Harm Reduction Good; Harm Reduction Bad

Harm Reduction Treatment is a term which is used commonly in Addiction Medicine. It followed “abstinence based’ treatment.  In other areas of medicine the term ‘palliative care’ is an equivalent expression.

The positive aspect of “Harm Reduction’ was that it provided care specifically for those who were not ready to embrace ‘abstinence based’ treatment or for those who had failed, even repeatedly failed, conventional abstinence based therapies.  

Historically ‘abstinence based’ therapy for alcoholism was exemplified by the Gold Standard , Navy Pilot program. Navy pilots cost millions to train and flew jets worth even more millions.  When they developed addiction as they did, grounding them caused  a major loss, often involving suicide, while letting them fly, was obviously dangerous. The treatment which followed included a 30 day inpatient treatment, followed by 3 meetings a week of AA (Alcoholics Anonymous), weekly drug and alcohol counselling and monthly visits to see a psychiatrist. At 5 years 80% of pilots were abstinent and flying.  A major success.  

This treatment with some variations is the treatment principally used for judges, doctors, other professionals, union members and all those ‘contributing citizens’ who individually or by insurance can afford the ‘best’.  It is well known by the advocacy of such distinquished treatment programs as Betty Ford, Talbot, Homewood, Edgewood, Orchard etc.  Often patients begin with a period of detox and follow up today can include SMART, a cognitive behavioural group therapy.  Group therapy is the cornerstone of abstinence based therapy.  A fundamental principle of addiction treatment in this model is that substance abuse compensates for relationship deficits.  Accountability and support come through fellowship and community.  Isolation begets addiction, participation treats addiction.

By contrast Harm Reduction Treatment has tended towards maintaining the substance use with a view to control. Originally the World Health Organization validated the Harm Reduction Programs only as they ‘lead to abstinence’. Abstinence is the ‘cure’ per se for addiction.  To this end methadone, suboxone, Kadian and now Heroin are used as Opiate Replacement Therapy.  Eventually patients were weaned off opiates however where in the abstinence models this occurred in weeks, in the Harm Reduction Model this might well take years.  

Alcohol is provided in a controlled fashion on the hour for chronic alcoholics, maintaining the steady state alcohol level and avoiding withdrawal as well as the revolving door detox, hospital and jail scenarios.

There is no doubt that harm reduction is good Community Medicine. 30 years ago when I was doing a Community Medicine Residency I studied the Swiss Methadone Maintenance programs of the day, showing then as they do today, that providing methadone, reduces the spread of diseases associated with needles, like infections, most importantly hepatitis and HIV.  They also dramatically reduce the cost of revolving door hospital, detox and jail scenarios. The legal cost alone for the theft associated with heroin use is horrendous and methadone simply dramatically reduces this.  

Harm Reduction Treatment is very good for the community when it is approached responsibly and it’s fiscal benefits are understood.

 Locally the Portland Hotel Society was a scandal with all manner of corruption and devastating failure as their Harm Reduction Model became dominated by crime and a ‘better living through chemistry’ attitude which indeed promoted drug abuse as opposed to treating it. The Portland Hotel Society has since modified it’s approach. 

For individuals as opposed to the community, harm reduction can be very good.  Methadone and suboxone specifically impressively reduce the use of needles and help individuals get free from the life of servitude supporting the criminal drug dealer factions and associated crime.  Eventually patients who might otherwise have died often have the time to move on to abstinence based therapies.  When the patients come for methadone or suboxone their other physical and mental health needs can be addressed.  Otherwise they might well avoid health care.  Housing, food, health care are all available as part of the a good methadone program.  Certainly we encourage participation and provided biopsychosocial interventions to the patients on methadone. The College of Physicians and Surgeons of BC like other College programs across Canada and similarly in other civilized first world countries,  historically managed the methadone programs and encouraged they take a wholistic approach to the patient.  Opiate programs required a federal government waiver given that the laws against drugs like heroin were nation wide. Locally the addiction treatment has been transferred mostly to Province or State and University care. 

Harm Reduction Therapy could well be seen as bad if all the doctor was doing was being a ‘drug pusher for the multinationals’ rather than using motivation therapy,   12 step facilitation therapy and cognitive behaviour therapy to move patients along the spectrum of motivation to change as laid out by Prochaska.  The preventative medicine aim was through relationship therapy with the physician , psychiatrist, pharmacist and overall treatment team aiming to ensure the patient’s self esteem and health indices  improved.  These indeed do and for many individuals the methadone and suboxone treatment have been life saving.  Heroin and other ‘needle maintenance programs’ are early ‘add ons’ whose value is not nearly as evident given that the key feature of methadone was that it moved patients off needles with the community risk inherent to methadone or suboxone, oral medications.

The alcohol therapy has been an end stage treatment model for chronic alcoholics who have failed all other programs and whose lives are more manageable without the drunk then withdrawal roller coaster broken by relationship with health care and managed hourly alcohol intake.

Champix  and bupropion, nicotine replacement gums and patches, and vapes are all Harm Reduction Therapies which have had proven success in helping people become abstinent for nicotine and smoking.

Revia (naltrexone) is a medication which reduces craving for alcohol and empirically reduces alcohol intake in those who abuse.  Acamprosate is another such medication. 

Narcan kits which reverse overdose are definitely a harm reduction strategy especially when put into the hands of first responders.  They are a simple preventative medicine strategy for those of my patients who I encourage to have on hand when they are using with family or friends trained to know how to use them. 

The safe injection site is obviously another  harm reduction strategy.

Needle Exchange programs are proven harm reduction therapy where the patient exchanges a dirty needle for a clean needle. Unfortunately locally the needle exchange program devolved into a ‘free needle’ program with needles being tossed out of a basket in the local park. 

A variety of medications have been used along with diets to treat obesity and overeating, sometimes call food addiction. At the extreme, when behavioural change fails, surgical interventions such as stomach stapling have been long acknowledged as life saving.

So why is Harm Reduction Bad?  Obviously it isn’t of itself.  Reducing harm is good and the use of this marketing term is very seductive indeed. Unfortunately it can be ‘enabling’ and can cause the disease to persist given the huge element of denial involved in addiction.  Further the Harm Reduction Therapies tend to be pharmaceutical or medicalized  and costly compared to the low cost equivalence of the more labour intensive approaches of treatment centres and frankly almost cost free community support programs.  Often all the high cost and front end approaches are used and use up the patients resources while in the end the recommendation is to continue in AA/NA or SMART as this is a chronic disease process and unfortunately the real issue is prevention of relapse.

When patients have work and family and community relationships still in tact they are most likely to benefit and succeed with the conventional abstinence based programs, detox, treatment centre, and group therapy. In traditional medicine this is considered the ‘primary’ care model and harm reduction therapy is considered ‘secondary’ or ‘tertiary care’.

Harm Reduction becomes ‘bad’ when judges and doctors and the wealthy are given the abstinence based approach while the poor are ‘maintained’ on their drugs without giving them the opportunity of ‘cure’ which comes with abstinence based models.

Further, the harm reduction models can contain an inherent negation of the patient’s capacity to change.  Seminal studies have shown that a patients capacity to change and get well depends strongly on the therapists belief in their capacity to do so.   If the therapist doesn’t believe the patient can overcome their addiction to heroin the therapist will indeed prove to be the rate limiting step. The success of AA and NA is that the rooms are simply full of individuals who have indeed climbed the Mount Everest of Recovery and encourage others to believe they too can succeed.  

Both models have their naysayers and both models have their glorious success stories. The social justice warriors often argue that the addict and alcoholic should have ‘free’ stuff , in this case ‘free drugs’.  Unfortunately the disease of addiction is one of ‘more’ and there simply isn’t enough of whatever to suit the active alcoholic or addict who will die or commit crimes to persist in his or her narcissistic hedonistic pursuits.  

Should society pay to increase the risk to itself.  Part of the difficulty today is that there are increasing numbers of those who feel society should allow them to ‘spread their disease’ , a group of HIV positive individuals having parties with ‘non infected’ but those seeking “solidarity”.  

In the best of possible worlds when physicians, psychiatrists and other care givers are seeking what is best for the patients ,understanding the severity of the disease, the limits of resources and looking at each case individually there is rarely any conflict between the models .as in the individual’s life and care both models are at different times and sometimes together  being used.  

Politically, Harm Reduction Therapy has, I believe, a great deal more potential for harm than traditional abstinence based therapies.  Naturally there is a concern that the rise in addiction and death has been parallel to the increase in Harm Reduction Programs. Is this an association or is some of this cause and effect.  Changing the ‘drug dealer’ from the street criminal to the State has sent a different message. Legitimizing drug and alcohol abuse can be problematic.  Promoting marijuana use for profit just like promoting alcohol for profit may cost individuals and communities while a few profit.  

What is best for the individual, what is best for the community and what is best for the State and treating services are great when they all work together. Historically, the individual has been lost in the demands of community and State and those that ‘profit’ from individuals with disabilities such as addiction.  

