A Brief Guide to Evidence-Based Self-Care for Recovery from Addiction

Intended to supplement medical and professional care for substance use disorders, this guide offers a brief, straightforward distillation of the latest information and research on addictions recovery self-care.

Organized in a series of three handouts, the guide offers compassionate, supportive assistance to individuals with substance use issues who are already receiving medical and professional care. Professionals and concerned others may want to offer it as a link or printed packet. Passages are stated simply, but link to authoritative sources for corroboration and further exploration.

Self-help does not equal treatment. Substance use disorders are complex health conditions requiring medical and professional care.

The handouts were originally written by the author as personal guidance after extensive reviews of the research on addiction, hence the use of the pronoun “you,” but they are for informational purposes only and are not a substitute for individualized medical or professional advice. Individuals are urged to consult with qualified health care professionals for personalized medical and professional advice.

Original segments of this post were first published by The Fix here, here and here.  This post was last updated 7/18/17.

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A Brief Guide to Evidence-Based Self-Care for Recovery from Addiction

Handout 1

“Love, evidence & respect.”
– Maia Szalavitz’s answer via Twitter to the question, “What fights addiction?”

1.  Who you are does not cause addiction.

2. Nothing bad you have done, nor good you failed to do, caused addiction.

3. You do not deserve addiction, nor do you deserve not to have addiction. It’s just an unfortunate condition having no moral value one way or the other.

4. You are not the problem. Addiction is the problem. Let’s see what we can do to solve or improve this for your unique, individual situation. And we’ll do this with compassion. As Maia Szalavitz writes, “To return our brains to normal then, we need more love, not more pain.”

We need more love, not more pain

“…we need more love, not more pain.” – Maia Szalavitz

5. Get medical care for the medical condition of addiction. Forced abstinence can result in dangerous withdrawal symptoms, decreased tolerance and increased craving, an intolerable emotional and mental state, and risk of a dangerous, potentially deadly, return to use.

6. Symptoms of addiction can appear as thoughts, words, and actions perceived as irrational, anti-social, and immoral. Addiction is not, in and of itself, a thought problem, a moral problem, a spiritual problem, a mental illness, or a behavior problem. Addiction is not a personality type. It’s a brain condition, contentiously defined, uncertainly located, and uncertainly targeted for treatment, but detectable in the brain at the minutest level.

7. Unfortunately, at this time, we know of nothing you can specifically do on your own to immediately and directly treat, cure, or reverse malfunctions in brain structures associated with addiction. Until we can identify exactly which brain structures and circuits to treat with medications, stimulation or probes, and what beneficially modifies them, for now, other than directly through the medications we know of, we’ll have to use indirect means.

8. However, what can directly administer care to brain structures is protecting them from problematic substances. That’s why obtaining medical care and professional help to assist with abstinence or harm reduction is critical. Over time, helpful changes may occur in the brain in the absence of overwhelming or damaging substances.

9. Focus maximum effort on becoming aware, very specifically, of what helps you stay abstinent and what does not. If you’re practicing harm reduction, discover what helps you use less, less often, or use less problematic substances. Acute awareness takes painstaking attention, but the logic is simple. If you can become aware of inner and outer conditions that precede use, you may be able to do something about them. If you don’t know, you can’t.

10. Needing or wanting to abstain, and firmly deciding and being resolved to quit, unfortunately – as you know from former heroically determined efforts to quit followed by heartbreaking returns to use, all explained by the brain science of addiction – aren’t sufficient to achieve abstinence.

11. You must learn what each substance did for you or meant to you, how you related to it, how it worked for you, and how it eased or enhanced your experience or your life. Discovering this, and finding alternate ways to get your needs met, is difficult but worthy, essential work. Again, the logic is simple. If you can learn what substances did for you, and find alternate ways to get most of that done – regrettably, possibly never again to the extent substances did – you’re more likely to be able to do without them.

12. Repeat: Go to a doctor. Although medical treatments for directly treating the brain for most substance use disorders are currently unknown (however, methadone and buprenorphine directly affect brain areas involved in opioid use disorder), several medications can be helpful with creating the stability necessary for intensive self-learning. In addition to being assessed for medication-assisted treatment (MAT), ask to be screened for mental illnesses and physical illnesses that might be causing conscious and unconscious stress and distress, the primary precursors to a return to use. (If you don’t have health insurance and can’t afford to self-pay, try to find local organizations that will help you get health insurance or help you with costs for medical care.)

13. Abstain from self-judgment. Become aware of a learned pattern of self-harshness, now nearly automatic. It feeds shame, a primary source of inner distress. Self-discernment is a compassionate process of discovering one’s strengths. In contrast, self-judgment cruelly weakens, reduces and demoralizes. As Maia Szalavitz urges, treat yourself for addiction by loving yourself, getting evidence-based care, and respecting the gravity of this illness and the heroic effort required to handle it.

Turn towards reality and truth

Turn towards reality and truth, not away from them.

Handout 2

“Addictive disorders are a major public health concern, associated with high relapse rates, significant disability and substantial mortality. Unfortunately, current interventions are only modestly effective. Preclinical studies as well as human neuroimaging studies have provided strong evidence that the observable behaviours that characterize the addiction phenotype, such as compulsive drug consumption, impaired self-control, and behavioural inflexibility, reflect underlying dysregulation and malfunction in specific neural circuits.”
– Spagnolo and Goldman, 2017

“[W]hat if the negative thinking patterns, feelings, and behaviors that keep them stuck have powerful, unconscious advantages serving vital, even life-preserving purposes?”
David Burns, 2017

“People may not have caused all of their own problems, but they have to solve them anyway.”
Marsha Linehan , 2012

1. Expect to feel shock, grief, rage and other strong emotions over the before-and-after states addiction brings to your life. Practice self-kindness and self-compassion and find others who can support you when you experience these.

2. Seek stability. Become aware of how you define stability, what individually helps you achieve and maintain stability (emotionally, mentally, physically, occupationally, relationally, situationally), and try to make these happen for yourself. Suppression, repression, avoidance and obfuscation can backfire and destabilize. Turn towards reality and truth, not away from them. (If you have concerns about whether or not what you’re thinking is real or true, see #5 below.)

3. Get counseling. At this time, it is not known if counseling directly treats the brain in an efficient, targeted way for addiction. (For opioid use disorder, for example, multiple studies fail to prove that counseling with medication increases abstinence rates over medication alone). But counseling can help people maintain abstinence, often by assisting with awareness. The main precursors to a return to use are stress, distress, and environmental cues. Environmental cues include being around substances, in situations, and with people associated with use. Make sure the counselor offers an evidence-based therapeutic approach. The Surgeon General’s report, Facing Addiction in America, lists cognitive behavior therapy, CBT, as the top evidence-based counseling approach for assisting people with addiction maintain abstinence or harm reduction. Dialectical behavior therapy, DBT, also included in the report, is increasingly proving effective as well.

4. The more you can 1) learn to become aware of, and regulate, your inner experience of feelings, thoughts and physical sensations – optimally for you individually, not by someone else’s methods or criteria, 2) discover what needs you personally have and what uniquely and healthily meets them, and 3) help yourself avoid environmental cues or manage exposure to them, the more likely you are to be stable and, therefore, the less likely you will be to use.

5. Run even your simplest ideas by others before taking action. Your thinking may not be as clear as it will be in the future.Consulting others will help protect you from error.

