Guinevere Gets Sober

Recovery news, reviews and stories, by Jennifer Matesa.

Tag: addiction treatment

Recovery Coaches Need Accountability.

holding hands

Years ago when writing a story for one publication or another about addiction, I had the pleasure of interviewing William White, a researcher and clinician whose experiences with healing addiction go back to 1969. Since then, I’ve followed his blog, which invariably offers cogent and thorough analyses of questions and problems in addiction treatment and the fostering of access to healing. And since he has followed these questions for nearly 50 years, his perspective is unmatched.

Today he published a blog on the quality and need for supervision of recovery coaches.

He investigates a couple questions I’ve been asking myself for a long time, about these two support functions: the question of “ownership” of the person seeking help, and the question of accountability.

Ownership

In one of the many papers he’s previously written on the differences between therapists and coaches, this caught my attention:

Where the sponsor and counselor are prone to take “ownership” of an individual (e.g., “my sponsee” “my client”), the recovery coach (RC) encourages those they work with to fully engage with other sources of recovery support. The “prize” to which the RC role is affixed is not the adoration and eternal gratitude of those they have coached, but the recovery of these individuals within a broad network of recovery support relationships.

As a therapist-in-training, I’m interested in the differences between therapy and recovery coaching. I have heard many recovery coaches use the term “my client” when referring to someone they help. And I have seen some recovery coaches post messages from people they help that express those people’s adoration and eternal gratitude.

Mind you, I’ve also seen many recovery coaches—perhaps more than those mentioned above—express abundant gratitude for the opportunity to make their work helping other people.

But frankly, last year a recovery coach who also holds a clinical license boldly discouraged me from seeking a graduate degree in clinical work—a goal I had carefully researched and assessed for a long time.

This person’s reason?

You can make so much more money doing recovery coaching! You can work with wealthier people. You can work over Skype, so you don’t even have to have an office. And you don’t have to fool with insurance companies. Don’t bother getting a master’s in social work!

Wow.

Accountability

This leads to my second question: who is overseeing all these independent recovery coaches?

I have learned in my short time as a therapist-in-training that supervision is absolutely critical for helping professionals—not just at the beginning of a career, but for the duration. Therapists who work inside agencies are overseen by supervisors. Independent therapists pay other more experienced therapists for supervisory consultations—at least twice monthly, according to the informal accounts I’ve been collecting.

And most important, therapists must be licensed. You can’t just put a meme on your IG or blog that says, “Skype me!”

When White talks about recovery coaches, he refers strictly to those who work within agencies, alongside therapists. These recovery coaches are accountable to their agency’s policies and supervisors. And those supervisors, he urges, must make sure that recovery coaches are not acting as sponsors. Those roles are very different, too.

I’d like to hear from independent recovery coaches. Do you take ownership of the people you try to help? What are the core competencies of a recovery coach? To whom do you hold yourself accountable to meet or exceed these competencies?

The Treatment that Might Have Saved Phil Hoffman.

Cross-posted with AfterParty Chat.

Philip-Seymour-Hoffman

Late last week it was suggested that a cultural stigma against maintenance medications such as methadone and Suboxone helped kill Philip Seymour Hoffman.

This doesn’t make much sense to me given the fact that, shortly after he died, it was reported that buprenorphine was found in Hoffman’s Bethune Street apartment. Buprenorphine is a long-acting opioid the FDA approved in 2002 for opioid detox and maintenance. It’s used mostly for maintenance: it’s the New Methadone, but it’s much easier to get, because while methadone is approved for addiction-treatment only in a clinic setting, buprenorphine can be dispensed in a doctor’s office. Refills can be called in or faxed to pharmacies.

So how did Hoffman get his bupe? Either he was being prescribed buprenorphine for his opioid habit, i.e. he was “on maintenance”—as so many opioid addicts are: buprenorphine maintenance is a booming business in this country. Or else, as many heroin users do, he obtained his buprenorphine on the street.