We have always done ‘Harm Reduction’ as doctors. My concern has principally been individuals get the best care. The group “Like Minded Doctors” developed in part to discuss these concerns. 

Five Years Abstinent: No Blow Up Dolls and No Goat fucking

In my work as an addiction psychiatrist I commonly advise people of the prognosis of their disease and the successful scientific treatments that have been beneficial.
I like to point to the studies, epidemiological and  anecdotal data which showed that those who attained 5 years of abstinence from drugs and alcohol  routinely had only  a few key points in common.
Number 1.  Persons with 5 years abstinence from drugs and alcohol had a HIGHER POWER.  Higher power in this case didn’t represent a white bearded god on a cloud or a big breasted woman deep in the sea.  What higher power referred to was simply something more important than drugs and alcohol.  Something that the person gave more power over their lives to.  It’s long been recognized that addiction is a religion. The drugs and or alcohol were the addict’s God, their direct dealer the deacon and the supplier the high priest of the cult church with all it’s rituals, paraphernalia and jargon. A higher power represented anything that was more important to the person than belonging to this church and religion.  Over the years patients had told me that their higher power was their children,  their family, their job, anything really.  Others had said that life it self was their higher power.  Addiction was killing them.  Some simply described their higher power as God.
C.S. Lewis the great Christian theologian said simply, “Why look in the wall for the architect?”.  Addicts and alcoholics are the most materialist hedonists.  Addiction is idolatry. They worship their addictive substance.  They commonly say their are atheists or agnostics when its obvious that they are stalwart members of their church of addiction.  They commonly say they don't want 'any religion' simply because their addiction is their religion. Translated they are really saying they're not ready to give up their addiction. Their brain is tricked into believing they are getting ‘high’ or even that what they are doing is a ‘party’.  Spirituality refers to an invisible God or power or force that people have in their lives and experience in their world especially after they’ve known the soul empty experience of addiction.  It is the interconnectedness and relationship of life.  It's there strongest in the prayer of the indigenous for 'all of my relations.'
For people to stay clean and sober there simply must be something else, something with greater meaning that gives more purpose and power to their lives than the slavery of the addiction. Their  dependency is making their dealer high priests rich in ferarri’s and yachts.
Scientifically today we measure a person's 'motivation to change' because it's obvious that it's hard for the addict to admit that they have been suckered or duped by the ultimate con artist. The emperor has no clothes and often giving up addiction and entering recovery means admitting to oneself at least that for years and thousands of dollars one has been going backwards.
The Motivation to change assessment describes a person as 'pre contemplation', a true zealot for the church of addiction, a person in 'contemplation' recognizing that addiction was "fun", now it's "fun and trouble" and actually they might be ready to get off the slow to quicking descent before it was just plain 'trouble'.  Determination phase is when one is there.  They've made the determination that they don't want the lie and want the truth of life instead. In 'Action" phase they're 'walking the walk and not just talking the talk' , they're changing their behaviour and making themselves accountable to a plan of recovery.
Number 2.  Persons with 5 years of abstinence belonged to a group that supported their abstinence. When they look for people at 20 years abstinence or more the majority of people they find abstinent belong to AA, NA or some religious organization such as church, temple or synagogue.  Dr. Carl Jung recognized that people who developed addiction were spiritual people but that they were tricked into seeking the holy spirit in the "spirits" bottle. His famous Latin phrase for this was "Spiritus contra Spiritum".  Dr. Carl Jung said in a letter to Bill Wilson, co founder of AA ,that  the ‘craving for alcohol, was the equivalent on a low level, of the thirst for spiritual wholeness.”  He went on to say, “‘alcohol' in latin is ‘spiritus’ and you use the same word for the highest religious experience as well as for the most depraving poison. The helpful formula therefore is , “spiritus contra spiritum”. Addiction leads to alienation whereas recovery leads to participation.   At 5 years abstinent people found they were part of a better group. "We are not alone.” is the message that comes with recovery.  Though AA, NA and spiritual organizations were the most common groups there were many others that served as well such as community organizations like Kiwanis, Odd Fellows, Masons, Toast Masters.  These were not work associations as addicts and alcoholics commonly maintained work to the very last as work and work associations, professionals , unions and faculties gave them the finances to advance their addictions as well as the respectability to maintain the denial of the increasing desperation and the dehumanization.  With addiction people would rather be alone with their substance or drink or with others who shared their substances or drink than in any other recreational activity.
With respect to relationships and the damage to relationshionships, the delusion of addiction was best described by one recovered addict, “fucking a blow up doll and thinking it was love.”  Another said, “it got me high but it took away the sky”.  
Finally, Number 3.  The person was noted to have had a change in attitude.  The more one does drugs or alcohol, the more one minimizes the abnormality of the behaviour and the associations.  People who once loved to be outdoors will instead sit in a dingy bar all day or find themselves living behind closed curtains all the while thinking they’re ‘not that abnormal’.  Everything related to their addiction is justified and yet in recovery they have an awakening and increasingly see what they had become and want never to go there again.
My favourite description of this phenomena was a from fellow who said, “when I got off drugs my life got better immediately. I had money again. I had friends that weren’t trying to steal from me.  I had time and energy to focus on myself and my work and my family. Being an addict takes up all your time.  I had time and I put it to good use. At five years abstinent I was living in a beautiful condo in the west end, had a job I loved, friends I cared about. Nobody used drugs. No one knew that part of my life in detail, not that I hid it but I didn’t get into the sordid details and they just didn’t know.  I mean they knew but they didn’t know. It’s one thing to know that women and men exchange sex for drugs with the lowest scum of the earth and that we’d steal or lie and cheat. It's another thing knowing it. I ripped off my family. I’m not proud of that. Not the lying, betraying, not the person who  didn't care about anything or anyone.  But I’d changed.  It was a bad time in my life and now I was on the other side of it.
That’s when this guyI knew, I’d thought he had got clean and sober, showed up at my door one night.  I buzzed him in. Immediately he’s pulling out this powder,  showing me it and saying it was the best stuff ever.  He's wanting me to do it with him.  He's saying how he could even sell me some if I liked it.
Well, right there and then I kicked him out. I would have physically thrown him out if he didn’t go. I was really furious.   I shouted at him, “get the fuck out of here. I don’t do that shit any more” . When he was leaving I almost whispered, I was so angry, and embarrassed, I was embarrassed too.  I said ;don’t ever come round here again or don't even talk to me if  you’re not clean and sober. "
He went on to say, “I don’t think people get it.  What he’d done was an every day thing in my old life. But now, it may as well been having this guy show up at your westend downtown apartment. Right there at your condo where people know you as a regular guy.  Then there's this guy standing there with a goat and he's saying,
 ‘hey man I got a new goat.  You're really going to like it.  I brought it over so we both could fuck it. If you like it like before I know where we can get more goats to fuck."
That’s how weird it was for me having this guy I’d known in the past,  show up at my place with powder. "
"I realized my attitude had changed.   I was seeing drugs and addiction the way healthy people see it. I just say now.   If some one wants to do it, just leave me out of it.   Live and let live.  I don't fuck goats. so don’t bring any goats around my place.  I don’t want even to be  seen with guys who fuck goats. "
Dr. Vaillant, former head of psychiatry at Harvard studied addiction extensively throughout his career and noted that at 5 years abstinent the risk of a person relapsing to their previous level of abuse was no greater than the risk of an unidentified user becoming an alcoholic or addict to that extent.
Higher power, a supportive group and a change of attitude were the key features noted in those who remained abstinent 5 years.

