In theory, it seems a straightforward enough question—one that should have a more-or-less universally accepted answer. In reality, finding a definition that is satisfactory to everyone under the drug-user health umbrella is like seeking a syringe in a haystack. People’s answers are often inseparable from how the concept of recovery was introduced to them.

“Recovery” as presented to someone at a 12-step group or rehab—or who is merely passively ingesting the traditional public view—is much different from the idea passed along to people who use syringe services or are active in the harm reduction movement.

These two divergent versions⁠—one emphasizing abstinence from all illicit drugs and alcohol as an essential aspect of recovery, the other viewing each incremental step towards a healthier, less chaotic lifestyle as a goal in and of itself⁠—are often viewed as incompatible.

The Betty Ford Institute Consensus Panel, for example, defined recovery as a “voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship,” with sobriety categorized as “abstinence from alcohol and all other nonprescribed drugs.” This definition is often seen as being in direct conflict with one of the key principles of harm reduction, as outlined by the Harm Reduction Coalition, which “establishes quality of individual and community life and well-being—not necessarily cessation of all drug use—as the criteria for successful interventions and policies.”

Unfortunately, viewing these two visions of recovery as competing is a hopelessly ineffective strategy.

Most of the burden of coalescing these two recovery paradigms must fall upon the shoulders of those advocating for abstinence-based recovery.

If the United States is ever to have the faintest hope of ending the current overdose crisis and giving people with substance use issues the quality, evidence-based healthcare that they deserve, we must learn to view these definitions as complementary, not contradictory.

And in order for this to work, most of the burden of initiating the coalescence of these two recovery paradigms must fall upon the shoulders of those advocating for abstinence-based recovery. More specifically, governmental institutions and the addiction treatment industry must initiate this change and begin incorporating harm reduction practices into their currently abstinence-based frameworks.

To be clear, I’m not placing the responsibility for bringing together abstinence-based and harm reductionist recovery models at the feet of the Hazelden Betty Fords or traditional treatment-supporting politicians out of some sort of antipathy towards them.

In fact, I personally owe my quality of life, and very possibly my life itself, to Hazelden Betty Ford. It was at their Center for Youth and Families where I got sober a decade ago. I am also grateful that Congress and state legislatures have at least seen fit to finally begin providing the overdose crisis with the attention—though certainly not yet the resources—that it deserves.

I place responsibility with politicians and treatment industry titans because they, along with the media, control what is still the dominant recovery paradigm in the US. Traditional treatment programs also receive the lion’s share of the funding and therefore⁠—unlike their harm reduction counterparts⁠—have the scope to expand and diversify.

As such, they have the power to change the mainstream recovery conversation to one that includes evidence-based, harm reductionist principles.

When I was ushered into sobriety through a Minnesota Model, 12-step-based treatment facility, I thoroughly internalized the notion that abstinence—or at least the continual pursuit of abstinence—was a prerequisite for living a life free of addiction.

Despite routinely warning me of the dangers of engaging in “black and white thinking,” treatment staff never addressed the grayscale approaches to substance use disorders found in harm reduction. Moderating your use was presented not as a viable option if you didn’t desire abstinence, but as a delusion of the addicted mind.

In these spaces, “Go out and try some controlled drinking and using” was never a recommendation offered in earnest, but a rhetorical device to “prove” the individual’s powerlessness over a drink or drug.

“Come back to us when you hit rock bottom” is not a public health strategy. It is medical malpractice.

In retrospect, the complete absence of any instruction in the principles and practice of harm reduction in my treatment experience is jarring, but not altogether surprising. The traditional abstinence-based model of recovery was intentionally designed to create a sense of unity and purpose, but only for those who faithfully adhere to its precepts.

This conception, which seeks to bestow upon its membership the camaraderie and urgency of those trying to save one another from a sinking ship, can be quite successful for those who buy into it. Unfortunately, it provides very little for those who lack the desire or capacity to achieve abstinence.

It is worth noting that, in the 10 years since I was in its care, Hazelden Betty Ford has incorporated the use of medication-assisted treatment (MAT) with drugs including buprenorphine and naltrexone for clients with opioid use disorder—a development that would once have seemed unthinkable. Still, the deployment of MAT in its facilities is explicitly framed as a bridge to their ultimate goal of “a stable recovery based on the Twelve Steps and abstinence from opioids.”