Poor heroin users often cop street “bupe” to tide them over between fixes. But Hoffman was far from poor. So it’s speculation, of course, but I think it’s more likely he got his buprenorphine from a doctor. That’s what doctors do these days with opioid addicts: When we get honest about our addictions inside the exam room (and because Hoffman had spent 23 years sober and abstinent via 12-step fellowships, it may be fair to say he had practice in being rigorously honest) the doctors’ fear kicks in and they boot us into Suboxone clinics, where we’re prescribed upwards of 16mg of this very strongly-binding, fat-soluble drug that stays in our bodies for days before it’s excreted. In painkilling power it’s weaker than morphine or oxycodone, but in binding power—in its ability to stick to the body’s opiate receptors—it’s the second-strongest out there.

The strongest is fentanyl, the drug that’s been cut into heroin and has killed nearly two dozen in my region alone.

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Some publications are wont to report that opioid addicts—like Hoffman, like me—wreck our brains’ opioid receptors forever through drug-use. (This proves they don’t understand how the body’s painkilling system works: a great portion of the body’s opioid receptors actually reside in the gut. Which is why we get that lovely warm feeling throughout our bellies when we use painkillers or shoot heroin.) But there’s at least as much scientific and anecdotal support for the idea of neuroplasticity in recovery—the fact (it’s not just an idea anymore, it’s a fact) that the central nervous system is far more adaptable than we ever before believed and is evolved to use this resilience to recover from major traumas and illnesses, including addiction—especially if we help it by taking care of our bodies in basic ways, with exercise, good nutrition, and relaxation.

So the “old-school” idea is not 12-step programs, as these pieces suggest. “Old-school” is what I was taught as a kid: that once you lose brain cells, you never get them back, that our nervous systems cannot heal.

Still, these publications are putting the idea out there—and it is not a fact, it is just an idea—that if “most opioid addicts” don’t take maintenance medications forever to “correct” the “permanent damage” we’ve done through drug-use, we’re doomed to relapse.

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Philip Seymour Hoffman just four or five years before he got sober, in his 1985 high-school senior-year portrait.

Philip Seymour Hoffman just four or five years before he got sober, in his 1985 high-school senior-year portrait.

The clearest example that this isn’t the solution exists in our states’ physician health programs (PHPs)—systems of recovery designed to help addicted and alcoholic physicians keep their licenses to practice. These programs vary from state to state but generally provide five years of continuous care and oversight. Success rates for PHPs are extraordinarily high—upwards of 80 percent of physicians finish five years of treatment and are able to keep practicing.

These programs ought to be considered models for our citizenry. But they remain off the radar because they’re rigorous, expensive and intensive—five years, as opposed to a 28-day rehab, or even a ten-day or three-day detox.

Also, studies of PHPs show that linking recovery to one’s work is one of the strongest incentives you can give an addict to take responsibility for healing. Addiction thrives in situations of un- and under-employment not because the poor are somehow more susceptible to addiction, but because the people affected don’t have enough, or any, productive work.

It’s sometimes said that PHPs are effective for “highly motivated” addicts. Which leads me to my last point. I find it astonishingly patronizing that some are suggesting that public prejudice against maintenance killed Hoffman. Hoffman was an extraordinarily intelligent, articulate, “highly motivated” man and consummate professional whose work, he said, required him to be extremely introspective and emotionally present. I find it hard to believe he would be so easily swayed by public opinion about his choices.

I can more easily see him protecting his ability to work.

To act with the depth of feeling and nuance that he managed required full use of his entire internal emotional range. And opioid medications—including buprenorphine—necessarily dull one’s range of feeling.

I think it’s more reasonable to suggest that Hoffman tried bupe and found that, while taking it, he couldn’t access his feelings to the degree to which he’d become accustomed.

To be sure, he likely felt a great deal of shame during his relapse. One of the more damaging aspects of some 12-step groups, in my opinion, is their focus on “sober-time”: to “come back” from a relapse after a sober period of 23 years—half one’s life—would have been not only extremely embarrassing for anyone but also physically difficult, given that the heroin available these days is wicked strong.

But no way could Hoffman have wrecked his neurology permanently by using heroin for less than a year. I think it’s likely he did what so many who use heroin do: he chipped heroin, then switched to bupe, thinking it might remove his cravings. In fact, buprenorphine reliably does this for many opioid addicts who take it.

