Crash and Burn!

Yes. It’s true. Healthcare is going to crash and burn. The fee for service, administrative heavy, waste laden model is literally going to eat itself.

It is likely that new models will emerge out of the post fee for service-apocalypse. Models emphasizing continuing care, chronic disease management and long term engagement; among other things.

“Recovery” organizations need to be poised and positioned to be part of these new systems.

BUT IT IS NOT GONNA HAPPEN if we are hell bent on this “recovering people only” / self segregation “addicts are different” messaging.

FAVOR Greenville & youturn

At FAVOR Greenville and youturn we reject the idea that people with SUD are somehow different from the rest of humanity.

For example, this idea that we must be sent off and then return “fixed” is insulting. The concept of “addictive thinking” is insulting.

The idea that I need to introduce myself with a label of addict, alcoholic, or even “person in long term recovery” is demeaning. Of course, long term recovery is better than addict or alcoholic but how about no label.

Consider These Points

1. SUD is a healthcare issue. ADDICTION IS NOT WHO I AM. ITS SOMETHING I HAVE DEALT WITH AND OVERCAME. I need to follow a healthy lifestyle on an ongoing basis to ensure I stay safe. But quite frankly, zingers, energy drinks, convenience store pizza and 80 hour work weeks are much more likely to take me out than opioid use disorder. It’s not lurking around the corner ready to grab me. Oreo cookies are lurking around the corner …. but not opioids.
   
2. Like any other healthcare issue, there are different manifestations or stages of the disorder. Mild, moderate, severe are the official diagnostic stages (I would say its way more nuanced than that).
   
   Currently, we only deal with the most severe end of the “severe group” and we act as if this represents a comprehensive response to SUD. Addressing less that 10% of the problem is not comprehensive. Truly, you don’t even understand the problem if only work with 1/10 of the people impacted.
   
3. SUD is chronic, in the sense that phases of remission and phases of recurrence are common. Most people eventuality resolve these ups and downs on their own. #facts. We would do well as a society to provide education, information and (in some cases) unconditional support/health coaching along the way.
   
   I believe people would resolve these ups and downs earlier and progression could be slowed.
   
4. The family is deeply impacted. Family members frequently experience health issues as the direct result of dealing with a loved one’s SUD. FAMILY MEMBERS OF A PERSON WITH SEVERE SUD ARE 5x’s MORE LIKELY TO BE HOSPITALIZED than the general public.
   
   In certain cases the family is worn out (dealing with the issue for such a long period of time), put in dangerous situations and/or directly victimized. In those cases, detachment makes sense.
   
   However, automatically telling the family to detach, practice tough love, wait until they hit bottom is inhumane, mean and simply inappropriate and ineffective. Education, support and skill building for the family should be routine part of the process

New Solutions

Interestingly, much of the above applies to many other disorders/healthcare issues. As the health system comes apart at the seams (which it will) I believe the “new solutions”, that emerge on the other side, will address “other chronic disorders” in a more holistic way.

Let’s hope SUD is included in that new model.

But make no mistake, Substance Use Disorder is not going to be included if we hold tight to this “we are recovery you are not” messaging. Why do we keep telling the world we are screwed up in this super special way so they can send us off to the tuberculosis unit and cleanse us?

But you do not speak for me or the organizations I work with. I do not blindly endorse any agenda just because it’s labeled “recovery advocacy”.

We should also be talking “healthcare advocacy”….. It’s all unraveling right now.

This is the Time and Place

Be smart and think critically and define your position.

There will be no better opportunity to flip the script.

Note: If you are cool with the way things are currently handled then this post clearly doesn’t apply to you. If the outcomes are acceptable as far as you are concerned …. Well then, keep arranging the chairs on the deck of the Titanic.

Everything is fine. The ship unsinkable.

The post Healthcare is Going to Crash and Burn! appeared first on The Recovery Cartel.

The Recovery Pathway

In the interest of clarifying my opinion on “most effective” treatment and/or recovery pathway or approach. (Not that anyone ask for my opinion)…

Note: THINK “approach” or “pathway” or modality. NOT particular provider.

There is no such thing as a superior pathway or treatment “modality”….