6. Seek contact with people who help you clarify your feeling and thinking, who are non-judgmental, and with whom you feel safe and supported. Become aware of how you feel about yourself when you’re talking with anyone and everyone. If you don’t feel good, however you might define “good,” that’s stressful and potentially destabilizing. Find a way to have limited or no contact with those with whom you feel unsafe and unsupported, at least in the short-term.

7. Listen for fact vs. opinion when people talk with you about addiction. Are they sharing the latest science  and research reports on addiction or are they sharing opinions based on beliefs, personal experiences or outdated information? If they’re sharing an opinion, do they acknowledge it as such and explain how they derived it? Or are they stating opinions as facts? Practice caution and care with whom and with what you let into your vulnerable mind and heart.

8. Practice engaging, disengaging, and shifting your attention. Discover and focus your attention on what is preferable to you, rather than attempting to force your mind to think what you believe will please or protect, or letting it grind in patterns that have simply become habitual rather than helpful. This power over your attention can give you enormous power to enjoy your life, to assist yourself with enjoying the company of others, and to increase others’ pleasure in your company. Impossible as it sounds, exercising your power to focus your attention may exercise brain functions atrophied from substance use. Many people with substance use disorders have experienced trauma and find using the mind for meditation distressing. Meditation, therefore, may not be advised. Marsha Linehan, inventor of dialectical behavior therapy, DBT, recommends what she terms “mindfulness” instead. A simple, DBT-based mindfulness practice involves using your attention to observe what’s going on within and without and to describe those to yourself. (Here’s a brief YouTube video of Marsha Linehan explaining mindfulness, part of a series of videos on the core principles of DBT.) Some people find the Headspace app helpful.

9. Become aware of what helps you feel better. Whether it’s just for a few moments or for longer, become aware of what uniquely helps you via your senses – sight, hearing, smell, touch, taste – to ease, reassure, and comfort yourself. Google the term “self-soothing” and you’ll find lots of ideas to try.

10. Believe that you, yourself, can do this. In addictions recovery circles, you may hear about admitting powerlessness, surrendering, relinquishing control, and the dangers of “self-will.” The opposite is true. The more self-aware you are and the more self-power you see yourself as having – the more “self-efficacy” you possess – the more likely you are to stay abstinent. You be you.

11. Practice “love love”  not “tough love” with yourself and others. “Tough love” is a euphemism for smiling while wielding a 2″ x 4″ of hostile methods to exert psychological control. Practice self-kindness and other-kindness. And distance yourself from those who profess to be treating you with the “tough love” they think you “need” or “deserve.” In fact, with the whole concept of “tough love,” practice hostility. But briefly. Then compassionately self-regulate and return your attention to recovery-enhancing stability.

Seek out supportive others

Seek out supportive others.

Handout 3

“…but seven years is long enough and all of us
deserve a visit now and then
to the house where we were born
before everything got written so far wrong”
– Peter Meinke, “Liquid Paper”

“The most natural way for human beings to calm themselves when they are upset is by clinging to another person.”
– Bessel van Der Kolk, M.D., The Body Keeps the Score

“Do not attempt to take away a person’s main means of trying to cope with pain and suffering until you have another effective coping strategy in place.”
Alan Marlatt

“I don’t believe in getting ‘in the moment’ and then exercising will-power. I believe in avoiding ‘the moment.’ I believe in being absolutely clear with myself about why I am having a second drink, and why I am not; why I am going to a party, and why I am not. I believe that the battle is lost at Happy Hour, not at the hotel. I am not a ‘good man.’  But I am prepared to be an honorable one.”
Ta-Nehesi Coates

“It’s my life. Don’t you forget.”
Talk, Talk

1. Attach to yourself. Discover the curl within you of your truest self, “before everything got written so far wrong.” Gently begin to view yourself as someone with whom the vulnerable essence of you can feel safe. Many people with addiction have experienced abuse and neglect from caregivers  and have attachment challenges. What shouldn’t have happened did, and what should have happened didn’t. They may feel undeserving and unqualified to care for themselves. They may believe they can’t be entrusted with themselves and fear the piece-of-shit messages they’ve heard all their lives might be true. Given what many people have been through, having these beliefs is sadly understandable. Still. Kindly and protectively begin to identify yourself more by who you are, and less and less by what you’ve done or what has happened to you.

2. Take care of yourself. Try to imagine finding the truth of who you are showing up as a foster child on your doorstep right now. What do you need?! What do you want?! Remember the best of what you’ve learned, experienced and observed. Start with basic needs. Do you need to be invited in or given some time to adjust? Do you need something to eat, a nap, something interesting to do, a hug? Experiment and see what seems to work. What a huge responsibility! But what a relief! Finally, finally, after all that’s gone down, you can have your own consistent, kind, reliable, present, attentive caregiver who knows you better than anyone else on the planet and who wants the best for you, no matter what. And you don’t have to be a perfect self-caregiver. Good enough will do. Addiction – like life – is a 24-7 condition and other people aren’t always available to help. But you can be there for yourself. Whenever you need or want to, you can cling to your own good-enough self.

3. Seek out supportive others. Social connection can assist with abstinence. Stress and distress are part of human relationships, but the benefits of de-stressing need to outweigh the costs of stressing. No gathering with others will leave you stress-free. The goal is to find people with whom – enough of the time – you can feel good enough and safe enough to feel stable.

4. Try a variety of places and situations in which people gather in groups without use of problematic substances. Consider asking someone you trust to accompany you. Become aware of how you feel afterwards. If you feel neutral or better, you might return. If you feel worse, try another group, or, perhaps, try it a few more times and see. Keep visiting groups of any kind, whether recovery support groups, community groups, or hobby groups, until you find places that feel safe, supportive and helpful. If you don’t find established groups that are a fit for you, try to find individuals with whom you can meet one-on-one or in small, informal groups.

5. To further develop stability, establish priorities, schedules, routines and budgets. Figure out what you can do at the same time each day that’s helpful and do those things. Become aware of foods that fuel you and create a menu for yourself featuring those foods. Note which physical activities support your overall energy level throughout the day and do those. Figure out how much it costs to be you and find ways to supplement what’s missing and to modify spending for shortfalls. Discover the uniqueness that is you and set yourself up individually to thrive as only you would know, understand and be able to do.

6. Try to do your homework, honey. Whether self-assigned or suggested by trusted sources, research reports that those who do therapeutic homework fare better than those who don’t.

7. Use “enough” vs. “all” as a standard. While you may want to examine your values, principles and beliefs more closely and decide what might work best for you individually going forward, for now, strive to get enough of your needs met enough of the time, to feel pretty good enough of the time, and to be with people with whom you usually feel safely supported. Since no one can deliver “all,” expecting all one’s needs to be met all of the time will result in disappointment which is stressful and destabilizing.

8. Stigma is real. Give yourself private time to take care of yourself and to feel better before you consider whether or not to share your condition with others. Keep your circle of confidantes thoughtfully selected and discuss your motivations and the pros and cons of self-disclosure with trusted others when you feel or think you might want to share your situation with others.