But craving is a feeling, and you can’t numb feelings selectively. My bet is that, feeling not-high but not-normal—after all, he’d been sober for 23 years: he knew what His Normal felt like; he knew what it took for him to do his job with the precision and quality with which he was used to doing it—he said what so many of us say when we’re caught between a rock and a hard place.

Fuck it.

What he needed was not more drugs. What he needed was a better form of treatment, perhaps the best evidence-based addiction treatment system we have going: the time-consuming, attentive one we give to doctors, the people we trust to protect other people’s lives.

But because Hoffman was “just” an artist, he followed the cheap, easy, brief trajectory that ordinary people in this country follow.

Pills. Then heroin. Then Suboxone. Then heroin again. Then death.

Hoffman in perhaps the last photo ever taken of him, a tintype made by Victoria Will two weeks before his death.

Hoffman in perhaps the last photo ever taken of him, a tintype made by Victoria Will two weeks before his death.

In Wake of NY Pharmacy Killings, Demands to Train Doctors to Spot Addicts

Been following the story about Dave Laffer, the 33-year-old guy who last week shot four people and robbed 11,000 Vicodin tablets from a Long Island mom-and-pop pharmacy. First saw the story in the New York Daily News, at my own pharmacy, where I stopped in last week for some snacks.

Apparently Laffer’s girlfriend, who was also arrested, was an addict too. The Daily News story says she told police Laffer committed the crimes because she was “sick.” (Dope-sick? Mentally ill? The story doesn’t say)

The Daily News says police identified Laffer because he repeatedly bought painkillers and also owned a gun like the one used in the murders of the pharmacist, the pharmacy assistant (a high-school girl), and two customers.

The murders, in all their grisliness, were caught on surveillance tape and understandably have outraged the families of those killed and people in the community.

Mugshot of Dave Laffer, suspect in Long Island pharmacy robbery-murders.

Here is a photo of Laffer after his arrest. He was also charged with resisting arrest. They obviously beat the sh*t out of him.

 

The number of armed pharmacy robberies is apparently increasing across the country. According to the Associated Press, California had 61 in 2010, New York’s robberies increased from 2 in 2006 to 28 last year, and there were 65 in Florida, the pill-mill capital.

Robbers are stealing oxycodone and hydrocodone preparations—Percocet, Oxycontin, Roxicodone, Vicodin, Norco, and others.

Last week the Substance Abuse and Mental Health Administration (SAMHSA) released a report showing admissions to treatment programs for opioid abuse quadrupled from 1999 to 2009 (the most recent year for which figures are available).

The report said opioid-addiction admissions made up 33 percent of all treatment admissions in 2009, up from 8 percent in 1999.

A USAToday story quoted Lynn Webster, director-at-large for the American Academy of Pain Medicine, as saying the prescription drug abuse problem began 10 years ago when doctors began treating chronic nonmalignant pain with opioids, seeing them as safe and effective solutions to the problem of inadequately treated chronic pain. “We were naïve as clinicians,” she was reported as saying.

In the wake of the Long Island drugstore murders, Sen. Charles Schumer (D-NY) is comparing prescription opioid addiction to the 1980s and 1990s crack problem. According to the AP, he’s proposing legislation that would

  1. limit the number of prescriptions doctors can write for opioids
  2. increase prison sentences for prescription drug theft
  3. require better training for doctors before prescribing opioid drugs, to “help doctors better identify patients vulnerable to addiction”

The last one is pretty good. Doctors who prescribe opioid drugs ought to know about addiction. Because a certain percentage of the population, when exposed to drugs like this, will become addicted—in a lot of cases it’s just a matter of odds, of activating a biological predisposition.

But the bill needs to go further. If doctors are going to prescribe drugs that can cause addiction, they need to be able not only to identify patients who are vulnerable to addiction—people with addiction in their families, people who have used addictive substances (including nicotine). Doctors also need to be able to learn how to treat patients who have both pain and addiction.

Having addiction should not disqualify a person from getting pain treatment.

If Schumer’s goal is to “screen out addicts,” then this just adds to the stigma of addiction and prevents people from getting the help they need—for both their addiction and their pain.

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