Trying to rank program effectiveness is like trying to make a list of the Cleveland Browns best seasons…I guess 1987 was better than the rest but they all still sucked.

It’s like ranking the world’s most compassionate 3rd world dictators. Or the best Boy Bands in music history…. it’s all relative. 💯💯💯

It’s an exercise in identifying less shitty; more so than identifying most effective.

Facts…as things currently stand:

• Any program/pathway is better than doing nothing at all (well…maybe not all of them). You will not be struck sober while hanging at the trap house. Do something.

• All programs systematically and pridefully ignore and reject 90% of people in need because those people “don’t want it”…. “won’t follow the program”….”haven’t hit bottom” etc…. there is nothing earth shattering about working only with the “willing” few….

• This is also the case for most Recovery “innovations” you see being promoted. Every “breakthrough app” or transformative “tele-coaching” program is founded on the assumption of a motivated and compliant patient. Even though motivated and compliant patients comprise less than 10% of the disorder. It’s not innovation. Innovation requires paradigm shifts and much more risk.

Nothing ever changes (in terms of improved outcomes) until time, money, energy and effort is brought to bear on solving the “unwillingness” problem.

No More Hitting Bottom

Breaking the old hit bottom paradigm will not be easy:

• Time- to develop and test engagement protocols and staffing issues. 
• Money- substantial money to start up, execute and scale engagement and retention programs. 
• Energy-bringing in non-treatment/and non-recovery problem solvers. New blood and new ideas. Turn away from traditional gatekeepers for ideas. Nothing non-traditional comes out of the traditional… logic. Use logic. 
• Effort-find people who will execute on this like a start up business. Incentivize the effort. This is an 80 hour a week problem. Obsession is required to turn this thing around.

Again I ask the question – Is Addiction a Healthcare Issue?

The post Is Addiction a Healthcare Issue? appeared first on The Recovery Cartel.

Recovery Slogans

Terms like “rock bottom” and “willingness” could be viewed as nothing more than slogans batted around at various self-help groups. It that were the case there would be little need for alarm.

Recovery slogans are common sayings put forth by people who volunteer their time to help others.

These folks have no ethical obligation to look beyond their own personal experience.

However, when professionals, programs and an entire “healthcare”/treatment industry base their system on these principles; we have a major problem on our hands.

10% Engagement

We have the type of problem that leads to only 10% engagement of people in need, 73,000 per year dead of overdose and 88,000 per year dead as a direct result of chronic alcohol misuse.

Standard operating principles such as administrative discharge, labels of treatment resistant, labels of the family as enablers, and termination from therapy groups for displaying symptoms of the disease (ie..relapse), clearly indicate that the industry is beholden to these misguided assumptions.

Rock bottom and willingness are myths and fortunately more people than ever are challenging these ideas.

I guess that is what happens when 73,000 people die of overdose every year.

No Research

We start questioning concepts that have never before been challenged. There is no research that supports the legitimacy of hitting bottom as a helpful construct, at least in terms of outcomes.

I’m not sure there is a more important outcome than staying alive and we know that rock bottom directly contributes to increased deaths. Especially in this age of fentanyl and carfentanyl.

In addition, the necessity of willingness as a pre-requisite for successful treatment has been completely deconstructed by motivational interviewing.

Interestingly, despite the widespread adoption of motivational interviewing in the addiction field, providers do not actually practice motivational principles.

Cookie-Cutter Treatment

For example, kicking someone out of a therapy group for using or out of a residential program for “non-compliance” is 100% antithetical to motivational principles.

Cookie cutter after-care plans demanding 12-step attendance and involvement in intensive outpatient programs do not reflect individualized client-center programming.

In addition, encouraging the family to “get out of the way” and wait for bottom remains the default setting where family support is concerned.

Baffling

This baffling reality begs at least three questions:

• How did these practices become the industry standard?

• Why is this (clearly inappropriate outlook) still the prevailing attitude?

• What other options are available for the individual and/or family looking for support?

How Did We Get Here?

Understanding the origin of “rock bottom” and “willingness”.

It is nearly impossible to trace the origin of rock bottom, or any slogan for that matter.