Doc-Side Medical Clinic

Dr. G. Horvath has had  low key Downtown East Side medical clinic for many years. A family physician with advanced training in physical injury and addiction medicine, he manages this 'walk in clinic' as well as maintaining a methadone/suboxone clinic.
As an addiction psychiatrist I met him when I was licensing to provide methadone treatment. One of the most respected clinicians in the field he commonly trains new physicians in the addiction medicine practicums.
Licensed now in methadone treatment and well credentialled in psychiatry and addiction medicine,  I was actually happy to continue to work  at Doc-Side clinic if only because Dr. Horvath is an excellent colleague who is glad to share his knowledge on complex cases.  He's a doctor's doctor, a consumate clinician, caring and extremely conscientious.
I've worked here five years now.
In addition to managing methadone patients a couple of afternoons a week I provide psychiatric consultation to addiction medicine patients one morning a week.  This is possible because if patients don't show for an appointment the clinic has a 'stand by' arrangement so I'm able to work and not lose income.
Private psychiatrists who make up over 75% of psychiatrists tend to be cautious about seeing patients with drug or alcohol problems because this group is notorious for missing appointments. When a patient misses the appointment the doctor doesn't get paid. Since we're all running businesses with overheads of roughly forty per cent, drug addicts and alcoholics, often the most in need of psychiatric services, fall between the cracks.  Further the DTES patients are no able to pay the 'missed appointment' fees that the better heeled carriage trade can.
The other 25% of doctors work  in salaried positions with all the benefits. The public mental health programs have physicians as 'consultants' but mostly the patients see counsellors.  The 'team' approach is ideal to care but patients complain commonly about a variety of factors, some of which might well have validity.
At Doc-Side medical there is an Administrative Assistant and two or three administration personnel maintaining records, ensuring clinic payment and managing medication timing and urine testing.  The clinic costs at a methadone clinic are substantially more than a regular clinic because of the urine testing, random urine testing and required provincially mandated rules for clinic maintenance.
In British Columbia there are three forms of methadone license.  A physician or psychiatrist may have a license to prescribe methadone for pain. Methadone is a potent long acting narcotic that has specific benefits and use in oncology and palliative care as well as other areas of medicine.  I have this license but while I prescribe narcotics occasionally for pain haven't had a major pain practice in which I'd be using that license for this purpose.  Other narcotics not requiring special license are usually sufficient for most doctors who don't 'specialize' in pain areas specifically.
The second methadone license is that for prescribing methadone in a Methadone Treatment Clinic.  All the doctors working in methadone maintenance programs must have this special license and must in addition to academic training, have a day at least of apprenticeship experience with a senior methadone doctor.  Dr. Horvath, as an acknowledged leader in the field of heroin addiction and methadone maintenance is such an individual
The third methadone license is a clinic license.  Dr. Horvath, having a license for methadone maintenance also has a license to run a methadone clinic.  Methadone maintenance programs in the province are run out of clinics.  I and a half dozen more doctors who have a methadone prescribing license rotate through Doc Side Medical Clinic.  The requirement for a methadone doctor to have a methadone clinic license includes extensive experience and standards of excellence in their history of medical practice.  Others, such as pharmacists may obtain a 'methadone clinic' license, I believe, but the process is rigorous.
Because addiction is often associated with a higher risk lifestyle, from a public health perspective there is increased concern for communicable diseases and trauma associated illness.  There is further a very high overlap between addiction and alcoholism and co morbid psychiatric disorders.
Since working in the clinic I've treated all manner of psychiatric disorder, from gross psychosis, schizophrenia, neurotics, psychopaths, sociopaths, personality disorder, Bipolar disorders, Traumatic Brain Injury, Paranoid Disorders, Disocciative Disorders, Anxiety disorders  and alot of PTSD.
I was a supervisor in the Vancouver General Hospital Psychiatric Emergency so the psychiatric conditions are well within the range of my subspecialist training and experience. What is difficult about the work is the overall lack of resources.
Two of my suicidal depressed patients went to the hospital last year only to be turned away. They hung themselves. I don't fault the ER because the threat of suicide is high with alcoholism and addiction.  I only wish that I was there and  grandiosely hope that I might have stopped my patients from premature death.  Working with addicts and alcoholics I've seen more death than when I worked with HIV patients.  Suicide is difficult to deal with an I know many psychiatrists who have avoided the high risk areas choosing more boutique practices where patients are less suicidal and have more resources available to reduce the risks.
What I find interesting though here is the burden of physical illness I encounter.  The other doctors I work with, like Dr. Tsung and Dr. Kljajic are excellent family physicians like Dr. Horvath.  They have excellent cutting edge diagnostic and therapeutic knowledge .  I was a country family physician and treated the physical illness of many patients in my psychiatric practices but it's been often years for me in terms of therapeutics. I daily look up the latest treatments and often have luxury of asking one of my esteemed colleagues their opinions.
 Diagnostically I believe I'm far better than I was as a young doctor, simply because of experience.  I did appreciate asking my colleague when I saw a classic case of erysipalis.  Thankfully he knew what it was and what the treatment was.  I just recognised the pathology  but couldn't remember the name and treatment.  I am blessed with having seen so many patients I know 'normal' and am very alert when I see 'abnormal'.   The forms of cellulitis here are very variable. Last month I diagnosed a new TB case. Hep C is prevalent. I have several HIV patients.  Among ourselves invite each other to listen to heart murmurs and observe unusual patholgy. It's a joy working with other clinicians.
Only last month Dr. Horvath diagnosed a pulmonary embolism we all auscultated.  Last year I sent a patient to cardiology with myocarditis because the heart sounds were abnormal. We've felt our share of abnormal livers so don't bother each other with those.
 Every patient entering the Methadone Program gets a complete physical and standard screening laboratory and hematology testing. So we pick up our fair share of anemia and hypothryroidism.  I diagnosed a cancer last month sending the patient for confirmatory xrays and onto the appropriate sub speciality clinic at the hospital. I appreciate asking the other doctors who work on the same days I do their opinions and they seem very happy to have my psychiatric input on some of their more unusual patients.  Psychopharmacology is second nature to me as is physical pharmacology to them.  We do see a lot of trauma and order a number of ultrasounds and xrays. Dr. Horvath's orthopedic training has been as helpful as my rodeo doctor experience in diagnosing dislocations. Addiction obscure symptons and often patients aren't that good historians because of mental illness. So it all helps.
Methadone clinics reduce crime and disease spread by stopping the theft and sex trade that so often goes with addiction. But it's especially good for it reduces and stops illicit needle use. Doc Side Medical Clinic is a major unsung public health resource in the Downtown East Side,
In addition to the medical and administrative staff with patient follow up and administrative close contact with pharmacies we maintain a close collegial relationship with the various housing assistance programs, the major local detox programs such as Harbour Light  and the long term facilities such as Union Gospel. We're also fortunate to have a very good relationship with Vancouver's outstanding "drug court".   We encourage attendance in peer support programs such as NA and AA and the new SMART group programs routinely.
Presently there is a counsellor associated with Doc side who is here half the week. He's highly informed about various resources and has been most helpfull getting patients a variety of services. He's assisted people on the methadone program finding housing, getting rape crisis assistance, advocacy and as well provides both Cognitive Behavioural Therapy and Mindfulness Meditation Therapy for patients.
All we're lacking from my perspective is an outreach community nurse.  When a patient misses their methadone for three days the dosage must be lowered to the starting dose because of fears over overdose.  The pharmacists keep a record with computers of 'reversal' of methadone dosage. If a person were to miss 2 dosages an out reach nurse could find out what the problem is and hopefully arrange for the person to get their methadone rather than being lost to follow up. It's the one major disruption in care that often results in the patients ongoing relapse.  Relapse is common with addiction but the key is ensuring that the person gets back into the program as soon as possible. Further we have patients with major medical and mental health issues who just fall below the radar. A community nurse could follow up with a home visit to see what the concern is.  It's sad to say but patients have been found dead in tenements after days. This could be preventable.  I think of my patient who had a heart valve issue and simply with the winter cold didn't have the energy to get out to the pharmacy.  With a community nurse we would have found out early rather than late.  Just like my schizophrenic patient who became psychotic and afraid to leave his room when he stopped his anti psychotic medications.  The drug dealers sell door to door and do deliveries so we're commonly 'competing' with 'saving souls' from the lowest forms of drug dealers. It would be nice to have the resources.
Increasingly addiction is being conceptualized as very like an infectious disease. It 'spreads' through neighbourhoods.  This is especially true with young people.  A drug dealer will show up at a school or workplace or construction site also and slowly 'push' to a widening circle of addicts. It starts as 'recreational' but the aim of the dealer is to find the vulnerable because addicts are major cash cows.
The good news is that Recovery is even more 'infectious'.  For most of my patients , I am the only person they really get to know who is 'clean and sober'. They get to know the staff and counsellor then the pharmacists and slowly a widening circle of people who are normal surround them.  It's further recognised that physicians have a great deal of importance in initiating behaviour change.  It's no surprise that the Big Book of Alcoholics Anonymous 50 years since it's inception continues to start with the Doctors Opinion. A day doesn't go by that my colleagues aren't promoting smoking cessation and working here I see every once and a while their gargantuan efforts pay off.
Drug dealers are death salesman and they pile lies upon lies. Commonly patients are grossly misinformed about addiction and alcoholism. The methadone clinic is commonly their first contact with the recovery movement.
Thanks to the leadership of Dr. Horvath , all the doctors who choose to work at Doc Side maintain a recovery focus.  We encourage people to change their life style and get better health care and move onto abstinence based programs such as Narcotics Anonymous. We encourage patients to get into 'safe' housing.  We discourage crime. It's a great atmosphere to work in.
Research has shown that patients who are in well run methadone programs will tend to progress out of the sickness and criminal life and back to work and health and better social relationships by 2 to 3 years in methadone treatment programs. By contrast patients who continue to use heroin IV on the streets may be dead in that time or have acquired more chronic lifestyle related diseases. We also detox mostly younger patients over months from shorter addictions to heroin and other narcotics. Increasingly Suboxone has helped in this regard.
By contrast there have been reasonable criticism of some methadone clinics where the doctors and pharmacists were running a 'drug pushing' factory.  The patients were seen as 'customers' and the pharmacists especially didn't seem to want to lose the high priced drug sales that are associated with methadone maintenance programs.
The College of Physician and Surgeons of BC and the College of Pharmacists of BC are both involved in tight regulation of the programs overseeing training and maintenance. Personally critical of some of the highly expensive and destructive aspects of political correctness in government bodies I've only seen the finest work done by the College in this field.  The Colleges even have 'sting' operations and work closely with the Vancouver Police and RCMP to manage the programs. Just this summer 46 pharmacists and pharmacies lost their licenses to dispense.  Every once  in a while too a doctor is reprimanded for mostly negligent work. Dr. Horvath is asked, for instance, to review the work of colleagues and other clinics to ensure their records and management are at the standard set by the Colleges for this program.  The Colleges much to their credit run a very tight ship.  The area of addiction is rife with potential for abuse and corruption so I've grown to admire those in the College that ensure these programs run with excellence.
So Doc Side Medical Clinic is this rather low key clinic doing a rather large amount of work in an area of greatest need. There are other methadone clinics nearby where friends work  too.  I know they're 'run' with the same concern and consideration that Dr. Horvath shows. We often run into each other in the regular continuing medical education events for addiction medicine we attend each year. Most of us are certified with the Canadian Society of Addiction Medicine which maintains the highest standards of care.
Methadone clinics, especially the well managed ones, are often under appreciated and not that well understood. There are no Doc Hollywood  working here, that's for sure.  I daily see the work and it's paying off with time. I see the benefit.   Because we cover for each other I see my colleagues work and talk with their patients.  I especially appreciate the work of Dr. Horvath and the other doctors he's attracted to working in one of the most difficult areas of medicine, in one of the most notoriously difficult areas of Canada.  Doc Side Medical Clinic serves the the Down Town East Side of Vancouver (DTES).  

