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 Scotlandâ€™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.