As previously mentioned, this concept was never meant to guide the healthcare (treatment) policies of any entire nation. It was a slogan that served a purpose within the confines of a self-help group.

We can, however, make some universally agreed upon assumptions that will help us understand how we got here.

Alcoholics Anonymous

Everyone agrees that the recovery slogan “rock bottom” or “hit bottom” (as it relates to addiction) originated in the rooms of Alcoholics Anonymous. The Alcoholics Anonymous 12 & 12 (12 Steps and 12 Traditions) published in 1953 stated:

1. “Why all this insistence that every A.A. must hit bottom first? The answer is that few people will sincerely try to practice the AA program unless they have hit bottom.” 12&12, p. 24
   Willingness, as applied to addiction recovery, was present in the AA literature right from the very start as well:
2. “If you have decided you want what we have and are willing to go to any length to get it – then you are ready to take certain steps” BB, p. 58.

I would like to point out that the 12 & 12 clearly states – “few people will sincerely try to practice the AA PROGRAM unless they have hit bottom”.

In addition, the Big Book said – “if you want what we have to offer (i.e. the AA program) and are willing ….”

Not The Only Way

The 12 & 12 doesn’t say that few people will sincerely try to get recovery unless they hit bottom, or few people will sincerely attempt treatment unless they hit bottom, or few people will sincerely try to get healthier unless they hit bottom.

The focus is on what is required for AA and AA is NOT the only way to recover.

We do not have to debate that do we?

If you object comment below and I will get you the quotes from Bill Wilson himself on multiple pathways to recovery. I will also get you the research on pathways to recovery.

The Big Book does NOT say if you want to get some help you have to be willing.

It does NOT say if you want to see a professional addiction specialist or receive medicine you have to be willing to go to any length.

Again, the Big Book was talking ONLY about the program of Alcoholics Anonymous.

These concepts, in their original intent, were 100% applicable to AA only!

Professionalization

The problem was, and still is, the professionalization of the 12 steps and the co-opting of a self-help program via the treatment industry.

Essentially, a violation of the 8th tradition: “Alcoholics Anonymous should remain forever nonprofessional, but our service centers may employ special workers”.

This is the great tragedy of the recovery revolution.

Perhaps then, the real question is:

“How did the treatment industry get away with professionalizing the 12-steps and other AA principles”?

We do not have the bandwidth in this blog post to provide a comprehensive review of the treatment industry in America.

There are many people who are much more qualified than I am to provide such a historical exposition.

For reference and verification of what I talk about below please see the following:

• William White Slaying the Dragon;

• Miller and Carol Rethinking Substance Abuse:
• What the Science Shows and What We Should Do About It;

• and Jerry Spicer The Minnesota Model.

Furthermore, most of this my opinion and my theory. It is logical and makes sense but at the end of the day it is one person’s take on how we got here.

It Works If You Work It?

What follows is a very crude summary of “how we got here”:

1) Alcoholics Anonymous works (if you work it). We have no idea about the recovery rates pre-AA and we have no idea about the recovery rates outside of AA post launch and we see much debate surrounding the recovery rates associated with AA right now.

However it is clear, that AA provided the first tangible program of hope and recovery for many hopeless alcoholics.

It was the first “program” that grew and it was certainly the first program with a “book or manual”.

Published April 10, 1939

The Big Book was published April 10, 1939 and is one of the most influential and important books of the 20th century. It could be argued that it is one of the most important books of all time.

2) The Stigma-Part 1: People with substance use disorder, regardless of the substance, are very difficult to deal with and in the mid 20th century the stigma was much stronger than it is today.

As time went by, Alcoholics Anonymous represented the only substantial group of people willing to work with those suffering with alcohol use disorder (and other addictions).

As the need for more formal “treatment” emerged Alcoholics Anonymous members were the ONLY ONES WILLING TO WORK WITH THIS STIGMATIZED GROUP.

Therefore, it was natural that the principles of AA were brought along for the ride.

3) The Minnesota Model: In 1948-1950 Hazleden Foundation.

The Minnesota Model

Pioneer House and Wilmer State Hospital in Minnesota develop a professionalized, multi-disciplinary team approach to “treating” addiction. It is aptly named, the Minnesota Model.