9. Approach the idea of “acceptance” gently. Research on wisdom posits “five integral components of wisdom: emotional regulation; humor; critical life experiences; reminiscence and life reflection.” Research on emotion regulation equates acceptance and regulation, i.e. rejecting what is upsets; accepting what is calms. Acceptance is not approval, agreement, or taking responsibility for what is or what happened. It’s just a simple acknowledgement: The grass is green, the sun is yellow, and what happened happened and what’s happening right now is happening. Attempting to force, demand, or will oneself into acceptance, or worse, attempting to submit or surrender to acceptance – especially when others behaved unacceptably, even heinously – results in pain. As Maia Szalavitz wrote, our brains need more love, not more pain. Practice radical self-kindness when considering the idea of acceptance, radical or otherwise.

10. You are a unique individual with an individual case of addiction. What helps you with your particular case will be unique to you. You are the expert on that and, ultimately, you are the decider. As you should be. Even if you have the regrettable condition of addiction, it’s still your life, your one precious life.

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Anne Giles, M.A., M.S., is the founder of Handshake Media, Incorporated. She is a counselor and writer and lives in Blacksburg, Virginia.

The opinions expressed here the author’s alone and do not necessarily reflect the positions of clients, employers, co-workers, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

A Packet of Evidence-Based Addictions Recovery Guidance

This post has been moved here.

 

Medication-Assisted Treatment for Opioid Use Disorder – Infographic

Medication-assisted treatment (MAT) with methadone and buprenorphine is the only known treatment – not abstinence, not counseling, not 12-step approaches – to cut death rates from opioid use disorder by 50-70% or more.

“The principle behind MAT is this: Because opioid addiction permanently alters the brain receptors, taking the drug completely out of someone’s system can leave them less able to naturally cope with physical or emotional stress…”

U.S. federal officials decry opioid misuse as a public health crisis, yet federal rules limit access to the only known effective treatment. Due to federal restrictions, few health care professionals are approved to dispense methadone or prescribe buprenorphine. Further, laws dictate how many patients those few can prescribe and, increasingly to whom, in what form, and how much medication can be prescribed. People suffer, even die, on wait lists to receive medication. In contrast, countries that effectively address their overdose crises, loosen, not tighten restrictions. Indeed, Stefan G. Kertesz, M.D. states, “The dominant priority should be the assurance of subsidized access to evidence-based medication-assisted treatment for opioid use disorder.”

In the event that lack of understanding of MAT may be contributing to restricting access to it, we offer this simple infographic explaining medication-assisted treatment (MAT) for opioid use disorder (OUD).

Medication-Assisted Treatment for Opioid Use Disorder

Medication-assisted treatment (MAT) does not replace one addiction with another. It creates stability by treating the medical condition of addiction. Currently, effective medications for addiction create dependence – negative symptoms from withdrawal if doses are discontinued – but not addiction, which, per its definition, involves continued use despite negative consequences.

Tolerance occurs when people’s bodies adapt to a drug over time, responding less and less to the same dose. In order to have an effect, doses must keep increasing for people to continue to get high, or to keep from getting sick. When people use opioids regularly, therefore, they tend to use more and more of the drug over time. Even if they stop using, then return to use, they are at risk for overdose because illegal drugs are not monitored, and so they may be cut with much more powerful drugs, such as heroin with fentanyl.

(Recent increased rates in drug overdose are due to heroin and illicit fentanyl, not prescription pain medications. Reported deaths in 2015 from opioids by prescription account for under 15%. Of those addicted to prescription pain medications, 75% received them from a family member, friend or dealer, not through medication prescribed to them.)

When people with OUDs enter abstinence-based treatment, or otherwise stop using, their tolerance drops. They may not know their tolerance is diminished, or they may not know how much it has decreased, and if they take an opioid at the high dose they were once used to, they are likely to overdose and die.

People who are given MAT for OUD take an opioid (buprenorphine or methadone) at a consistent dose, which effectively stabilizes them. Once stabilized on an effective dose, they do not experience withdrawals, cravings, or highs. They can provide child or dependent care, hold a job, adhere to treatment, and comply with the law.

In contrast, people who are not on MAT will experience withdrawal symptoms and strong cravings, especially when under stress. People with OUDs permitted only abstinence-based treatment are at high risk for all of the same problems people with untreated addiction are at risk for: recidivism and crime, unemployment, contracting and transmitting diseases, overdose and hospitalization, and fatal overdose. Up to 90% of people with opioid use disorder relapse when not on medication-assisted treatment.

Maintenance may need to be long-term, or even life-long, because while addiction lasts, people who terminate maintenance treatments are at elevated risk for fatal overdose.

The US opioid epidemic has changed profoundly in the last 3 years, in ways that require substantial recalibration of the US policy response…Heroin and fentanyl have come to dominate an escalating epidemic of lethal opioid overdose, whereas opioids commonly obtained by prescription play a minor role, accounting for no more than 15% of reported deaths in 2015…The observed changes in the opioid epidemic are particularly remarkable because they have emerged despite sustained reductions in opioid prescribing and sustained reductions in prescription opioid misuse. Among US adults, past-year prescription opioid misuse is at its lowest level since 2002. Among 12th graders it is at its lowest level in 20 years. A credible epidemiologic account of the opioid epidemic is as follows: although opioid prescribing by physicians appears to have unleashed the epidemic prior to 2012, physician prescribing no longer plays a major role in sustaining it. The accelerating pace of the opioid epidemic in 2015–2016 requires a serious reconsideration of governmental policy initiatives that continue to focus on reductions in opioid prescribing. The dominant priority should be the assurance of subsidized access to evidence-based medication-assisted treatment for opioid use disorder. Such treatment is lacking across much of the United States at this time. Further aggressive focus on prescription reduction is likely to obtain diminishing returns while creating significant risks for patients.
– Stefan G. Kertesz, M.D.

People with opioid addiction can live full lives as family members and citizens. MAT benefits the general public health, employers, law enforcement, taxpayers, and the human beings who need our help.

Infographic by Laurel Sindewald. A printable .pdf version is here.

Laurel Sindewald contributed to this article.

Related reports on addictions treatment, addictions recovery, and addictions policy from Handshake Media, Incorporated:

This post was last updated 5/4/17.

On Counseling and Medication-Assisted Treatment

Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health categorizes substance use disorders, a.k.a. addictions, with “chronic and expensive medical illnesses” such as heart disease, diabetes, cancer, hypertension, asthma, arthritis, and chronic pain. The first order of treatment for these illnesses is medical care, primarily through medication. Patients with these illnesses are not required to receive multiple counseling sessions prior to receiving medication.

Challenging Myths about Medication Assisted Treatment for Opioid Use DisorderCounseling and support groups do exist for assistance with these illnesses. But counselors help patients comply with the course of treatment determined by their physicians. Support groups can help people live life while having the illness. But counseling and support aren’t replacements for medication and medical care. Except in addictions treatment.

Counseling is not medical care for a medical condition. We need to give people with the medical condition of substance use disorders (SUDs) medical care first – which may or may not include medication-assisted treatment (MAT) – but which may include stabilizing medical treatment for co-occurring mental and physical illnesses. Confusing medical care with counseling results in what the New England Journal of Medicine reported in December 2016: “Despite the demonstrated efficacy of maintaining abstinence by treating patients with opioid agonists, patients can remain on clinic waiting lists for months, during which time they are at risk of premature death.”

