oriented practice and to ensure that this is effectively and consistently implemented and embedded against a set of standards for LEROs to sign up to.  Performance against these standards will be rigorously assessed by those with lived experience.

During the COVID crisis in the UK, there is a general recognition that LEROs and other community organisations have generally been adaptable and effective in responding to threatening and rapidly changing environments. Our aim is to champion this kind of adaptability based on the needs of people in recovery, their families and (crucially) the wider communities. It is often difficult to quantify some of these benefits to service commissioners (whose models are typically designed to address deficits) but they are critical in understanding why LEROs should not be considered as treatment providers nor judged against treatment standards. Our aim is not to be an ‘add on’ to treatment but an equally valued, evidenced and significant component of a balanced recovery-oriented system of care with different (but just as rigorous) standards and values.

Since its inception in the late 1990s, a central goal of the new recovery advocacy movement has been assuring the representation of recovering individuals and families in the decision-making venues that affect their lives. As this movement matured, the complexities of achieving such representation became increasingly apparent. Dynamics within and beyond communities of recovery can threaten authentic recovery representation. Below are six critical dimensions of recovery representation and proposed benchmarks for each.

Authenticity of Representation is the assurance that those representing the recovery experience within decision-making venues are individuals and families with lived experience of recovery who are free from undue conflicts of interest. The problem that sometimes arises is that of double-agentry—persons who present themselves as representing the recovery community who, with or without conscious intent, represent instead personal, ideological, institutional, or financial interests. People with personal knowledge of the recovery process and the historical challenges faced by people seeking and in recovery free of such conflicted interests are the best suited for recovery advocacy leadership.

Guidelines: 1) Members of recovery communities are provided a voice in the selection of persons who represent their experiences and needs. 2) Those representing the recovery experience at public and policy levels possess rich experiential knowledge of personal and/or family recovery from addiction. 3) Persons representing the experiences and needs of people seeking and in recovery are free from ideological, political, or financial conflicts of interest that could unduly influence their advocacy efforts.

Depth of Representation assures a sufficient density of recovery representation within any decision-making group. The challenge is to avoid recovery tokenism, e.g., a single person asked to represent the broad range of recovery experiences and recovery support needs. Too many organizations exploit people in recovery to burnish their organizational image or superficially comply with an external recovery representation requirement, while affording little opportunity to affect policy decisions. Depth of representation also assures that people in recovery are at policy decision-making tables and not just involved in an advisory capacity, e.g., representation on governing boards as well as advisory committees.

Guidelines: 1) Recovery community organizations (RCOs) maintain authentic recovery representation greater than 50% at membership, board, and staff levels. 2) RCO leaders are drawn from individuals and family members in recovery or allies vetted by communities of recovery. 3) The RCO is committed to leadership development of its members. 4) Recovery representation in local organizational decision-making is commensurate with the degree to which recovery is central to the mission of an organization or project. The greater the focus on recovery, the greater the desired level of recovery representation.

Diversity of Representation assures the inclusion of people representing the growing varieties of recovery experiences and the diverse cultural contexts and community spaces in which recovery flourishes or flounders.

Guidelines: 1) The pool of available recovery representatives reflects secular, spiritual, and religious pathways of recovery as well as natural recovery and peer- and/or professionally-assisted recovery (including medication-assisted recovery). 2) Recovery representatives are knowledgeable about diverse communities of recovery and speak publicly not as individuals or representatives of one path of recovery, but on behalf of all people in recovery. (The fact that no one is fully qualified to do that helps us maintain a sense of humility, open-mindedness, and inclusiveness.) 3) Recovery representatives embody a spirit of anonymity—the suppression of self-centeredness—embracing and celebrating the wonderful varieties of recovery experience rather than competing for personal attention or pathway superiority. Falling short of these aspirational values is far too easy in the rarified air of public attention.

Stability of and Support for Recovery Representatives assures that people representing the recovery experience at the public level have sufficient recovery time and stability to offer a positive face and voice of recovery without threat to their continued recovery or their physical and psychological safety.

Guidelines: 1) Recovery representatives exemplify a recovery custodian orientation (rather than a celebrity orientation). 2) The custodian role properly places the focus on recovery messages and off the person or persons serving as messengers. 3) Recovery representatives exemplify servant leadership, affirming their role in serving the community. 4) Recovery representatives are not placed in roles involving physical or psychological risk without supervision and clear safety protocol.

Scope of Representation assures that people in recovery have a voice in shaping the full continuum of care related to alcohol- and other drug-related problems. Recovery representation is critical to effective AOD systems design, program implementation, service delivery, systems performance evaluation, and ongoing systems refinement.

Guidelines: 1) Recovery representation is included in policy and programming decisions related to primary prevention, harm reduction, early intervention, clinical treatment, community-based recovery support services, and the larger arena of alcohol and drug policy decisions. 2) Recovery representation is included in decision-making bodies charged with addressing common recovery challenges and resource needs, e.g., co-occurring health conditions, educational opportunity, employment opportunity, etc.

Public Enfranchisement assures that people in recovery are free from arbitrary restrictions on voting, holding public office, or exercising rights afforded other citizens.

Guidelines: 1) Local recovery community organizations exist and advocate for the full enfranchisement of people in recovery, including encouragement to vote and serve in public service roles. 2) People in recovery disenfranchised due to past addiction-related crimes have their full citizenship rights restored following release from prison or completion of probation or parole. 3) There are no state or local laws or regulations that otherwise suppress the voting, e.g., statutes requiring all fines be paid before voting rights are restored. 4) The addiction treatment and recovery support workforce fully reflects the diversity of the community, is provided a living wage, and is free of administrative burdens that interfere with service provision. 5) The treatment and recovery support system addresses barriers to employment and volunteer participation of people with lived experience of recovery.

Closing Reflection

Supporting and strengthening long-term recovery across multiple pathways of recovery and diverse cultural contexts must remain a central focus of our efforts. This is “the commons” of our movement for which we need deep, equitable, and inclusive representation in matters that effect our lives.

Nihil de nobis, sine nobis is Latin for NOTHING ABOUT US WITHOUT US and has been a rallying cry for democracy and disenfranchised groups for over 500 years. It means that no policy should be decided without the full and direct participation of those affected by that policy. We must ensure that our voices are included in all systems addressing alcohol- and other drug-related problems.