Similarly, while syringe services programs (SSPs) are slowly gaining acceptance among some Republican politicians at federal and state levels in the wake of the injection drug use-fueled HIV outbreak in Scott County, Indiana, the partial ban on funding for SSPs remains in Congress. Very little of the money coming out of federal and state legislatures to address the overdose crisis is being given to harm reduction-centered organizations.

At this point, with scores of thousands of deaths every year, it should be painfully clear that any treatment modality or conception of recovery which fails to take care of those who don’t rigidly adhere to it and alienates broad swaths of people who use drugs is unsustainable.

“Come back to us when you hit rock bottom” is not a public health strategy. It is medical malpractice. And the biggest players in Washington and the addiction services industry need to realize this.

“Our idea of recovery … is that any positive change is recovery.”

Fortunately, there already exists a version of substance use disorder recovery that incorporates abstinence as one of a range of positive outcomes based on the desires and capacities of drug users themselves. This is evidenced, for example, by the involvement of many people in abstinence-based recovery in the harm reduction and drug policy reform movements—including in leadership positions.

This inclusive vision of recovery is currently being practiced by a number of innovative providers—perhaps none more successfully than the Missouri Network for Opiate Reform and Recovery.

“Our idea of recovery is piggybacking off of [harm reduction pioneer] Dan Biggs’ idea of recovery, which is that any positive change is recovery,” Executive Director Chad Sabora told Filter. “It may not look like the recovery that you’re used to hearing about, but it is recovery.”

Sabora and his colleagues accordingly provide a mixture of harm reduction and peer recovery support services to people with substance use disorders in the Greater St. Louis area. Missouri Network for Opiate Reform and Recovery operates an SSP, distributes naloxone and refers individuals who wish to go to abstinence-oriented treatment. The organization’s Recovery Community Center holds everything from 12-step meetings to harm reduction trainings and even acupuncture.

Sabora’s personal journey—which saw him transform from an exclusive advocate of abstinence-only recovery, based on his own experience, to an avowed champion of harm reductionist principles who also maintains a strong toehold in the 12-step community—is instructive. These ostensibly opposing viewpoints can co-exist in a mutually beneficial fashion, as long as impacted people are empowered to make their own choices and pursue whatever works for them.

“We all have the same goal,” Sabora said of abstinence-based recovery proponents and harm reductionists. “Our goal is to keep people alive. If we worked in unison, we’d have a lot more success.”

Photo adapted from Jens Lelie on Unsplash

The post Can Harm Reduction and Abstinence-Based Models Constructively Co-Exist? appeared first on Filter.

Unfortunately, when it comes to drug-user health, opposition to many best practices like syringe service programs or safe consumption sites can’t be traced back to something as benign as habit and routine. I know, because at one time I personally harbored the kind of instinctive opposition to best practice that holds back progress. 

This also holds at a political level. Stigma, not science, is what has maintained Congress’s partial ban on providing funding for syringes and cookers at syringe service programs. Stigma is also the driving force behind the Trump administration Department of Justice’s decision to file an action to prevent Safehouse, a proposed safe consumption site in Philadelphia, from opening its doors to drug users in need. 

Much like arguments about access to abortion and healthcare for transgender people, the debate around drug user health is stuck in that unenviable space—with one side supporting its argument with science and the other countering with arguments based on their conceptions of morality and tradition.

Earlier this month, the organization I work for, AIDS United, joined 11 other national medical and public health organizations in signing on to an amicus brief in support of Safehouse, which is currently embroiled in a legal battle for its very existence. The brief, which was coordinated in large part by the Drug Policy Alliance, laid out in great detail why safe consumption sites (SCS) are an evidence-based response to the US overdose crisis.

From the perspective of evidence-based, scientific inquiry, there is no debate to be had about the efficacy of SCS.

Luckily, since there are already 120 legally sanctioned SCS around the world, there is a mountain of evidence for the efficacy of these programs from a public health perspective. SCS have been found to significantly reduce overdose deaths, prevent the spread of infectious diseases like HIV, and increase access to substance use disorder treatment and other healthcare services. At the same time, studies have shown that SCS actually reduce both the number of publicly discarded syringes and the frequency with which people inject in public. 