Addiction Dialogues, Hillcrest Community Centre

The Hillcrest Community Centre host for the evening was very helpful and organized.  We had a large room upstairs  away from the busy but healthy pool and gym activities below.  We began as people were still coming in till it was finally a full house.
David Berner, radio host, actor, founder of X-Kalay Foundation for addiction, author of the recent book, All the Way home and group therapist at Orchard Treatment Centre on Bowen Island, was the moderator extraordinaire for the event.
Opening the panel was Counsellor Candace Plattor, author of Loving an Addict, Loving Yourself.  She spoke mostly to the effect of addiction on family and community. She described solutions for treatment incorporating choice and choices individual and family needed to make to avoid enabling.
Brenda Plante, Executive Director of Turning Point Recovery Society , spoke to the incredible success of their recovery home programs over that last 30 years. Brenda Plante is a household name in the recovery community of Vancouver for her big hearted, thoughtful but well managed programs. She has support from communities, neighbours, clients, governments, RCMP and all the doctors and counsellors working in addiction.   Already with houses in Richmond she's  just opened their newest house for women in North Vancouver.  She spoke of the program and the need for addicts to be reintegrated into life. Addiction is so isolating. It takes everything away. She encourages  people to become involved in groups,  clubs and various activities as part of their process of abstinence and recovery.
(I already have half a table of  tickets to the Turning Point's annual Gala. This year  Mathew Perry of the show "Friends"  is the keynote speaker.)
I, a physician, psychiatrist and addiction medicine specialist,  sat next to Brenda,  proud to be among such greats of the recovery community. I spoke mostly to the medical and psychiatric aspects of addiction, talking about genetics, liver, damage, lung damage, cancers caused, HIV and Hep C spread,  neurochemistry, harm reduction and medications, only being valid as they lead to abstinence and recovery. The 'cure' for addiction is abstinence.  (I did express my concern that there is a ‘customer’ model developing in the ‘harm reduction’ arena, with  conflict of interest, lack of faith and cynicism with increasingly two tiers of treatment, abstinence for the rich and educated and  harm reduction for the poor and less informed.  I spoke to the tremendous success of smoking cessation and how only 20 years ago this room might well have been filled with smokers and their accompanying clouds.  No better example could attest to the success of recovery. What is possible for cigarettes is equally possible for other drug addiction and alcoholism.  I mentioned Sabet's definitive book, Reefer Saniety, on the myths associated with marijuana.
AnnMarie McCullough began the first Recovery Day in Vancouver Canada. Now it’s spread throughout the provinces  so that it’s likely to be a national day perhaps as soon as  this year or next.  She also began Faces and Voices of Recovery while working at Orchard Treatment Centre. She spoke to the millions who are in recovery and the significance of their vote and political power. She was glad that the Health Minister, Terry Lake, provincially and Health Minister, Tony Clement, federally were so supportive of recovery. She encouraged everyone to speak to MP's and MLA’s and get involved like they were this evening, increasing  community awareness of the disease and need for treatment.  She spoke to the success of 12 step programs, other group therapies, treatment centres and recovery houses.
David shared a letter he’d received recently from a man, 35 years, clean and sober from drugs and alcohol, thanking him for believing in him in the days of  X-Kalay.
The audience participation began their with questions and answers.  Members from the Portland Society used this time to speak of  their controversial  provision of  alcohol for alcoholic and crack pipes for crack addicts. This lead to some interesting discussion.
A school teacher expressed his concern for the need for adolescent services.  Brenda Plante and Ann Marie spoke of the acute shortage of beds and other resources for adolescents.   Last Door Treatment Centre had however just opened some more  The need for adolescent services was a major concern to the audience.  I shared how Dr. Shimi Kang, an adolescent addiction psychiatrist was doing truly amazing work in the field.  (Our host  later told me he knew her and her husband personally and what a wonderful caring people they were.)
A tall man shared sadly how many friends of his had been killed by addiction. He spoke of Canadian solders who’d survived tours in Afghanistan only to come home to die in the clutches of drug addiction. He was very angry with  criminals invading every aspect of Canadian society with their "drug terrorism".
I couldn’t help remember  Sturges North motorcycle rally hearing  the great Canadian rock and roll band, Steppenwolf, singing their classic song, Goddam the Pusherman! I say, Goddam the Pusherman!
David thanked everyone for coming then individually we answered questions  speaking with people who told such tragic  stories of family members and friends  devastated by the disease of addiction.  A lovely woman was caring for the small children of her brother and wanted to know how to speak to the absences of addicted parents.
We were thanked all round.  Further Addiction Dialogues are planned.