With regard to MAT and counseling, my conclusions from reading the research are that for most people most of the time, counseling has no significant effect on abstinence among those receiving MAT for SUDs, whether for opioid use disorder or other SUDs. Counseling may have a larger effect on those with co-occurring SUDs and mental disorders, but those effects would occur over time. People with the medical condition of SUDs do not have time for the possibility that counseling might be effective. They are at higher risk of dying as long as they are not on opioid maintenance medication. They need medical care stat.

From the Surgeon General’s report, page 4-21: “Nevertheless, multiple factors create barriers to widespread use of MAT. These include provider, public, and client attitudes and beliefs about MAT…”

“Buprenorphine is an effective medication in the maintenance treatment of heroin dependence, retaining people in treatment at any dose above 2 mg, and suppressing illicit opioid use (at doses 16 mg or greater) based on placebo-controlled trials…Methadone is superior to buprenorphine in retaining people in treatment, and methadone equally suppresses illicit opioid use.”
Cochrane Database of Systematic Reviews, 2014

We need to shift our policies from belief-based practices to what the science reports is best practices addictions treatment for people with substance use disorders: medical care first. Then, we can work on secondary, individualized assistance, perhaps counseling, case management, support groups, or support services according to each client’s case.

. . . . .

“In fact, no rigorous study has ever been able to show that the addition of psychosocial services to opioid agonist therapy alone improves outcomes in the treatment of opioid use disorder.”
Lean Forward, Harvard Medical School, May 2017

“Despite the demonstrated efficacy of maintaining abstinence by treating patients with opioid agonists, patients can remain on clinic waiting lists for months, during which time they are at risk of premature death. The use of interim treatment with buprenorphine without formal counseling while patients remain on waiting lists may mitigate this risk during delays in treatment.”
New England Journal of Medicine, December 2016

“Unfortunately, despite decades of research, it cannot be concluded that general group counseling is reliably effective in reducing substance use or related problems.”
Surgeon General’s Report, November 2016

“The commonly held belief that opioid agonist treatment alone is inferior treatment to such treatment combined with psychosocial treatment (which many will understand to mean counseling) is not supported by the research evidence and it results in limitations on the use of these effective medications.”
Journal of Addiction Medicine, July/August 2016

“[T]here is little empirical evidence suggesting which psychosocial treatments work best in conjunction with medication-assisted treatment as there are relatively few studies comparing the differential effectiveness of various psychosocial approaches (eg, CM [contingency management], MI [motivational interviewing]) for individuals receiving medications for the treatment of opioid addiction.”
Journal of Addiction Medicine, March/April 2016

“Patients who received only psychological support for opioid dependence in England appear to be at greater risk of fatal opioid poisoning than those who received opioid agonist pharmacotherapy.” – Addiction, November 2015

“Clinical trials show that opioid agonist therapy (OAT) with methadone or buprenorphine is more effective than behavioral treatments, but state policymakers remain ambivalent about covering OAT for long periods…OAT is associated with lower total healthcare expenditures compared to other forms of behavioral treatment for patients with opioid addiction.”
– Journal of Substance Abuse Treatment, October 2015

“Supplementing standard medical management with cognitive-behavioural therapy did not further reduce opioid use or promote abstinence among primary care patients being maintained on buprenorphine.”
Drug and Alcohol Findings, 2013

“For the considered outcomes [retention in treatment and use], it seems that adding any psychosocial support to standard maintenance treatments do not add additional benefits.”
Cochrane Database of Systematic Reviews, 2011

“Consistent with results from a previous study of predominantly heroin-dependent patients receiving buprenorphine-naloxone in a primary care setting, individual drug counseling did not improve opioid use outcomes when added to weekly medical management visits.”
Archives of General Psychiatry, 2011

“We conducted a 24-week randomized, controlled clinical trial with 166 patients assigned to one of three treatments: standard medical management and either once-weekly or thrice-weekly medication dispensing or enhanced medical management and thrice-weekly medication dispensing…All three treatments were associated with significant reductions from baseline in the frequency of illicit opioid use, but there were no significant differences among the treatments.”
New England Journal of Medicine, July 2006

The Comprehensive Addiction and Recovery Act (CARA) requires that an MAT treatment provider be able to provide or refer patients to counseling. Other than this wording in CARA – “appropriate counseling and behavioral therapies” – neither mentions the type, length or number of sessions of counseling required. Wisely, for an individual, the law does not require him or her to receive counseling in order to receive MAT. Unwisely, in Virginia, Medicaid patients are required to receive SUD counseling in order to be covered for either methadone or buprenorphine.

Image: Challenging the Myths about Medication Assisted Treatment (MAT) for Opioid Use Disorder (OUD) from The National Council for Behavioral Health

Laurel Sindewald contributed to the research for this report.

Last updated 7/22/2017.

Addiction Is Not a Choice

Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health makes the current discussion we have about addiction, i.e. helping people with addiction “make better choices,” “make better decisions, or “understand the consequences of their behavior” – whether coerced through drug court or supported through counseling – well-meaning but, unfortunately, irrelevant. Addiction compromises all of those functions in the brain.

The brain no longer does what it needs to do in a person with addiction, just as a pancreas no longer does what it needs to do in a person with diabetes. Medical care for a brain illness – not tough lovearrest, commitment to a mental institution, or recovery support services – needs to be the first order of treatment, including assessment for suitability for medications. Medications need to be prescribed by qualified medical professionals, not by non-qualified court officials or lawmakers.

Surgeon General: I'll stand up for recovery with you

We would rush our neighbor with acute diabetes to the doctor. Why don’t we rush our citizens with an acute brain disease to the doctor as well? Because, at essence, contrary to scientific evidence, we still believe addiction is a choice. We believe that if people with addiction could just see the errors of their ways and would work hard on those errors (rather than be lazy, immoral, selfish, self-indulgent, or inadequately faithful or spiritual), addiction would go away.

Working hard on one’s ways may help one live a better life. Might working hard to be a better person alter the brain in targeted ways that reverse or  ameliorate addiction? Possibly. Neuroscience research may ultimately support that. Certainly on ways to live a better life, many people, both with and without academic or medical credentials, can offer helpful guidance. But, for now, what we know is that addiction is a medical condition, 1 in 7 Americans is expected to get it, a person dies of a drug overdose every 19 minutes in the U.S., and only a fraction of those who need help are receiving it. For this dire medical condition, insufficiently treated such that a public health crisis has occurred, medical care is an imperative.

Do no harm” is a principle of health care. By stubbornly holding onto the concept of “choice” – in spite of the data that says we’re simply wrong to do so – we’re harming, even killing, our own citizens when we require them to, at essence “be better and do better,” rather than provide them with medical care.

May the Surgeon General’s report inform and direct the treatment we provide our fellow citizens struggling with the grave and dangerous medical condition of addiction.

. . . . .

On 11/17/16, the U.S. Department of Health & Human Services issued Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health.

Here’s a link to the YouTube video of the 3-hour presentation of the Surgeon General’s report.

Here’s Maia Szlavitz’s commentary on the Surgeon General’s report.

This post is an updated and expanded version of my letter to the editor about the Surgeon General’s report published by the Roanoke Times on 12/13/16.

Applications of Neuroscience Findings to Addictions Treatment

The article annotated and excerpted below, published in 2013, offers a conceptual framework through which to apply the findings of neuroscience to addictions treatment. It may be explosively important. Translating its offerings into practical applications will be difficult. The article is lengthy, written in highly technical language, weighs in at 9,300+ words, and cites 182 sources.