From the perspective of evidence-based, scientific inquiry, there is no debate to be had about the efficacy of SCS. They work—and we know they work because hundreds of peer-reviewed studies and the lived experiences of hundreds of thousands of people who use drugs tell us so.

In a sane and rational environment, this robust body of evidence would automatically have dissuaded the federal government from trying to stop Safehouse. Sadly, we do not live in such a place. The US government has not based its opposition on public health best practices. In fact, at no point in its complaint does the federal government—in this case the US District Court for the Eastern District of Pennsylvania—even mention the health of people who use drugs in Philadelphia. Instead it simply states that Safehouse would violate a subsection of the Controlled Substances Act informally known as the “crack house” statute, which makes it illegal to “knowingly open, lease, rent, use, or maintain any place … for the purpose of … using any controlled substance.”

I won’t get into a back-and-forth about the legality of Safehouse and other SCS, or the proper interpretation of this particular portion of the Controlled Substances Act. There are plenty of folks out there who are much better equipped to make the argument for Safehouse’s legality. 

I am all too familiar with the mental gymnastics and cognitive dissonance that accompany being presented with the efficacy of SCS.

I’m trying instead to speak to anyone who is still skeptical of SCS out of a fear that they might enable drug use, or from that nagging feeling that SCS are antithetical to the traditional notion of recovery from substance use disorders. 

I know these fears and feelings because I’ve experienced them myself. 

As someone who found sobriety through an abstinence-based, in-patient treatment center, and who has been fortunate enough to find community and purpose at times in my life through the fellowship of 12-step groups, I am all too familiar with the mental gymnastics and cognitive dissonance that accompany being presented with the efficacy of SCS. 

After internalizing the disease model of addiction and seeing an abstinence-based approach work in my own life, I had a hard time conceptualizing “going back out” or continuing to use as anything other than an irreversible descent into an ever-worsening addiction leading to “jails, institutions or death.”

Having being told over and over that half measures avail us nothing, I initially looked at these harm reduction-based interventions as just that. 

It was only after I sat with my own discomfort at the notion of SCS—after I read studies and heard personal accounts of their transformative capacity in the lives of people who inject drugs—that I realized the true half measure would be to adopt an overdose prevention strategy that didn’t incorporate best practices, just because they made some people feel uncomfortable.

Total abstinence is still viewed by many in the recovery community as the only desirable outcome for someone who uses drugs, and if that’s your truth you can abide by it. But know that you can’t get sober if you’re dead. And at a time when over 68,000 people died of overdose in the US last year, creating safe consumption sites⁠—facilities where there has not been a single recorded overdose death in the last three decades⁠—just makes sense.

Photo adapted from William White on Unsplash

The post Why Those of Us Who Choose Sobriety Should Back Safe Consumption Sites appeared first on Filter.

According to a soon-to-be-released study* from the Brown University School of Public Health, the answer is a relatively simple one: Set up syringe services programs (SSPs) and set them up early.

At the 2019 International Harm Reduction conference in Porto, researcher William Goedel presented the findings from a mathematical modeling study that aimed to simulate what the average rate of HIV transmission would be in Scott County under the three separate scenarios.

In the first scenario, Goedel and his colleagues measured HIV transmission rates when an SSP is established in the community before a non-virally suppressed person living with HIV entered the drug using community.

In the second scenario, the study examined what HIV transmission rates would have been had an SSP been set up after 10 people who use drugs had contracted HIV.

And in the third scenario, the researchers modeled what the average rate of HIV transmission would be if there was no SSP at all.

Unsurprisingly, Goedel’s modelling found that SSPs were very effective in reducing transmission of HIV among people who inject drugs, and that establishing an SSP before the initial HIV transmission better prevents the spread of the virus than when the SSP is set up early on in the cycle of the outbreak.

After running 1,000 simulations in each of the three scenarios, the study estimated that an average of 133 people in Scott County would contract HIV over a five-year period if no SSP were present (the real-life outbreak in 2014-15 resulted in 215 people contracting the virus).

However, if an SSP were introduced proactively into Scott County before any HIV transmissions had taken place, the simulation showed only an average of 27 cases of HIV transmission over five years, representing a reduction in HIV incidence of nearly 80 percent.