Chronic Relapsers Misinformation

These are some rough estimates and truisms.. 10 % of people will have problems with an illicit substance. A proportion of those who avoid problems ‘spontaneously’ quit.  The earlier one quits substance abuse, the greater the success rate. Drugs and alcohol and other addictions are ‘fun’, ‘fun and trouble’ and finally just plain “trouble’.
Abstinence is the most successful ‘treatment’ for addiction. The WHO advocates that all harm reduction approaches should only serve as stepping stones to abstinence. There have been countless horror stories associated with ‘controlled drinking’ and clearly to date there are no good stories of ‘controlled crack’ use. The whole ‘control’ movement is as historic as ‘just say no’.
In studies of those who do ‘abstinence based’ therapies up to 80% achieve 5 year or more recovery. Dr. Marc Gallanter’s Harvard studies of doctors in recovery in AA shows 80% recovery up to 50 years after the last drink, decades of abstinence.  I personally know hundreds of people who once had severe addictions that cost them health, jobs and relationships but today are decades drug or alcohol free with successful careers and relationships.  Most of them are members of 12 step programs or churches.  Indeed addiction is described as a ‘spiritual disease’ by some and ‘cancer of the brain' by others.
The first ‘remission’ marker is one year.  The DSMV considers a person in full remission with a year of abstinence.  Most others including Dr. Vaillant of Harvard saw that the disease effects were significantly present for 5 years of abstinence when finally  a person potential for relapse was no greater than an as yet unidentified person’s risk of developing addiction.
In a famous Montreal study, 50% of those who returned to drinking, were able to avoid returning to their previous level of drinking, somehow maintaining ‘harm reduction’ without descending into their former abyss.  Interestingly a Holland study showed that people abstinent for 15 years who returned to drinking, 70% were able to maintain ‘harm reduction’.  While one in two odds of redeveloping a life threatening illness aren’t actually encouraging, and even a 30% chance of devolution at 15 years doesn’t look bright, this does suggest that the original disease appears to ‘burn out’ with abstinence over years.  The modern research on neuroplasticity and adaptation certainly takes into consideration the increasing information of the effects of ‘intoxication’ on the brain.  All research to date shows that those who achieve abstinence have the best life course, physical and mental health.
Note the word ‘toxic’ in intoxication. Addiction is associated with altered consciousness, dissociation and impaired mental capacity, the effects of which can last hours or days or , with marijuana for instance, weeks after the chemical brain trauma.  By contrast with alcohol, where there is social drinking where a person does not drink to toxicity (1-2 drinks)  with drug addiction, all drugs are used for the ‘effect’ :’chemical drunkeness”, “getting high”, ‘being stoned’.  People drank as a beverage whereas drug abuse is done to achieve 'toxicity'. Drug abuse alters consciousness. It impairs brain functioning. Enhancement of one function is countered by loss of other capacities as with drunkeness.
Addiction is like slavery.  A person is freed by abstinence but with relapse return to their slavery with the attendant lack of hope, lack of faith in their ability to get free, increased cynicism about their potential but more significantly increased negativity about ‘freedom’ itself despite the high success of those around them.  Their relapse and the associated depression that is usually concomitant in time is associated with severe 'cognitive distortions'.
Fruitflies were the great genetic tool of genetic research since they shared 70% of human DNA and had short life expectancy. Thanks to the overwhelming success and the extraordinary numbers involved in the recovery from cigarettes, Cigarette addiction and recovery have taught us as much about ‘addiction recovery’ in general as fruit flies taught us about human genome.
When people relapse they have already progressed through the Motivational stages of Prochaska from Precontemplation, Contemplation, Determination and into Action.  Unfortunately ‘relapse’ commonly throws a person back from the Action phase to the pre contemplation phase for a period of time.
In this phase they tend to be extremely negative and blame the treatment failure on a variety of usually inconsequential or irrelevant factors.  Rarely will they early acknowledge that they were no longer following a program.  Relapse is the outward manifestation of the 'thinking disease'  which is the precursor to actual substance abuse.  Mostly people begin by minimalizing their own previous difficulties with alcohol or drugs, begin to grandiosely believe that things will be 'different' this time round and delude themselves into believing that they can 'control' their drinking or drug use despite no personal evidence of their being able to maintain this in the past.
One of the prime criticisms of Alcoholics Anonymous was ironically the ‘god’ issue.  Addicts worship their alcohol and substance, living a ritualistic religion surrounding their death bound existence.  However in research with obese people, 12 step programs weren’t initially recommended but rather it was suggested that the grossly obese go to the gym. In contrast to alcoholics and addicts who are highly adept at ‘excuse making’ (the disease of alcoholism being personified as ‘cunning, baffling and powerful) the food addict, those grossly abese, simply said, “I don’t want to go to the gym’.  When advised to go to Overeaters Anonynous, they never mentioned the 'god problem's but  simply said “I don’t want to go out”.  It's refreshing to work with obese people in that they don't tend to waste their 'energy'  on 'excuses' despite their equivalent difficulties with stopping their compulsive food use.  At best they'll tell you they have a 'metabolic' problem.
It has long been known that alcoholics and addicts will go anywhere for a drink or drug and never complained about crosses in the room or pictures of the queen or president as long as their drug of choice was available there.  In the ‘contemplation’ phase of motivation they would complain about the colour of the paint if it convinced people they personally were the exception to the rule that recovery is good. The fact is, a person who has relapsed, has lost hope in themselves.
Psychiatrists long ago knew that with those who were ‘suicidal’ and had similarly lost hope in life, especially the chronically suicidal, needed the psychiatrist to ‘lend them their ego’.  We make decisions that suicide is not good for a person.  Similiarly those working in recovery who are successful maintain the idea that recovery is good for a person, much like thinking oxygen is.  Those who don’t, have been found to be associated with a very poor outcome measures as we saw with those who had a poor view of the suicidal. Outwardly the caregiver could go through the motions but at the covert and passive aggression level they were and are best recognized by their high death rates.
Much of the push for ‘harm reduction’ has been associated with a similar phenomena. The caregivers and those who promote harm reduction most are often ‘burnt out’ or always had a very negative view about the addicts and alcoholics.  One psychologist described this as 'caregivers and victims'.
It's even worse when those promoting harm reduction have an obvious 'conflict of interest'.
A recent Welsh study showed that Harm Reduction proponent counsellors  gave the success rate for recovery of their charges at less than 20% , but when these same people were in ‘abstinence’ based programs they achieved greater than 60% success.
This separation between those caregivers with hope and those without was also shown in cancer treatment.
Palliative Care is a program developed first for cancer therapy where the person’s disease was so severe and all alternatives for cure were tried without success and no successful treatment was known for the type of cancer the person had.  Palliative care is compassionate but it would not be if it was offered as a first choice or 'alternative therapy'.
Lack of success is not the case in addiction therapy.  Alcoholics anonymous has an 80% success rate 5 year and decades beyond but the ‘program’ is like the ‘birth control pill’.  If one takes the birth control pill once it is highly likely to fail.  This is the reason research did not identify the factors of high success in AA. Researchers simply asked people if they’d been to AA or NA. It’s common for people to go and not return, like those who asked if they used the condom for birth control might say they had but leave out that they’d only used it once in their life, and not the year they got pregnant.  The Navy Pilot program showed that 5 year 80% success with AA required a minimum of 3 meetings a week. The recent Scottish study which confirmed the 80% success rate included ‘home group’ and 3 meet ings and having a sponsor for instance to indicate ‘actual involvement’. As one person commented, a lot of people attend basketball games but you're more likely to find out how basketball is actually played and become good at the game yourself if you join the folk down on the court with the ball, rather than talking with drunk in the bleachers.
Relapse was associated with:
1) stopping or  reducing frequency of meetings. I often think this isn't different from any form of education since I meet people who despite having gone to university haven't read a book since and seem a hell of a lot stupider than people without a university degree continued studies.  With HIV treatment we need people to continue to take medication or they will die. We don't question the validity of the life saving 'medications' because people are 'noncompliant'.  We work on improving follow up and compliance but we are most impressed with our 'success' in developing treatments for HIV and Aids when at first there were no treatments. Since the 1930's we've made major strides in developing successful treatments for addiction and recovery.  Commonly people's lives are enriched in recovery and complacency returns.  Then stress occurs.  That's when all the 'tools of recovery' are thrown out.  I personally love the Dr. Martin Luther King quotation. "it's going to be a tough day so I have to spend more time on my knees".  When people have more stress, activity, change or success in their lives they usually need more 'recovery' activities, not less.
 2) Returning to previous association with drug abusers.  Recovery has been shown to be as “contagious’ as addiction. Having one abstinent friend in ones friendship circle reduces the chance of relapse by 25%.  People who relapse commonly begin to associate again with 'slippery people, places or things'.  Dr. Bob and Bill Wilson recognized that alcohol was ubiquitous in their society so said that recovery had to occur in the community. However it was also true they didn't recommend people avoid people in recovery and spend their nights in 'speakeasies'. In treatment today people are advised to avoid crack houses, dealers, and especially paraphernalia, as we know that 'jonesing' something not seen so much with alcoholism, but common in cocaine addiction does occur for up to a year after abstinence.  This phenomena is like we see with PTSD and the 'trauma' of addiction and the associated lifestyle. People with addiction today are often starting their addictive lifestyles earlier and have a world of hurt by the time they get into recovery with much less life experience, education or positive communities to fall back on.  
3) Commonly people recover from addiction but then have ‘expectations’ which are highly unrealistic.  Expectations have been called ‘preformed resentments’ and while AA and NA and other recovery programs treat the disease of addiction they specifically describe the need for members to get outside help with other issues.  These issues commonly include financial management advise, job advise and job training,  relationship counselling, pastoral care, anger management and a wide range of ‘maturity’ issues which are not achieved by addicts whose addiction stunts emotional, intellectual and social growth.  A person who has been hanging out with ‘potheads’ may stop their addiction but it takes time to develop a strong and positive friendship network , the kind that gives meritorious advice that makes life in general more successful and rich.  Increasingly the isolation of addiction is associated with the isolation of the internet following the positive experience of recovery in treatment.  Internet addiction then leads back to chemical addiction.
4) Attending a treatment centre may help establish abstinence and break the slavery to addiction but commonly just as with education there is a need for more advanced treatment education. Some treatment facilities like Betty Ford have programs for continuing education and also are set up for return of ‘sober’ or ‘abstinent’ members to work on more advanced issues like ‘emotional sobriety’.
5) Commonly ‘cross addiction’ leads to relapse. This is especially true with sex and gambling addictions which then lead to a return to chemical addictions.

It is critical to recognize that the ‘excuses’ that addicts and alcoholics give for relapse are usually time and ‘disease’ specific.  I’ve asked people who achieved abstinence after several initial failures what was the key. Almost invariably  I have heard that they really didn’t want to stop their addiction but had only planned to stop for a while to get somebody off their back. It's hard to accept having a lifelong disorder. I see the same difficulties with diabetics. No one questions the benefit of 'insulin' but all those who treat adolescent diabetics have seen the same problems we see addicts have coming to terms with the limitations of disease and the need to learn new methods of self care.
Often people in recovery get success but then the ‘boredom’ of everyday living lacks the ‘drama’ of the previous chaotic lifestyle and they solve the ‘little problem’ by creating a ‘big’ problem. Anyone who has 'worked on long term relationships' knows how the 'little things' if not addressed can grow into bigger things.  So often over time the 'little resentments' and 'lack of honesty' and 'living a lie' grow to a point where they taint the good life and recovery and relapse follows.  Recovery isn't a white knuckle affair but a lifestyle which is 'happy, joyous and free' because life is to be 'lived' not merely endured. This has been called 'emotional sobriety' and 'spiritual awakening'. It was always recognized that people who drank or did drugs has an 'underlying' predisposition or greater level of anxiety or sensitivity and had to learn new coping mechanisms for fulfillment.  When a person becomes an addict it is 'normal' for them to drink, drug or abuse. It is not 'normal' to be abstinent for an addict or alcoholic. To be abstinent requires them to daily live a life which promotes well being beyond that available by their previous lifestyle which 'lead' to addiction.