My intention is to attempt, however, to do just that. The work by Eric Garland, et al. – new research funding was just announced 9/6/16 –  could have weighty implications for individuals with substance use disorders (SUDs) and for SUD treatment professionals. My intention is to continue writing about addiction and addictions treatment as simply and directly as I can.

To that end, I have excerpted, annotated, added explanatory links to, and re-formatted the conclusion from Mindfulness Training Targets Neurocognitive Mechanisms of Addiction at the Attention-Appraisal-Emotion Interface and intend to link to this post from other writings.

We offer the following speculative, hypothetical account [demonstrating the conceptual framework described in this paper that applies findings of neuroscience to addictions treatment] based on our clinical and research experience using MBIs [mindfulness-based interventions] to treat persons diagnosed with substance use disorders.

When a recovering addict with a history of using drugs to cope with negative emotions encounters a cue associated with past drug-use episodes while in the context of a stressful environment (e.g., walking past a bar after getting in an argument with a work supervisor), this encounter may activate cortico-limbic-striatal circuits subserving drug-use action schemas. [In other words, the encounter may activate brain structures related to feelings, thoughts and behaviors associated with drug use. The authors write, “The urge to seek intoxication from addictive substances is driven, in part, by reactivity to substance-related stimuli [cues] which have been conferred incentive salience [priority importance], and is magnified by negative affective states.” The authors define “drug-use schemas” as “memory systems that drive drug seeking and drug use through automatized sequences of stimulus-bound, context-dependent behavior.”].

After completing a course in mindfulness training, the addict may become more aware of the automatic addictive habit as it is activated, allowing for top-down regulation of the precipitating negative emotional state and the bottom-up [brain structured-based reactivity] appetitive urge. [“Top-down regulation” is not to be confused with “willpower” or  “suppression” which, according to neuroimaging research, actually results in “hypoactivation in cognitive control circuits.” Attempts to suppress urges, paradoxically, result in 1) increased urges, 2) decreased resilience with regard to emotionally stressful events which is correlated with return to use, and 3) depletion of cognitive resources, thus increasing the likelihood of a return to automatic behavior to use vs. conscious behavior to abstain.]

Specifically, the individual may engage in mindful breathing to first disengage from and then restructure negative cognitive appraisals, thereby reducing limbic (e.g., amygdala) activity, autonomic reactivity, and dysphoric emotions related to the stressor. Concurrently, the individual may become aware of when his attention has been automatically captured by the sight of people drinking in the window of the bar, and, through formal mindfulness practice, activate fronto-parietal mediated attentional networks to disengage and shift focus onto the neutral sensation of respiration.

During this process, as sensations of craving arise, the individual may engage in metacognitive [the ability to become aware of, and direct, one’s thoughts] monitoring of these sensations, and in so doing, facilitate prefrontal down-regulation of limbic-striatal activation. [Author Maia Szalavitz uses the metaphor of a “volume control” to explain a person’s ability to up-regulate or down-regulate his or her own inner state.] As mindfulness of craving is sustained over time without drug-use, the sensations of craving may abate, promoting extinction learning to weaken associative linkages between conditioned addiction-related stimuli and the attendant conditioned appetitive response. [If “appetite” for drinking or using is present, but is not satiated with the anticipated reward, the tie between use and the reward lessens over time.]

Once working memory has been cleared of active representations of substance use, the individual may shift attention to savor non-drug related rewards, such as the sense of accomplishment that may arise from successfully resisting the temptation to drink (i.e., self-efficacy), appreciating the beauty of the sunset on the walk home without being clouded by inebriation, or the comforting touch of a loved one upon returning home safe and sober. [“Savoring” is defined by the authors as “selective attention to positive experience.”]

Through repeated practice of regulating addictive responses and extracting pleasure from life in the absence of substance use, the individual may re-establish healthy dopaminergic tone [to replace atrophy resulting from substance use] and foster neuroplasticity in brain areas subserving increased dispositional mindfulness. [“Dispositional mindfulness” is defined as awareness of, and attention to, what one is feeling and thinking in the moment.]

Ultimately, mindfulness may facilitate a novel, adaptive response to the canonical “people, places, and things” that tend to elicit addictive behavior as a scripted, habitual reaction. In so doing, the practice of mindfulness may attenuate [reduce the power of] stress reactivity and suppression while disrupting addictive automaticity, resulting in an increased ability to regulate and recover from addictive urges.

Posts that link to this post:

  • Forthcoming

Want to Help Our Community? Volunteer for SMART Recovery

For those beginning to discover they’re doing something they want to stop – or have tried stopping something and are having trouble – SMART Recovery welcomes all. Whether one struggles with alcohol and other drugs, smoking, gambling addiction, Internet addiction, sexual addiction, self-injury, problematic eating behavior, problematic relationships, or issues with other substances and activities, SMART Recovery meetings are the place to gather and talk with people addressing similar challenges.

What science is telling us and we know from personal experience is that we do better making changes with support from others!

If you’re interested in helping your community address its challenges with addiction, I invite you to train to become a SMART Recovery discussion host.

Based on my professional and personal assessment, holding SMART Recovery meetings is the closest we can get to community-wide, evidence-based, group-based addictions recovery assistance using resources already in place.

Welcome to SMART Recovery!

If we can, as a community, host SMART Recovery meetings every day at different times all over the area, we can provide free, near-treatment-level assistance to our people with addiction challenges. We don’t need to form task forces, write grants, or lobby public officials. We just need community members to do the training and sign up as hosts with SMART Recovery, and for community organizations with buildings to offer spaces for meeting locations.

  • SMART Recovery discussion meetings are free and open to anyone in the community.
  • Volunteers hosts DO NOT have to be in recovery from addiction to serve. Any community member – from the mayor to the maki maker to the mechanic – can serve as a discussion meeting host.
  • While discussion meetings are not generally facilitated by experts or licensed professionals, meetings focus on learning skills termed “tools” and are guided by trained hosts, thus extending the therapeutic value beyond more sharing-oriented support group meetings.

Here’s more information:

If you’d like to experience in-person what a SMART Recovery meeting is like, this meeting is open to all and you are welcome to attend:

Sundays, 4:00 PM, New River Valley Community Services, 700 University City Boulevard, Blacksburg, Virginia.

We’re compiling local recovery support resources here.

If you have any questions, feel free to contact, Anne Giles, [email protected], 540-808-6334.

(If you email me and don’t receive a reply, please check your spam folder. If you don’t see a reply in your spam folder, please phone or text me and we’ll connect that way!)

Hope to join you in volunteering with SMART Recovery!

How to Talk with Someone About Getting Help with Addiction

If you’re concerned about someone’s drinking, use of drugs, spending, gambling and other behaviors that might qualify as addiction – using or doing that continues despite negative consequences – and want to talk with them about it, here’s a suggested to-do list based on my personal and professional knowledge and experience.

Truly inform yourself about addiction. What most people think they know about addiction is belief-based, not evidence-based. My suggestion is to start with information from NIDA, a division of the National Institute of Health. NIDA’s publications on the science of addiction meet these rigorous standards. If other sources you read don’t link to sources that also use these standards, I suggest distrusting them. What works and didn’t work for one person cannot be generalized as applicable to your person.