Under the scenario where an SSP was introduced reactively, after 10 individuals had contracted HIV, there were still considerable reductions in new cases of HIV, with an average of 57 people contracting the virus over five years.

It is always useful when harm reduction advocates are provided with additional peer-reviewed studies that reinforce the utility of SSPs.

The results of this study are not surprising, as there is already a long evidence base that shows SSPs significantly curb HIV transmission among people who inject drugs—and a previous modelling study on whether or not an earlier response in Scott County would have effected the dynamics of the HIV outbreak by researcher Gregg Gonsalves, published in the Lancet last year, had similar results.

All the same, it is always useful when harm reduction advocates are provided with additional peer-reviewed studies that reinforce the utility of SSPs when speaking with government officials who erroneously view syringe access with suspicion.

It is worth noting that the results of this study are specific to Scott County, Indiana and may not reflect the impact of SSPs on other communities. That said, the effectiveness of proactive SSP initiation in this study—combined with the mountains of evidence showing the positive impact of SSPs in reducing HIV transmission among people who inject drugs—leaves little doubt as to the need for SSPs to be a part of the US response to the opioid-involved overdose crisis.

*The full study, entitled “Implementation of syringe services programs to prevent rapid HIV transmission in rural counties in the United States: A modeling study,” is set to be published in an upcoming issue of the journal Clinical Infectious Diseases.

Photo via Todd Huffman / Creative Commons

The post New Study: Syringe Service Providers Could Have Prevented the Scott County HIV Outbreak appeared first on Filter.

On the one hand, there was the old ONDCP—the ONDCP that served as the White House’s enforcer in the War on Drugs and helped perpetuate the kind of drug policy that has filled our nation’s prisons with non-violent people, disproportionately people of color, and spurned public health approaches for ones that lean hard on law enforcement. On the other was a new ONDCP—one that worked to embrace evidence-based and harm reductionist drug policy as much as possible, albeit within the restrictive framework created by Congress.

By the time I left ONDCP in May 2013, it was clear to me that the Office had chosen to embrace the identity that saw substance use as a public health matter, not a criminal one. I was fortunate enough to do research and analysis on ONDCP’s work around medication-assisted treatment; Medicaid expansion; Affordable Care Act implementation; and Screening, Brief Intervention and Referral to Treatment (SBIRT). While ONDCP’s policies on a number of issues were far from ideal, it was evident that for the moment, they were moving in the right direction.

I think it’s safe to say that the guarded optimism of people like me has proven misplaced.

So during my time there and for several years after leaving—up until the end of President Obama’s time in the White House—I routinely defended many of the ONDCP’s actions and positions. After I joined an AIDS advocacy organization in 2016, I did this with friends and colleagues who dedicate their lives to the intertwined causes of HIV/AIDS and drug-user advocacy.

Serving as a self-appointed defender of an organization long viewed as the point guard in the federal government’s War on Drugs is an unenviable task. It has often proved futile in the face of the lived experience of advocates with no earthly reason to trust the executive branch’s stance.

Yet because I had seen for myself a genuine commitment to harm reductionist principles and an approach to drug misuse firmly rooted in a public health framework within the ONDCP’s walls, I persevered.

Under the leadership of Michael Botticelli—a man with well over two decades of experience in substance use disorder, public health policy and administration prior to appointment—ONDCP vigorously championed widespread access to medication-assisted treatments like methadone and buprenorphine, and supported both syringe access programs to prevent the spread of infectious diseases and the availability of naloxone for opioid overdose reversal.

I realize that many of you may object to this characterization. Roughly half of ONDCP, even then, dedicated itself to the sorts of supply-reduction activities that have been the hallmark of the War on Drugs. But, so my reasoning went, their influence over the Office’s mission and direction was waning, and the good being done by those on the demand reduction side of the coin outweighed any of the harms being done.

And, while ONDCP was prohibited by Congress from ever endorsing the legalization of any illicit substance and I never heard anyone there speak openly of such a thing, there were Obama-era ONDCP staffers who privately considered pushing for the decriminalization of marijuana. Surely, I thought, it would only be a matter of time before the tides of public opinion and common sense pushed the federal government as a whole, and ONDCP in particular, away from antiquated, moralistic and punitive approaches.