The ‘treatments for addiction’ are to date superior than most of the treatments for physical illness when they are applied and managed as recommended.  The problem which occurs with addiction is the same as doctors are finding with all the chronic diseases or diseases of lifestyle.  Indeed the treatment of chronic disease is increasingly learning from the successes first seen in addiction. The advances brought forward by 12 step programs are actually being translated to ‘accountability’ groups and used in the "normal' work place.
AA and NA introduced the concept of ‘anonymity’ as a ‘spiritual foundation’. They didn’t want people to speak of their personal success at a time when people’s relapse caused people to question the success of prevention and abstinence treatments.  Today there is overwhelming evidence of success of prevention and addiction treatment but increasingly vocal chronic relapser misinformation.
We used to hear “I stopped smoking but I didn’t feel any better’ in the first weeks of people quitting smoking.  They then used this ‘excuse’ to continue smoking.  However, now, with millions having lasted that first year of recovery we hear endless numbers of former smokers saying what a relief it is to them to be no longer be a slave to cigarettes. This is true of 80% of those who maintain abstinence from substances for five years.  Then those who relapse stand a very good chance of achieving long lasting recovery with appropriate treatment and relapse prevention programs developed for the individual relapser.

I liken this in my work to people with bladder infections. The vast majority get better with one antibiotic. A number relapse and the the antibiotic works again but there are those who need a different antibiotic and even those who we simply find it best to keep on antibiotics indefinitely.
The one week detox program has now had the 28 day program and there are recovery treatment programs which last 2 years. This was the same with mental illness where patients with similar psychosis were unsafe for themselves or others even with 1 week, one month or 3 months programs and they benefitted for a year long recovery in asylums.
All of these approaches standard in the scientific medical treatments are the same as we use with great success in the treatment of addictions.
Part of the success in treatment of mental illness was the recognition that substance abuse, like marijuana, alcoholism or harder drugs were all interfering with the learning and recovery process from mental illness. When I reviewed the suicide completion statistics in one program I found that though there were many who were at one time suicidal it was almost only those who had addictions
that completed suicide.

I’m commonly asked to see people suffering from depression or anxiety and almost all the time the family physician and especially the parents,( especially the mothers) , rarely know how severe the patients addiction to alcohol or marijuania, crack, methamphteamine or heroin is.  The patients tell me because I ask very directly and am highly trained in recognizing the signs of dissimulation that the alcoholic or addicts uses to ‘guard’ their ‘secret’.  
Relapse is treatable but the best solutions to treating relapse are to be found from those who once were ‘chronic relapsers’ and succeeded. I liken this obvious reality to our collective human experience with climbing Mount Everest. For centuries people ‘failed’ and we learned ‘how to fail’ from the ‘failures’ and eventually when people climbed ‘Mount Everest’ we learned how ‘best to climb Mount Everest from those who "succeeded."

Today the ‘harm reduction’ groups are arguing not only that Mount Everest can’t be climbed but that we should listen to people who either have never seen a mountain or may never have got to a base camp.