Helping requires negotiationSeparate the condition from the person. Addiction is identifiable at the molecular level as a brain abnormality. While the first drink or drug or action or subsequent ones may have been the person’s “fault,” once addiction occurs, brain changes can impair the person’s ability to use judgment, make decisions, and choose based on criteria – whether good or bad. The abilities to make plans and to follow through with them are impaired. The ability to learn from the error of one’s ways, to learn from punishment or reward, to be shown a fork in the road and implored to take this path or that path and to decide which is the most helpful – all impaired. The person looks like the person we know, but the brain no longer works the way it used to. Addiction presents a horrifying double bind. The individual’s very skills and abilities that help make them who they are – and are needed to stop doing something – are the very ones that are impaired.

“People suffering from addictions are not morally weak; they suffer a disease that has compromised something that the rest of us take for granted: the ability to exert will and follow through with it.”
– Nora D. Volkow, M.D, Director of the National Institute on Drug Abuse (NIDA), quoted in What We Take for Granted

Know what you’re asking the person to do without. People with addictions describe the experience of using or doing as a feeling of love, a sense of belonging, bliss, meeting an unmet need, oblivion, sacred space, the only way to be pain-free, relax, sleep, be around others, and many others. Many people with addictions have anxiety, depression and other mental health challenges, trauma symptoms, issues of temperament, physical pain, and debilitating sleep disturbances for which drinking, using or doing provides the only relief.  Pause to reflect deeply on what purposes you think using or doing serves in the person’s life. Suspend judgment. Imagine you are the person and use this simple cost-benefit analysis tool from SMART Recovery to get a sense of what it might be like for the person to give up drinking, using or doing. To deepen your insights, put the items you’ve listed, regardless of the section, in rank order.

Know what you’re offering as a replacement. When people with addiction stop drinking, using drugs, or engaging in an activity, many are thrown into an acute state experienced as mind-breaking, spirit-shattering, life-threatening distress. And, for many, for the rest of their lives, they have to do without something that met needs that nothing else can meet. Based on your best judgment of what needs the person has that are met by their use of alcohol, drugs, or activities, what is your plan to get their needs met if the substance or activity is removed?

Specifically, what’s your short-term plan to help the person deal with acute suffering? (This guide to getting health care for addictions may be helpful.) What’s your long-term plan to help the person handle the on-going whine of distress that could spike at any time? Relapse relates for alcoholism, for example, don’t drop significantly for 5 years. “Just stop” is not a plan. The person has tried that plan more times than you can ever know. Drinking, using and doing again, when a person is experiencing what feels unbearable, is not weakness, but mercy.

Your plan will depend upon your locale’s resources. Feel free to use this guide to getting help with addictions in the Blacksburg, Virginia area to customize your own plan. (If the person has an opioid addiction, more specifics are at the end of that guide, and here and here and here for myths about heroin.)

Ask: “What do you think would be helpful?” Once you understand that addiction is medical, not personal, i.e. neither about the person nor about you, and you’re savvy about your locale’s addictions treatment resources, you know what’s on offer. With goodwill, good intentions, a clear mind and calm heart, you can essentially enter a business negotiation. You want the person to buy some combination of addictions treatment products and services but which ones match this person’s needs and preferences? You have to ask to find out. Then you’ll have to discover whether or not what you’re offering is perceived as valuable enough for an exchange.

What we know isn’t helpful and we know doesn’t work: negative consequences.

Persistence in spite of negative consequences defines addiction. Therefore, negative consequences don’t arrest or cure addiction. Emotional punishment such as shouting or the silent treatment are akin to psychological abuse and are destructive to you and to your person. Physical punishment – including getting locked up in rehab or jail – can traumatize the person, which is already a pre-existing condition for many people with addictions.

Plan for yes. Plan for no. If the person says they want help, you better be able to act on that immediately, i.e. put them in the car and start driving. If you don’t know your locale’s resources and you don’t have things lined up, you’re going to put that person in a world of hurt. Any delays decrease chances for engagement in treatment. They’ll very likely have to return to what they were doing and their trust in you will be harmed. If the person doesn’t want help, this will require a terrible judgment call on your part. It’s time to use the cost-benefit analysis tool on your own dilemma. Just replace “using/doing” with “helping,” be sure to rank order what you list, and see what comes up for you.

“Love, evidence & respect.”
Maia Szalavitz’s answer via Twitter to the question, “What fights addiction?”

Acknowledge the complexity of the situation. People with addiction continue to do what they do for reasons that make sense to them – even with impaired cognitive functioning –  and, with a little imagination and empathy, we can make sense of those reasons. Given that people with addictions, depending upon the substance or activity, may or may not experience dependence, given that addiction is classified as a brain disease, and given that the brain’s executive functioning is impaired by addiction, well, who would know how to talk with someone about addiction or would know what to say? By what criteria would we measure rightness or wrongness of a layperson’s – even a professional’s – attempt to broach the subject? For both parties, it’s a wicked, wicked problem.

When attempting to help people with addictions, I use the words of Maia Szalavitz for guidance – sometimes as prayer: “Love, evidence & respect.”

Photo by Zane Queijo

What’s a Town to Do About Addiction? Let’s Continue the Conversation

Let’s continue the conversation about what a community can do about addiction started by Maia Szalavitz ‘s visit to Blacksburg, Virginia!

Continuing the Conversation:
What’s a Town to Do About Addiction?
A Community Discussion

Wednesday, August 31, 2016
7:00 PM
Blacksburg Library
200 Miller Street
Blacksburg, Virginia

The event is free and open to the public.

Blacksburg conversation on addictions begins!

If you’ll sign up on the Facebook event page we’ll know how many chairs to set up!

If you’d like to prepare for the conversation, feel free to try any or all of these:

For more information, please contact Anne Giles, [email protected], 540-808-6334.

. . . . .

Handshake Media, Incorporated was honored to present “What’s a Town to Do About Addiction? A Conversation with Maia Szalavitz, Author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction” on Wednesday, August 3, 2016, at New River Valley Community Services in Blacksburg, Virginia.

Anne Giles made the introduction, Mike Wade of New River Valley Community Services filmed the presentation, and Shawn You and Daeshaun McClintock of Mor11 Media photographed the event. Laurel Sindewald transcribed the presentation, with almost 9000 total words spoken in about one hour.

In her presentation, Maia Szalavitz mentions initiatives in Ithaca, NY. We’ve compiled a report here.

Photos from the event are on Facebook here.

The invitation describing the August 3 event is here.

For more information about local efforts to organize an effective response to local addictions challenges, please contact Anne Giles, [email protected], 540-808-6334.

A page with the above information, the video, plus a transcript of the presentation, is here.

What I Would Do to Help a Loved One with an Addiction in the New River Valley

I live in Blacksburg, Virginia. Blacksburg is located within Montgomery County, and within a larger area generally termed the New River Valley (NRV) in Southwest Virginia. Blacksburg, Virginia, according to the U.S. Census Bureau, has over 46% of its population living in poverty. More than 16,000 people in my locale have problems with alcohol and other drugs. In terms of receiving or allocating funding for health care, Virginia is ranked poorly with other states. This means we have scarce health care resources and high demand for them.

Scarcity requires scrambling.

