Much of why public policy moves as it does from generation to generation and from place to place can be attributed to simple, well-articulated ideas that guide all the players both explicitly and implicitly. “Addiction is a sin and a sign of God’s disapproval” is one such influential idea. “Addiction is a chronic medical illness” is another. An idea that is currently profoundly shaping drug and alcohol policy developments in a number of countries, and in a way I consider very positive, is that there is something called “recovery” and policy should try to bring it about more often.
But what is it? Bill White finds U.S. precursors going back in the history both of Native Americans and the European immigrants of prior centuries, but its modern forge has clearly been 12-step organizations such as Alcoholics Anonymous. They posited that recovering from addiction involved not only cessation of substance use but also restoration of emotional and spiritual health and responsibility to others. AA has been misunderstood, including by its own members, as saying that every addicted person must go through this process. In fact, the founders believed the evidence of their senses that many people who drink too much can put the plug in the jug full stop (or cut back and “drink like a gent”), and live good lives without further reflection. But AA’s founders also believed was that whoever those problem drinkers were, it wasn’t them; they needed something more.
Over the past 15 years or so the definition of recovery in the U.S. has broadened to include recovery from mental illness and to recoveries from addiction via routes other than AA, including other self-help organizations, psychotherapy, addiction treatment programs, faith-based organizations, self-change and yes, medication-assisted treatment including anti-depressants and methadone. Not being in recovery myself I stand in awe of those who have had their lives saved by one route of recovery but have gained the maturity and perspective to acknowledge that their way is not the only way.
Politically, this has transformed the recovery movement from a group of battling sects to a genuine force for change in the U.S. and increasingly, in other nations as well. Among its political demands, pushed by organizations such as Faces and Voices of Recovery and Legal Action Center and adopted as policy in President Obama’s National Drug Control Strategy, is that government should remove barriers to addicted people entering and staying in recovery, including the withholding of student loans, employment, housing and other benefits from people who been convicted of drug-related crimes during their period of active addiction.
The Betty Ford Institute held several influential consensus conferences of thought leaders that defined recovery as follows: A voluntarily maintained lifestyle characterized by sobriety, personal health and citizenship. The use of medications was explicitly accepted as a potential part of that equation (contrary to stereotype, Betty Ford Center participated in the Clinical Trials Network study of buprenorphine and are not anti-medication zealots). The BFI definition and working papers really did echo around the world, attracting some criticism but moreso being regarded as a breath of fresh air.
In recent years the recovery movement and its ideas have crossed the pond, and as far as I can tell the first interest came from Scotland. As one government official put it to me in Edinburgh, “Focusing on recovery gave us a chance to move beyond the stale, endless and unproductive arguments between radical abstentionists and militant harm reductionists”. Scotland adopted a recovery-focused policy framework, and as part of that made extensive contact with colleagues in the U.S. who were pursuing the same goal.
The Scotland Futures Forum 
devoted to Recovery is available on line here and if you watch one thing I suggest you see Bill White’s talk and his follow-up one on one interview. What cannot be completely captured on the film is the spirit of the audience. There was intense fear and concern about Scotland’s drug problem, there was hope for a better future, but most impressive to me was the rage of service users about the addiction treatment they had received, particularly in methadone clinics. “Take your script, shut your gob and piss off” were the acerbic words one attendee used to describe the attitude she had encountered (see my last post in this series for a bit more on this) and she was among many who found such experiences degrading and discouraging.
Understanding these experiences of drug-addicted service users is critical to understanding the backlash against methadone in the U.K. Many people want more from treatment than the very valuable biological stabilization methadone can provide, they want a life, they want recovery. In UK methadone services they too often encounter a mentality that resonates uncomfortably with the country’s class system, i.e., You are an addict and will always be an addict, mind your place, don’t think you can rise up above your station, you bounder. The sense of aspiration to something greater is what many people with drug problems and their families have been thirsting for and want the new UK government to support.
When people are angry, they make strong judgments and take more extreme rhetorical stances, one of which is that because many UK methadone clinics do not currently support recovery, that methadone itself is somehow an inherent barrier to recovery. This view makes those who provide methadone services angry, and leads to accusations that recovery is just the new abstentionism. It all reminds me a bit of my days as a marriage counselor, listening to both unhappy spouses declare “I won’t say anything nice about him/her until he/she says something nice about me”. But within this situation are the seeds of a compromise: We both want some acknowledgment and respect, so how about we start by giving it to each other?
When ONDCP Deputy Director McLellan visited the UK, I felt a rush of tension exit the room of his main public address when he said that recovery could be achieved without medication, and that it could also be achieved with it. I talked to people afterward on both sides of the debate and was happy to see how well received this stance was, namely that it became much easier for everyone to acknowledge that their way was not the only way as soon as someone had acknowledged their way had value. That isn’t happening much in the UK right now, it’s combat, like a bad marriage, with good people on both sides feeling disrespected and devalued. For an outsider with friends on both sides, it’s frankly painful to observe.