Ignorance, Arrogance and Fecklessness

Well, after the kleptocratic nightmare that has been the Trump presidency so far, I think it’s safe to say that the guarded optimism of people like me has proven misplaced.

Right now, in the midst of an opioid crisis that was the primary driver in an estimated 72,000 overdose deaths in 2017, President Trump and his political appointees have displayed a staggering combination of ignorance, arrogance and fecklessness with regards to drug policy that shows no signs of abating. Whether it’s trying to inflate the budget of the DEA, calling for giving drug dealers the death penalty, or working to systematically dismantle the health care safety net and take away protections for people with pre-existing conditions, the Trump administration has systematically added fuel to the fire of the opioid crisis.

This dead zone is populated by cast-offs and rejects from other corners of the Trump administration.

Developments like these, in demonstrating the power of the executive branch to trample over public health and progress, have convinced me that the ONDCP should be dissolved, or at least fundamentally altered.

It has been 20 months since Donald Trump was sworn into office and we still do not have a Senate-confirmed director of the ONDCP—popularly known as the “Drug Czar.” I’m not concerned about this. Because it’s arguable that we no longer have an Office of National Drug Control Policy—rather, just a physical space where that Office used to be.

This dead zone is populated by cast-offs and rejects from other corners of the Trump administration, for whom the president no longer has a use, but who are in possession of knowledge he would rather not see released.

ONDCP’s current acting director is Jim Carroll, a former counsel at the Ford Motor Company with almost no experience in drug policy who was assigned to lead ONDCP after being deemed a failure as White House deputy chief of staff. At around the same time Carroll was being reassigned, two high-level staffers for Tom Price, the now-disgraced former director of Health and Human Services, were moved there too: Price’s former director of communications at HHS, Charmaine Yoest, and his former chief of staff, Kristin Skrzycki, both found jobs at ONDCP.

When not serving as a safe haven for undesirable appointees from elsewhere in the Trump administration, ONDCP has been used to provide spoils for unqualified 20-somethings who worked on Trump’s campaign. Take Taylor Weyeneth, a 23-year old former Trump campaign worker who managed to finagle himself into the role of ONDCP deputy chief of staff.

Unsurprisingly, a large number of career staff at ONDCP have left in the last year-and-a-half.

With ONDCP’s role having been relegated in these ways, the President’s opioid response is being led by Kellyanne Conway, a woman with no experience in public health or substance use policy who said earlier this year that kids could avoid addiction by eating ice cream and french fries.

The Department of Justice, meanwhile, is being helmed by a mendacious little drug warrior in Jeff Sessions, a man who once said that “good people don’t smoke marijuana” and who, when he isn’t demonizing drug users, is actively working to dismantle our nation’s healthcare infrastructure and reduce access to substance use disorder treatment and prevention services.

Having failed to dismantle ONDCP by trying to cut the Office’s funding by 95 percent in both his Fiscal Year 2017 and 2018 budgets, the Trump administration did what they viewed as the next best thing by turning ONDCP into a husk of its former self, with no real responsibility beyond working with other federal agencies to try and convince Trump himself that marijuana is evil.

This latest effort, dubbed the Marijuana Policy Coordination Committee, has ONDCP asking 14 federal agencies and the Drug Enforcement Administration to submit all of the negative data and stories they can find about marijuana use to combat what they view as the emergence of a dangerously pro-pot narrative among the general public. They will then present Trump with a compelling case for joining his attorney general in strict opposition to legalization or decriminalization.

In an ideal world, ONDCP would be used to provide the president of the United States with a vehicle for promoting a coherent vision to address drug-related problems and implement a public-health framework. In reality, the ONDCP has been repurposed as a retirement home for disgraced staffers, which doubles as an anti-pot propaganda shop.

Photo: ONDCP acting director Jim Carroll, a former counsel at the Ford Motor Company [via Washington Examiner]

[Correction: The author worked at the ONDCP in 2012 and 2013 as an unpaid research assistant while pursuing a master’s degree in Social Work from the University of Maryland-Baltimore. An earlier version of the headline incorrectly suggested that he was a paid employee.]

The post Is This the Last Drug Czar? As Someone Who Worked in the ONDCP, I Hope So appeared first on Filter.