Disclosure and disclaimer: I am a counselor at New River Valley Community Services. The opinions expressed here are mine alone and do not necessarily reflect the positions of my employer.  This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Reaching out to help someone with addictionIn this post, I elaborate upon What You Can Do to Help Fight Addiction with specific details on what to do for a loved one with addiction in our area.

This list is based on my experience in getting help for myself and others. Some readers may find themselves outraged by the workarounds needed to get addictions care. I have no time for outrage or debate. I may not want to be a do-it-yourself addictions treatment care coordinator, or may feel unqualified or ill-prepared to do so, but addiction is a critical illness and right-here, right-now, I need to get my loved one care.

“Love, evidence & respect.”
Maia Szalavitz’s answer via Twitter to the question, “What fights addiction?”

How to Help a Loved One with Addiction in the NRV

If I discovered my loved one had an addiction and I wanted to get him or her addictions treatment in my locale, this is what I would do to address immediate needs.

[A .pdf version of this guide – last updated 9/19/16 – is available here.]

0) SAFETY FIRST. Unfortunately, much addictions treatment in our area begins with a medical or legal emergency resulting from untreated addiction progressing to an acute stage. If my loved one, or I, or anyone present is in danger or is behaving dangerously, that must be addressed first. I may need to remove myself and vulnerable people immediately – even if I long to stay and help my loved one or fear his or her anger, even retribution – then call 911.

Important: The rest of this list is based on getting help for a loved in an urgent situation, not an emergency situation. The loved one is able to converse, perhaps unwillingly, but perhaps willingly enough to co-create next steps.

1) Lead with my heart to support my loved one.

Hug my loved one. Say, “I am so very sorry you have developed this health condition. It’s too bad but you are not bad. I love you and I am here for you.”

Realize I need to become my loved one’s care manager and advocate. My loved one is ill. Few can take effective action when they don’t feel good.

2) Lead with my head and prepare to take strategic action.

Recognize my loved one needs full physical and psychiatric evaluations to determine the dimensions of his or her particular case. Addiction is often accompanied by mental illness, physical illness, emotional and physical pain, and trauma. Issues of temperament and personality may need assessment. All of these factors need to be considered and evaluated by medical professionals to determine what principles of effective addictions treatment need to be activated for my loved one.

Blood work needs to be done to test for the presence of function and dysfunction, both to diagnose illness and to assess suitability for medications. Ideally, these assessments would be done by one specialist or a team of specialists, but I may need to cobble this together from multiple sources. From all this data, the first version of an individualized treatment plan can be devised.

Realize I need to get my loved one “in the system” ASAP. Wait lists exist for all services.

Realize that understanding addiction is a health condition needing health care – rather than believing it is a moral problem needing punishment – is new. I will need to listen carefully to what care providers advise. In 99% of my contact with local health care providers, I have experienced them as caring, determined, and resourceful. But if I hear disrespectful, shaming statements, or presentation of beliefs rather than science about addiction, I can’t walk away because I’ll just be put on another wait list. I’ll need to work with this care provider and his or her views in order to receive the piece of data this provider can offer. I must do what I can to protect my vulnerable loved one, but I may, at times, feel challenged to manage my own emotions.

Prepare to document. I’ll need to get copies of all previous medical reports for as many years back as I can find them, keep them organized in reverse chronological order in a binder, and take that binder to all appointments. I’ll need a list of all current and past medications. Our multiple health care providers have electronic health record software programs that don’t “talk” to each other so care providers may not be able to “see” data from other providers. Data from previous years may still be in paper file folders rather than available electronically. I’ll only have a few minutes with each care provider so I need to have a one-page summary at the front of the binder, then the medications list, so the care provider can be oriented to my loved one’s case quickly. I’ll need to update the summary after each appointment.

Consider the ER. If my loved one is in a state of emergency, I will call 911. If my loved one is not in a state of emergency, I need to know that it is through the emergency room that many people with addiction make first contact with our local health care system. ERs help stabilize patients briefly, but are limited in the length of care they can provide, sometimes under 24 hours. Local hospitals do not provide addiction treatment, medication-assisted treatment, or prescriptions for detox or pain meds. If my loved one is released without immediate follow-up care, relapse is probable.

Depending upon the system in which the ER operates,  referrals will be made to additional treatment through these emergency evaluation services. Referrals from those services are to local treatment providers. Many referrals are for treatment at in-patient facilities, few of which have beds available immediately, most of which require health insurance or a needs-based assessment prior to admission. If my loved one is considered a threat to himself or herself or others, a stay at a mental hospital is required. An ER visit may result in a range of outcomes, including release of my loved one into my care, to a stay at a mental hospital, possibly in another part of Virginia. When I/we leave, I will be sure to get a printout of lab reports and treatment notes, or return the next day for copies of them to add to my documentation binder. Again, in an emergency, I would call 911.

Consider urgent care. I have taken several people with health insurance coverage with illnesses or injuries that have resulted from addiction – not for addiction itself – to Velocity Care urgent care centers and have been impressed with how quickly the person is seen and how much attention each person is given by the care provider. Velocity Care also hands me a printout for my binder without asking. If my loved one is in a state of physical or mental emergency, however, they will refer us to the ER and it is a wasted trip.

Ask my loved one, “What help do you think you need first?” Although I’m nearly insane with worry and I see my loved one is in dire condition – but I have determined I do not need to call 911 for an ambulance and my loved one is not a child for whom it is my responsibility to make decisions – if my loved one’s answer to the question, is “I don’t want or need help,” then that is where the conversation must begin in hopes of mutually-deriving a plan of action.

In my experience, my view of what is the most important next step has never been what my loved ones have thought was important. I wanted to hurry them into shoes so I could get them into my car and race them to the ER faster than an ambulance could get there. They wanted a glass of orange juice. I need to continue to remind myself that this is a person, however ill or impaired, with needs, wants, preferences, priorities, and values. In my experience, co-creating next steps has been the most difficult, frustrating, and anguish-engendering part of helping someone with addiction. When is the person too ill to make a decision? Should I step in or not? Am I respecting this person’s autonomy and right to decide next steps on a life’s path? This is a realm of terrifying uncertainty, sometimes requiring life-and-death judgment calls, all made in the context of respect for human dignity.

3) Make appointments.

Start trying to get an appointment with a psychiatrist now. Most psychiatrists require a referral from a primary care physician (PCP) so an appointment with a PCP needs to be made ASAP. The PCP will make the appointment and can get back to me. Hearing back from the PCP, plus the wait to see the psychiatrist, and can take 6 months or more. Whether or not my loved one has insurance, whether or not I have a clue how we’re going to pay for it, whether or not my loved one may be able to make the appointment, I’m going to make an appointment now knowing I’ll have 6 months to figure out the money.

If I or we can self-pay, I would make an appointment for my loved one to see a physician at TASL, the one and only medical practice specializing in addictions medicine in our locale. Clients pay directly for services and the provider does not bill insurance. Payment in person by cash is required to make the first appointment and cash or credit cards are accepted after that. TASL explains its services clearly and specifically via phone recording. Select option 3 for new patient information, 540-443-0114.

If I can’t find a way to self-pay, and my loved one has health insurance, acknowledging the need to wait half a year for a psychiatric care appointment, I would immediately make an appointment with a primary care physician (PCP), ideally with my loved one’s current PCP or, if he or she doesn’t have one, with mine. An appointment with a Nurse Practitioner (NP) can be more readily available for immediate care if the PCP is booked. I would be sure to still keep the appointment with the PCP. The NP’s assessment will become part of the data that the PCP considers.