Recovery ideas have now come to England, and the new government is taken with the idea and is finding that it resonates with many stakeholders. My fondest hope is that the addiction advocacy and treatment community can rally round the idea of multiple pathways to recovery and lay out a system with an attendant array of options, including better methadone services, more SMART recovery and other self-help organizations, residential rehabilitation programs (including some that are religiously affiliated) and primary care based screening and early intervention programs. My greatest fear is that in what is by any standard a brutal budget environment, the UK addiction field will not hang together, and will end up hanging separately.
Thanks Keith for another blog in a series which has repeatedly hit the spot about the situation in the UK. Thanks too for the reminder of that day last year when you joined us in the Recovery Learning Exchange organised by Scotland's Futures Forum and Keeping the Door Open Scotland. It is symbolically so important that such free-ranging discussion events, open to any interested citizen or organisation, take place within the Scottish Parliament building and involve face to face discussion with leading influencers from other countries and cultures - as we did on that day with yourself, Pat and Bill. Since you were here, public debate and policy proposals have been mainly about the challenges of harms from alcohol - long overdue.
Regarding your fear about the consequences of a brutal budget environment(which will happen), the jury is out on how it will affect the addiction field in Scotland. But one very hopeful factor is that the current drugs and alcohol policy frameworks have considerable cross-party consensus. Another hopeful sign is the way the Parliament's Finance Committee is currently conducting wide consultation not only on options to reduce budgets but also looking for ideas about how we can use this time of significant change to lay down the framework of prevention over the long term that will really reduce the population prevalence of alcohol and drug problems in Scotland. In fact earlier today, Finance Committee members met with a range of stakeholders in an informal exploratory discussion about this very topic organised by Scotland's Futures Forum. A lot of thinking is taking place in some newly emerging networks and some really interesting ideas surfacing.
Thank you Keith for another thoughtful and well-balanced article in this series.
I am today including this weblink in the Addiction Recovery Foundation's response to the Drug Strategy Consultation!
As an alcoholic/pot addict who has worked in the field, on and off, for 25 years:
1. Addiction is usually accompanied with mental illness and/or a character disorder.
2. There are many paths to recovery. Some studies suggest half of people who stop using simply stop using, without anything else (treatment, 12 Steps, therapy, etc.). Plug in the jug.
2. Abstinence alone will provide dramatic improvements in physical health and life manageability.
3. Emotional health? Who among us is enlightened, or self actualized? It's a health problem first; going beyond that concern starts getting into some interesting but tricky social engineering, involving value choices.
4. The war on drugs is a war on our neighbors.
5. It's a battle between a punitive mindset and a nurturing one.
Just some quick thoughts.
Keith just came across this and your other blogs, Fantastic! you have captured the feeling and momentum of that day at the Scottish Goverment briliantly, Thankyou! and I from reading your blog today I am reminded of some of Bills words from ‘Towards a Recovery Movement’.
“The long term fate of this movement may hinge on its ability to tolerate differences and tolerate boundary ambiguity while forsaking calls to create a closed club whose exclusiveness would leave many suffering people refused entry at its doorway”
“Somewhere in this movement’s maturation, a message of unification needs to be extended that psychologically and socially links the growing number of recovery groups and solo flyers into a community of shared experience that can transcend differences and allow it to speak powerfully on one issue: The very real hope for permanent recovery from addiction”
“It is crucial that a way be found to transcend the internalised shame that turns members of stigmatised groups upon each other in frenzies of mutual scapegoating”
“The most serious battles fought by this movement are best waged, not with each other, but with more formidable forces in the culture that seek to objectify, demonise and sequester all those with AOD problems”
As you might know we are walking on the 25th September in Glasgow for the UK Recovery Walk and like Mike I too am hopeful that our politicians will continue to provide the support and understanding shown so far, infact I know they will, Scotland needs it! I Hope our paths cross again soon. Big Hug xxxxx AnneMarie
About twelve years ago, New Labour was looking towards the US for ideas about how to move the drugs agenda forward, and the view of the field was there was nothing that those loony, ideologically-driven extremists in the USA could teach us. It's interesting that today, we've got a con-lib coalition, and here we are, looking to Americans as the voice of moderation and reason.
I get really tired of the way this field shifts from one fashion to another, in the process, jettisoning everything of value that we've learned in the last ten years or so. It would be nice if recovery — as addicts define it for themselves — could be the kind of unifying, organising principle that causes this field to break out of those ideological traps. The danger is though, it's yet another buzz-word that poor quality services use to redefine themselves, and that it's used to reinforce the kind of stigma that this field has always imposed on those unwilling or unable to achieve total abstinence, and in doing so, it perpetuates the very trap it claims to be seeking to escape. Anne Marie's point above is very well made.