Addiction Dialogues, West Vancouver

I was honored to be asked by David Berner to be apart of Addiction Dialogues.   A panel discussion would allow the community to discuss and answer the concerns of homeowners, citizens, parents, employers and others interested in what addiction is and what can be done about it at an individual, family, work and community level.
David Berner, Executive Director of the Drug Prevention Network of Canada, had founded the first residential treatment centre which began in Vancouver British Columbia as the X -Kalay foundation and continued in Manitoba with Jean Doucha and the Behavioural Health Foundation.   His recently published book, All the Way Home, tells of those early years. Today as well as being an endless crusader for truth and proponent of living life to its fullest, as a weekly talk show host  and addiction counsellor, he helped co found the first Recovery Day in Vancouver.
AnnMarie McCullough started the Faces and Voices of Recovery and began the first Recovery Day in Vancouver which now occurs nationwide.  She also leads work at Orchard Treatment Center.  She was radiant sitting beside me, her inherent beauty even more so, since her recent engagement announcement.
Lorinda Strang, Executive Director the the Orchard Treatment Centre sat next to me. Her experience and work in the field is especially well known to the community of West Vancouver where she raised her family.  Wealthy communities such as West Vancouver are preyed on by drug dealers, their children at greatest risk.  
Candace Plattor, Registered Clinical Counsellor, and author of Loving an Addict, Loving Yourself, completed our panel.
As moderator, David Berner opened by asking us all what we thought addiction was.
Candace spoke mostly to it’s impact on family and relationships as well as stealing the life from the individual.  In her work she as often cares for family members who find themselves pulled into the desperate chaos of those addicted to a variety of chemicals as well as the process addictions, like sex, internet, eating disorders, gambling.
Lorinda Strang spoke to the total destruction of the person’s life purpose and the loss of all their interests and relationships and their failures in their relationships and the workplace.  She described how positive it was that businesses and families were recognizing addiction earlier and getting these members to treatment centres such as Orchard earlier when successes were most assured. She described the denial process and the abhorrent thinking, the rationalizations that ‘explained away’ all manner of loss and failure but never addressed the addiction itself. She talked of the wasted lives she saw daily in their work, people arriving like zombies and becoming human again in their relationships with other, lives restored with hope and joy and purpose.  She spoke of detox as only a first phase but the next months made easier in a treatment centre but then the life long need for awareness. The disease of addiction is a waxing and waning  condition from which one may recover, as evidenced by the millions that have,  but still they carry the risk for relapse.
I spoke to the neurochemical evidence of disease, the  genetic evidence, the twin studies, fMRI data, the hijacked dissociative thinking likened to a computer virus or cancer so that a person begins to ‘worship’ and ‘serve ultimately as a slave’ their God of addiction despite ‘negative consequences’ such as health problems,  failure in school, athletics, loss of important relationships and inability to maintain or manage work at previous level.  Whereas I tended to quote studies and research and stats, boringly, impressed myself by the science, the others tended more to tell personal stories, speak of clients, their families, friends and lovers and the communities they knew.
AnnaMarie McCullough spoke to the negative effects on the individual and the community. She spoke to the stigma associated with the disease and the isolation the individual experiences and the road back to community which comes in the recovery.  She expressed concern about the ‘enabling’ individual and community services which were in as much denial as the individual with the disease of addiction. She spoke of Recovery Day’s function in increasing awareness and helping individuals and their communities see just how successful recovery is and how beneficial it was for the community.  She especially emphasized the joy that recovery restored and the love that people felt after often years of being desperately hiding and lying about their disease.
David Berner spoke to the grief and tragedy of the individuals who turned to addictions as their only solace and how this immediate relief then turned around and hurt them more and more as time went on.  He spoke to these individuals not wanting to be addicts, their mothers and fathers and brothers and sisters. He spoke to their being sick and the horrible lives they so often endured before  they became addicts. He spoke to the child who was physically and sexually abused and developed an addiction as a teen. More and more he said his concern was for the children who were turning to addictions and becoming horribly addicted because of the high risk teen agers have for addiction to marijuana, alcohol, cocaine, and all the process addiction. He said more and more the people he was seeing had not known any normal life having so often left homes and schools to follow their addictions.  He spoke eloquently for the tragedy of the addicted, their families, the loss to individuals and families. There is so much grief, he said.  He was sad that so many young addicts had lost the capacity to work and how much work had meant in his life, how addiction took away purpose from individuals he saw and yet how much joy he'd had himself having purpose in life and working to complete what he set out to do.
When the subject turned to treatment each individual spoke to the hope and the scientifically proven successes of a variety of treatments, the high success of 12 step programs and abstinence, the benefits of treatment centres and recovery houses, the amazing successes of the drug courts, the usefulness of urine testing and variety of medications and services that were of proven benefit.
Candace spoke of the benefits of the therapy to family members and how even when an addict didn’t respond family could learned to protect themselves from the consequences of the addictions and be prepared to help when they could.  She described her work of recovery with loved ones and how as they learned to take care of themselves the addicted one often came round.
Lorinda Strang talked  of the countless successes that she had seen in her 20 plus years working in Addictions and the work of the Orchard Treatment Center on Bowen Island. She described her anxieties raising her children in West Vancouver, the difficulties that wealthy communities faced when it came to addiction and what could be done for the community and the children.  Living in this community she had seen the success of recovery and still continued in contact with people who once were thought to be untreatable but had recovered and gone on to be shakers and makers of society.
I spoke of the need to treat addiction and mental illness, as a dual diagnosis.  Yes it was common for those who abused alcohol to be anxious and depressed (alcohol is a depressant - 2 drinks on occasion, beneficial, 3 or more drinks toxic)  No treatment of only the anxiety and depression was  going to improve the addiction. Freud said addicts and alcoholics were untreatable and Dr. Carl Jung said only a miracle would work.  Because addiction is a brain disease the thinking of the addict is diseased so one had to treat the addiction first then it was possible to address whatever mental illness was underlying. All the attempts at treating the ‘underlying’ conditions first were proven repeatedly to lead to failure in the majority of people, but especially children and teen agers.  It was like trying to stop the bleeding being made by slashing without taking the knife out of the persons hand.  Hence the dual diagnosis and concurrent treatment programs that focussed first on the addiction then as safety and stabilization was achieved more and more secondary treatment of the mental illness was incorporated into the overall treatment plan.
I said that the success of all addiction treatment was evident in the amazing society success of the anti smoking campaigns.  Being of an age when all such community meetings were in a 'cloud of tobacco' smoke one didn't even have to think of the actual incredible reduction in cigarette smoking in society.  The loss of adult sales had caused the evil tobacco empire to directly target children in their marketing campagns so to my mind, we'd stopped short not arresting the CEO”s of Tobacco Companies.
These were the people who were now looking to make even more money selling misery to the young  by offering their ‘marijuana smoke’ or maybe even a ‘lighter cigarette, one half tobacco and half marijuana’ . As Amsterdam and Holland have moved their BC Bud products into the most restricted drug category, the same as Heroin and Cocaine, these big business forces were pushing for legalization of marijuana so they could get greater access to the teen and children ‘customers’ .  All the abuse of drugs including heroin and cocaine, except marijuana, had been falling as a result of education and recovery but now big business was targeting the young with marijuana.
No smoke is ‘safe’ and all evidence points to the the extensive health costs of all smoke (tobacco, marijuana, cocaine) yet these same corporate individuals who profited from tobacco smoke are now funding the marketing behind the ‘legalization’ of another ‘smoke’.
(I think I got a little upset at this point and told of the three young men I’d seen last year who’d developed schizophrenia after smoking BC Bud, and spoke of my scotty dog being murdered by the drug dealers who objected to my refusal to lie about their positive urine tests when they wanted to get “safety sensitive’ jobs where the other workers there didn’t want cheech and chong ‘pot smokers’ in their midst because they caused so many workplace deaths and accidents’)
David Berner kept the topic on track and opened the floor to comments from the audience. One amazing young man spoke eloquently of his experience with addiction and recovery and seeing so many of his friend damaged by drugs and then those like himself who got clean and sober getting back to school like he did, getting work and having great lives compared to their previous lives.
The audience asked great questions.  Someone talked of Gabor Mate’s book, Hungry Ghosts and how it helped them understand the trauma of addiction. Asked about the use of hallucinogens to treat addiction, I pointed to the possibility of a ‘sexy’ treatment helping one individual in a thousand but that we’d seen such ‘sexy’ cancer cures come out of Mexico with false promise only to have people spend their life savings on these 1 in 1000 remedies and then die when they could have taken a safe and proven treatment.  
I commented on the local work and research of Dr. Ray Baker, who started the first Canadian addiction education program for medical students . Working in Occupational Medicine he speaks to the high success of addiction treatments, in the 80% range, when the disease is caught early enough that the person still has a job or is  in school and has supportive family.   Dr. Baker still shows that in those who are at the end stages of the disease, physical illness, unable to work, isolated, that the success that present day addiction treatments with modern approaches, 12 step programs, treatment centres and recovery centres is still greater than the rest of our medical colleagues treating end stage diseases like tuberculosis or diabetes.
There were excellent questions about the lack of government funding, specifically for adolesenct treatment facilities.  AnnMarie McCullough and Lorinda Strang spoke of the poor histories of past governments in their waking up to the epidemic of addiction but that increasingly the government has been on board with helping but still had to come to a better understanding. David Berner spoke of his meeting this week with the British Columbia Minister of Health, Terry Lake.  “Terry Lake was very concerned about addiction in the community, especially it’s affect on adolescents”.  The BC Liberals were invested in addressing the need for increased treatment.  An example was the support the new Turning Point Recovery House in West Vancouver had received from local and provincial government.
I answered the questions about changes in methadone ‘delivery’ policies stating that the primary concern of the College of Physicians and Surgeons of British Columbia was the safety of the citizens of BC.  The greatest concern of the College of Physician and Surgeons is the ‘diversion’ of methadone and the risk diverted methadone would pose for an adolescent or child.  The concern for that ‘risk’ was the basis of the review of the present day ‘delivery’ policies because some pharmacists had not been able to ensure the level of safety that the College of Physicians and Surgeons and their sister organization the College of Pharmacists require for the Methadone Program to run.
Regarding the question of Harm Reduction versus Abstinence I pointed out that the World Health Organization position was that all harm reduction program were only valid so far as they worked towards abstinence.  Controlled drinking had been a failure and as David Berner pointed out Mothers Against Drunk Drivers had done amazing work to ensure that judges, especially  remembered the danger that addicted persons posed to the community and didn’t just listen to the major alcohol  producer and sales lobby.
There was question too about some of the  more controversial local Harm Reduction programs. I quoted the Welsh study that showed that the lack of faith and hope of some counsellors for the recovery of their members was often far far less that the scientific evidence of success of the individuals themselves. In the Welsh study the ‘harm reduction’ counsellors had commonly given their ‘clients’ an under 10% or  30% likelihood of success when the follow up studies showed that 60% of these individuals a gained and maintained abstinence.  Dr. Marc Gallanter of Harvard showed that 80% of doctors maintained long term recovery in Alcolics Anonymous and Narcotics Anonymous many being 30, 40 and 50 years abstinent in his research.  I expressed the concern locally that no judge or doctor with addiction would be advised to accept a “harm reduction’ program whereas often that’s all my poor patients were being advised to take.  This white collar and blue collar approach to treatment was simply wrong.  Further when I talked to some of the harm reduction proponents they were really saying there was no 'hope' for their 'customers' and that they should be just given 'palliative care' (i.e. comfort, since no cure was available).  I found myself thinking of some of the people I'd met who had promoted 'euthanasia' for all mentally ill patients. I was so thankful that the Welsh study showed how wrong these individuals usually were.
Everyone loved Candace' concern for family and friends of addicts;  Lorinda’s experience and expertise helping individuals and family, the world renowned fine work of the Orchard Treatment Centre, AnnMarie McCullough’s passion for community and recovery and David Berners great sense of humour and skill as a public speaker and moderator.
I was just thankful to be apart of something very good  and be there for those special moments when David, AnnMarie, Lorinda and Candace’s words touched my very soul. The people who were present wanted the very best for their community as their presence, attention and questions showed.  I really admired them most

Recovery is Contagious

"Change your playmates and you  change your life".

It's well documented that addiction is contagious. People who associate with those who have an addiction are most likely to develop addiction themselves. The presence of a only one abstinent person in one's social network reduces the risk of developing addiction by more than a quarter.

The greatest density of long term abstinent persons are found in 12 step self help groups.  Doctors in recovery had a greater than 80% likelihood of long term abstinence and the vast majority of those return to and continue working in their recovery. There is even evidence that people who recover become 'better than well'.  Followed as a cohort they are indeed healthier.

There is a tendency to provide 'housing' and other 'services' to those who are addicted without realizing that it isn't 'housing' alone that is beneficial but 'safe and clean' housing. Locally the greatest difficulty for those recovery is the constant harrassment and forceful marketting by 'drug pushers'.  'Goddam the Pusherman' written by the Canadian rock bank, Steppenwolf, summed up the 'problem' decades ago. 

The illicit drug industry is no different from the tobacco industry. Promotion and marketting are central to the multi billion dollar profits. Marijuana is such an illicit drug too.  Once a 'near beer' potency, today its potency is the equivalence of the 'white lightning' LSD of the 70's.

Those who attend self help programs are the most likely to sustain long term sobriety.  Research shows that attendance is not as effective as participation in the 12 steps.  Those who actually participate show a high rate of recovery. It's been compared to knowing basketball, those who are playing the game versus those who are sitting in the bleachers. That said, even those who are required to attend self help programs are at higher likelihood of recovery than not as evidenced by the overwhelming success of 'drug courts' compared to jailing drug abusers.

The more 'activity' in a persons life, like work, volunteer work, hobbies, activities, institutions, group involvment , the greater the likelihood of success. "Change your playground' and you're stay clean and sober is a motto well demonstrated by research. However those who have an apartment where they have used and is associated with abuse may in fact have greater risk than those whose addiction causes them to have to find new accomodation that is drug free.  Those who are able to live in drug free environment surrounded by people who do not use are most likely to obtain long lasting recovery.