If my loved one doesn’t have health insurance, I would assist my loved one in calling  ACCESS at New River Valley Community Services, 540-961-8400, between 8:30 AM and 5:00 PM, and asking for a GAP insurance assessment appointment. (Appointments must be made by the individual requesting an appointment. Assessments are not done on Mondays). If my loved one is assessed as having a severe mental illness (SMI) he or she may qualify for coverage through the Virginia Governor’s Access Plan (GAP). If I can bring documentation of my loved one having been diagnosed with SMI to the GAP assessment appointment, that can expedite the process. (Although the National Institute on Drug Abuse (NIDA) itself defines addiction as a brain disease, addiction/substance use disorder is not considered an SMI.)

If we can’t self-pay, my loved one doesn’t have health insurance, and doesn’t qualify for GAP insurance, I would call the Community Health Care Center of the New River Valley, make an appointment to see a physician, prepare the application forms, and start calling churches and asking for help with co-pays.

(Community members, please help me expand this section. How would a person get cash in the NRV to pay for non-covered medical expenses for addictions treatment?)

For each appointment, I would make a list of the top questions, in priority order, for which answers are sought. To get the most out of my limited time with a care provider, I need to focus primarily on information, secondarily on getting reassurance for my loved one. I will talk with my loved one beforehand, take notes, and co-create a brief list. If I can accompany my loved one, I can bring the list, listen carefully, and ask for assistance with any questions not addressed. If I can’t go, I can provide the list for my loved one to take. After each appointment, I will cross off answered questions and note additional ones for the next appointment.

Contribute to my loved one’s documentation. I would hand write or type a timeline of what I know about my loved one’s life with all of these components in order as they happened. I would include years and ages if I can: 1) first use of cigarettes, alcohol, marijuana, other substances; 2) substance use history – what did they use, when did they use it, how much did they use, and how long did they use it, prescribed or otherwise, any incidents that seemed like just teenager stuff or just overdoing it at the time? 3) onset of physical illnesses or occurrence of physical injuries; 4) traumas – deaths in the family, losses, neglect, abuse, witnessing or experiencing emotional, physical, or sexual violence; 5) incidents I remember in which the person seemed to have a very strong reaction or surprisingly little reaction to an event, 6) anything else I think might be helpful for care providers to know.

4) Get my loved one to appointments.

Cover transportation. My loved one may not have a license or a vehicle. Ideally, I would transport and accompany my loved to all appointments to listen and to help as needed. If I can’t take the person myself, I need to help them find a ride, or find them a ride myself, perhaps from a friend or neighbor. If I have a credit card and a late model smartphone that can handle the Uber app, I could arrange for and pay for transportation through my local Uber service.

Cover dependent care. My loved ones may be parents of small children, and/or may provide care for a partner, ill or elderly friends or family members, or have pets. I need to find a way to arrange for coverage to ease my loved ones’ stress and concern about beings in their care.

Cover medication costs. Physical and mental stability is the top priority for my loved one and meds will likely be needed to achieve that. If my loved one can’t pay or doesn’t have insurance, I need to think about finding a way to cover this necessary expense.

5) Follow-up on recommendations received during health care appointments.

If out-patient treatment is recommendedNew River Valley Community Services (NRVCS) is the public provider of behavioral health services and the primary provider of addictions treatment services in our locale. To be screened for services, I would assist my loved one in personally calling ACCESS at New River Valley Community Services, 540-961-8400, between 8:30 AM and 5:00 PM, and asking for a Rapid Access intake appointment.

If in-patient residential treatment, i.e. “rehab,” and/or “detox” is recommended for my loved one, I would read carefully Maia Szalavitz’s article on the rehab industry, then call providers in this area and listen carefully to what they have to say about their services. Residential treatment can be helpful to some. For others, life is distressingly disrupted. An extended absence can compromise jobs, finances, relationships with children and partners, and subject one to addictions-related stigma. Many with addictions have trauma-related issues and find that in-patient treatment can exacerbate trauma symptoms. Rehab can be enormously expensive and is increasingly under scrutiny for ineffective treatment outcomes and high relapse rates upon release. This is a decision that needs to be made thoughtfully.

If my loved one did attend residential treatment, during visits, I would do my best to co-create with my loved one a life-in-recovery schedule for us to follow that would begin at the moment of discharge. Because I can’t do my life and theirs, too, I, would create a Doodle schedule, then ask for help from my friends. At my loved one’s discharge, I would be there to transport my loved one into our best efforts to create a new life in recovery.

If individual counseling is recommended, I know of two counselors in our area who specialize in substance use disorders and both are not taking new clients. I would ask physicians and friends for referrals, screen that list for counselors who specialize in cognitive behavior therapy, the top evidence-based counseling method for addressing substance use disorders, and take the first available appointment with the first available counselor. (Few specialize in Dialectical Behavior Therapy (DBT) which is showing increasing promise as an evidence-based counseling protocol for addictions treatment.)

Understand that addiction, in early recovery, is a 24-7 condition that requires 24-7 care. Although I may assist my loved one, once stabilized, a person with addiction serves as his or her own primary care provider. I would point my loved one to these self-help suggestions:

Practice self-care. Although it’s last on the list and hard to practice in urgent moments, self-care is to what I have to continually return my attention. I need to be high-functioning to help anyone with anything. And this may well be one of the hardest fights of my life. I need food and rest. I may need counseling for myself and definitely need time with supportive friends. The self-care checklist for addictions recovery that I will suggest to my loved one can assist me with my self-care, too.

I need love, too.

. . . . .

If my loved one has an opioid addiction, I would:

Buy opioid overdose antidote Naloxone kits – available now without a prescription from the pharmacy at CVS on University City Boulevard in Blacksburg – for my loved one, myself, and others with whom my loved one has frequent contact in case of my loved one’s return to use. (See helpful discussion of Naloxone in NYT letters to the editor, 8/7/16.)

Study carefully and learn What Science Says to Do If Your Loved One Has an Opioid Addiction and the New England Journal of Medicine’s report on opioid addiction released 3/31/16.

Get my loved one assessed for medication-assisted treatment (MAT), the top evidence-based treatment for opioid use disorder. Unfortunately, my loved one has an immediate need for an MAT assessment and wait lists for assessments and treatment from local public providers and providers who take insurance are 6 months or more. (Here’s an explanation of why we have wait lists for opioid addiction treatment.) To bypass wait lists, I have to self-pay. The closest self-pay source of buprenorphine/Suboxone/Subutex to me in Blacksburg is TASL, 540-443-0114. Methadone is only available at highly regulated clinics in Salem and Roanoke.

. . . . .

I am so grateful to the many who have shared their lives and struggles with me so that I could write this post in hopes that we can help many more.

This post is a work in progress. If you have suggestions, pease leave them in the comments or email me at [email protected]

UPDATE: On my personal blog, I am writing a series of posts entitled DIY Addictions Recovery for people with addictions who are seeking help for themselves.

Last updated 10/11/16

If you or someone else is experiencing a substance use and/or mental health emergency, call 911 and/or ACCESS, 540-961-8400.

Disclosure and disclaimer: I am a counselor at New River Valley Community Services. The opinions expressed here are mine alone and do not necessarily reflect the positions of my employer.  This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.