The model is founded on AA principles combined with medical staff and eventually professional counseling. However, it is naïve to think that AA principles did not guide the process.

Imagine a “non-recovering” doctor arriving to work in a Minnesota Model program.

The patients were probably a challenging group and the AA model probably held things together.

AA members were fully conditioned to believe that their way was the only way. For non-recovering staff it was either assimilate or move on. This was not really an interdisciplinary model as much as it was an AA model with some medical and psychological consultation. But more on that in a moment.

Notably: on an anecdotal level these programs work.

For the first time ever there is hope and a method to the madness of dealing with an active alcohol use disorder.

28 Days

The Minnesota Model is a great way to kick-start the treatment industry.

However, it is problematic to underestimate the primacy of Alcoholics Anonymous in the model and it become mores difficult to reconcile this reality in relation to a healthcare issue.

This model eventually becomes the 28-day inpatient rehab program reimbursed by health insurance and expands rapidly across the nation.

It becomes the “default setting” for addiction treatment.

The National Center for Biotech Information (NCBI) put it this way: “For many years, some in the treatment field considered the Minnesota model the only “workable” method of treatment for substance use disorders”.

I would argue that most professionals in the treatment field continue to think this way and that the AA/12-step principles are still the cornerstone of most programs.

4) The Stigma Part 2: Since the “general public” views addiction as a moral failing there is little interest or pressure for the delivery of addiction treatment services to be studied and evaluated. “Who cares what happens to those wretched addicts and alcoholics; they did it to themselves”.

The Minnesota Model carried on unencumbered by oversight or research, relatively speaking.

Unproven Practices

For decades these unproven practices plows deeper and deeper into the collective conscious of the industry. Before long even the non-recovering staff are converted.

5) Professionalization fails to produce diversity in treatment approaches:

The 1970’s and 1980’s saw the movement away from hiring recovering people toward the employment of licensed professionals.

This is not necessarily a positive step in and of itself, however, one the logical results should have been a de-emphasis on the one-size fits all model. If you have less AA members or NA members being employed you would naturally assume a retreat from some of the ingrained practices.

This did NOT happen. Mainly, because the administration and leaders in the industry had come up in the Minnesota Model and remained committed to that approach.

6) Hazleden starts selling books and positions itself as the nation’s expert:

William White

According to William White:

“In 1954, Hazelden entered the world of publishing when it bought the rights to Twenty-Four Hours a Day, a recovery meditation book that would go on to sell more than seven million copies. Hazelden went on to publish materials ranging from scholarly texts such as Not-God: A History of Alcoholics Anonymous by Ernest Kurtz, to popular self-help books such as Melanie Beatties Codependent No More. Hazelden publishing grew from this single title to a division that today distributes more than three and one half million books, pamphlets, videos, and recovery celebration items per year”.

Naturally, the emphasis from one of the founders of the Minnesota Model will be on Minnesota Model type programs. Abstinence-based and 12-step oriented.

7) The 12-step foundation is useful for after care and a synergistic relationship has been formed with AA world service: The 12-steps hang in nearly every treatment center in America.

The Backbone

They form the backbone of the daily schedule for many inpatient programs and they form the core of most after-care plans.

These treatment centers receive reimbursement for professional services.

How is this NOT violation of the 8th tradition and why has AA world service never pushed back? Simple, rehabs fill the rooms of AA. It’s a mutually beneficial relationship.

I also assume there is literally nothing AA can do about this practice.

How could they stop it even if they wanted to?

Treatment Culture

This all adds up to a treatment culture that primarily reflects the values, traditions, mores and norms of Alcoholics Anonymous.

This is clearly inappropriate and does not reflect a practice consistent with evidenced based healthcare.

Then again, there are many things about other aspects of healthcare that is problematic, this is just addiction treatment’s most obvious issue.

Since the values and norms of the “rooms” also carry the day in the treatment space; slogans like “hitting bottom” and “willingness” drive everyday policies and procedures.

This is how we got here.

The post The Myths Of Rock Bottom and Willingness—Part 1: appeared first on The Recovery Cartel.