The fact is, people have always exited treatment to lead drug free lives of varying quality. The overwhelming majority of people who have done so in the UK have managed that without this paradigm shift. Good workers have always met their patients/clients where they are, and have worked with them to achieve their objectives, and lousy workers continue to try and impose their own values and agendas on us, regardless of how poor their outcomes happen to be.
For me, the important issue isn't whether we call what we do recovery, whether we call it treatment, or whether we call it voodoo. For me, the important issue is how do we begin to raise the quality of our services and the skills of our workforce in such a way as to improve the outcomes and meet the aspirations of everybody who has a problem with substance misuse, and in that respect, I'm hearing an awful lot of noise, but not quite so much light. Nearly thirty years ago, I recall reading that around ten percent of the treatment population are prepared to contemplate abstinence-based treatment at any given time, and of those, approximately ten percent successfully manage to achieve sustainable recovery. Have those figures changed at all in the last thirty years?
The other part of that package is that those people who manage to achieve and sustain recovery for five years or more are invariably those who find and sustain full time employment. We're headed into the biggest recession this country has seen since the 1930's. My wife of 28 years, who has never been unemployed in all that period, has been made redundant twice in the last year. This, despite having two post graduate degrees and numerous professional qualifications. The idea that all of the multiply disadvantaged people with complex needs are going to be walking out of treatment and into this brave new world of employment is a cruel deception. Of course, some of them will. Inevitably, it'll be those with the most social/recovery capital. But we mustn't lose sight of what we do with the rest of them.
Just today, I was listening to an NTA regional manager talking about how, in the future, more and more people will be faced with the choice of continuing to use or abstinence-based treatment, and the way that he framed it was that choosing continued use is tantamount to a death sentence for this group. But anybody who's been in this field for longer than five minutes knows that many — perhaps even a majority — if forced to make this choice, will choose continuing to use. We've got a moral obligation to do what we can to ensure that those who do make that choice have as much assistance as we can provide to see that that decision doesn't end in death.
Because dead addicts *never* recover.
It's important to remember that:
"As with problem drinking, gambling, and narcotics use [1]–[9] population studies show consistently that a large majority of smokers who permanently stop smoking do so without any form of assistance [10]–[15]."
http://www.plosmedicine.org/article/info:doi/10.1…
So the fact is, the majority of addicts stop using without any 'treatment' whatsoever.
I agree with Peter's point about providing much more assistance to those people who actively choose, permanently or for a period of time,continuing use of drugs such as heroin. To increase our understanding of how this is done with maximum personal and societal safety we should be funding more research about the experience and know-how of those who are currently using drugs in a way which is largely "unobtrusive" i.e involving minimal harm, similar to the controlled use of alcohol. But I hear that research funding is practically impossible to find for the longer term follow up of cohorts featured in published studies of successful "unobtrusive" use of prohibited substances. Or can someone point to research funders interested in so doing or even examples of such research currently under way?
I agree with Peter, I think its a strange day when we are looking to the United States for examples of a way forward, there are far more interesing balanced policies in many European countries. The social and prison policies of the US are shocking and regrettably we are drifting in that direction. In particular the policies on social benefits in the US, are grim and not to be wished on any one. I think that the way a vested interest group have split the treatment field for their own particular benefits is very unhelpful. When we had the Task Force in the early 90s the direction of travel was clearly multi modality treatment and the innovation of methadone maintenance which was strongly resisted. It has taken a long time to get MMT accepted as an important treatment modality with limitations. The discussion on quality is bogus and a smokescreen for a subjective and emotional assault on this valuable form of treatment. Like Keith I have the most incredible respect and admiration for all those people I know who are involved in AA and NA. What I became aware of years ago, is that the community is a true community 24/7 and that the residential sector of it is only a tiny, often commercial aspect, of an extraordinary movement. Anybody seriously involved in addictions treatment will have strong support for that community but will also know they do not need patronising new recovery initiatives to further the valuable work they have been involved in for the past decades. The current Scottish Academic Input to this is shallow and self serving and does not deserve much attention.
The significant difference between nicotine addiction and addiction to mood altering chemicals is that use of the latter is strongly involved in medicating emotions (hence 'mood altering'). People drink, in large part, because alcohol is a good anti-anxiety agent.
In contrast, nicotine addiction is primarily physical and minimally emotional, and is more similar to caffeine addiction.
I am glad to see this issue being brought forward. Yes, addiction does seem to be somewhat of a stigma but we all really should be focused on recovery. Hopefully, the British will take some positive steps forward and create some incredible policy out of this.
Humphreys nails it on the head when he says those in recovery, including those being treated with medication, are desiring for an upward mobility in life station and that we don't want to be defined by our disease alone. As he describes melding the divide between medication advocates and abstention, the same reasoning must be applied to the current state of available medication. Without devaluing methadone treatment and the path to recovery it's treatment can provide, we should also be able to address it's shortcomings and the need for dramatic retooling of addictive research so that better medicines are developed.