There is a 'myth" that abstinence and recovery are less likely. The research shows that over time 60% of people achieve lasting recovery and those who have 5 years of abstinence are most likely to remain abstinent for life. The reason for the 'fallacy' that 'few achieve recovery' is that people in the field tend to see the revolving door patients who are least successful. The same observation was true with asylums where the staff thought schizophrenics were mostly in asylums when in fact the vast majority of those with schizophrenia commonly are living in the community and may only be in hospital a few months of their life time.  Those who recover from alcohol and drugs tend to move out of self help groups and return to community pursuits. Because of their success and the tendency to discretion about past difficulties they aren't considered as part of the stigma that can be heightened by the overt drug abuse of prominent politicians or others in the news media.

People remember the overt aberrant drug addict and forget the less dramatic successful person in recovery especially as those in recovery are now usually part of the mainstream of community. 

Recovery is contagious. As one leading addiction doctor is prone to say "you either run with the turkeys or you run with the cheetahs."

Social Recovery and Abstinence

This was truly one of the very best presentations that I have ever heard. It was given as part of the CME  at the IDAA 2013 conference in Denver, Colorado. The presenter was truly inspiring and a great presenter. I apologize for these rough notes and have recommended to friends that I'd encourage anyone who wants some cutting edge research and a terrific presentation to get in touch with Dr. David McCartney……Despite being from Scotland he spoke the English language with great clarity.
I was further impressed to learn of the great work being done by Bill White whose original papers I'll definitely be obtaining.

National Health Service UK LEAP

Lothians and Edinburgh Abstinence Program

 

Recovery and Social Factors

 

Dr. David McCartney

 

Scottish Context (or whit ye need tae ken)

1.Do People Get Better

2.What is recovery?

3.What is the evidence?

4.How Does Recovery Happen?

5.Social influence, visibility and contageon

 

1. “Scotland - we are a small country with a big problem”

Pop 5.3 million

54,000 problem heroin users

Twice rate of England and 5 x that of US

22,000 on methadone

584 drug related deaths in 20011

Costs 3.5 billion pounds ($5.4 billion)

 

34% of men and 23% of women drinking to excess (self report)

5% of pop dependent on drink

Cirrhosis rates have doubled

 

Vast majority of liver cirrhosis deaths are related to alcohol

 

Enormous increase in alcohol related mortality

 

Alcohol related deaths - high related to neighbours.

 

It’s multifactorial causation

 

Change in perception - unacceptable to be seen drunk in public in my granny’s day where as today any weekend night you’d see lots of people drunk in street

Supermarket spirits

Price of alcohol falls and alcoholism rises

 

1. Do people get better?

“Saw administrator in Scottish harm reduction facility and told that if you want to succed in this work you have to believe no one will get better.”

“I decided not to work there.”

 

Desistance (crime)

Belief nothing works

-85% of repeat offends desist from criminality by the age of 28 (Blumstein and Cohen 1987)

Recovery rates

-CSAT (2009)  58% of life course dependent users of substance will achieve lasting recovery

-Bill White (2012 50.3%

-Welsh workers estimate 7% (Best)  - asked the addiction workers and this was their idea - this is the “Clinical Fallacy”.  Major gap between reality and belief

 

Outcomes (US) physicicians

80% pluse sustained abstinence

70% return successfully to work

High expectation

Intensive treatment

Monitoring

 

Outcomes (UK) physicians

79% abstinence (at 3 years)

Most return to work

Most avoiding GMC (Boards)

Unlike their patients most opiate addictied physicians don not end up on opiate replacement therapy

 

Lothians and Edinburgh Abstinence Programme

• positive residential treatment program, medical and social, 3 months
• funded at point of contact through NHS

 

Seven Pillars of LEAP

-medical

-therapeutic

-housing (safe, supported)

-education/employability

-mutual aid/recovery community

-family programs

-aftercare  (2 years)

 

This is fairly new in United Kingdom

 

300 referrals/year

 112 admissions/year

62% completion

52% graduates maintain abstinence (one year)

 

Do people get better?

YES

 

Duration of Recovery

(Bill White 2013)

 

When does recovery today predict recovery for life

Point of durability seems to be reached by 4-5 years of recovery -stay sober and clean for life

 

What is Recovery?

-voluntarily sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society - UK Drug Police Commission - 2008 p6

 

-Recovery is a process through which an individual is enabled to move on from their problem of drug abuse towards a drug free life and become an active and contributing citizen -
Scotland

 

Betty Ford - sobriety, personal heallth and citizenship.

 

You are in recovery if you say you are - valentine - abtinence alone is not recovery

 

Evidence Review

There is little UK based research and international evidence base on recovery is limitted by 3 factors

1. dated 

2. much is based on alcohol and not illict drugs

1. much of it was US

 

But

Sustatined recovery ‘is the norm”

Recovery is related to the 12 step process

-

-

 

Study of workers in the field in recovery from heroin addiction (108)

‘tired of lifestyle, found rock bottom, 

why did they stay stopped

-moved away from using networks

-found treatment not that important

 

Mapping the recovery journeys of former drinkers (Hibbert and Best (2011) Drug and Alcohol Review)

-graphs

• physical health
• psychological health
• environment
• evidence - in early recovery - first 2 years a little lower than society norms
• “BETTER THAN WELL RESEARCH” after 5 years appear to do better than the population norm. 

 

Post Traumatic Growth

-from natural disasters like tornadoes, plane crashes murders( McMillan 1997) , sexual assault (Frazier 2004) 

-pain touchstone of spiritual recovery and growth

 

How does recovery happens

Several models

1. Social control
2. Social Learning
3. Stress and Coping
4. Behavioural economics 

 

Structural equation modelling results

over 2000 patients

Self help movement involvement - active coping, motivation to change, friendship - all contribute to substance reduction.

 

"Getting you plugged in makes you well"

Holt-Lunstad & Colleagues (2010)

Grella and colleagues (2008)

Best and Laudet (2010)

 

*Number and quality of social relationships predicted long and healthy life

 

 

People who relapsed were less likely to use self help movement

 

Community benefit - increased non using relationships

 

Lit et al “changing network support for drinking (2009)

-one abstinent person in network decreased risk of relapse by 27%

 

Recovery studies in Birmingham and Glasgow (n=205)

-more time with other people in recovery

more time in activities.

 

Recovery Capital

-breath and depth of internal and external resources that can be drawn on to resist alcohol and drug abuse

• can increase ‘recovery capital’ 
• clean housing, friends, family ,health, volunteering, peer support, work
• new concept in UK - assertive referral to mutual aid
• - mostly getting people on to AA/NA
• -find out what meetings are available
• hard to get professionals to believe this and do this despite all the evidence that this work
• less than 5% will respond with just a brochure
• need to have someone meet them and go with them and ask about the meeting in follow up
• 1,200 groups weekly
• various family and servicers groups

 

How are we doing in Edinburgh (The Gap)

Do you or have you ever used AA/Na

AA- .8%

NA - .4%

 Part of it is the misperception about the success  - self help recovery is very successful

Clinical fallacy exists that recovery isn't successful mainly because - we don’t see those who get well

Misperception it’s an religious group

 

Alcoholic Anonymous in UK

• all the mutual aid groups are growing and some very rapidly

 

Social Influence and Contagion

-"hang around recovery people long enough and you might catch a dose of recovery"

• same is true with addiction

 

Framingham Heart Study - Christakis and Fowler

-person’s odds of becoming obese increased by 57%

(similar research with smoking -if your partner stops smoking 67% increased chance you will)

-Conclusion ‘your friends can make you fat’

Obesity Epidemic

64.3% Scots obesid

 

“obesity is catching’

 

Social learning and Social Control

 

Social Network and quality of life

-Holt-Lunstad - 2010 - individuls with good social networks 50% greater likelihood of survival

 

12 step affiliation versus involvement

• **attendance at 12 is not likely to be as helpful as becoming actively involved
• ***getting a sponsor at 6 months 4 fold likelihood of not relapsing

 

“My recovery gave me a new life”

-recovery from addiction makes Scotland stronger”

-visibility important

 

Recovery communities 

outside mutual help

UK Recovery Walk

 

relationship between treatment and recovery

• treatment can be a part of recovery ‘initiation’
• gives the client the tools - managing your own recovery
• -self efficacy and enduring recovery (recovery maintenance)
• a journey, not a destination
• eg diabetes and emphysema - movement to training patient to manage their own 

illness from original management plan of solely seeing speciality

 

Contagion

• have treatment providers got it the wrong way round?
• Recovery is contagious
• Reocvery champions

 

What does it all mean?

1. Recovery is a reality - evidence - recovery narratives
2. Recovery is social - takes place in 12 step groups
3. Recovery is contagious - attraction, power of example
4. Worldwide evidence base needs to develop a  bit - 12 step evidence is strong and growing
5. We can actively connect people to recovery resources (