If only my loved one had been able to get in to treatment on time.
The lament of every family member, partner or friend who is trying to support someone who is suffering from substance use disorder or has died from it.
If only.
Well maybe I can help with that thought, or maybe not. Either way here is the truth of that.
As many of you know, I am a retired mental health and substance use clinician. I often start with this statement, not to brag or boast, but to let you know that even if I don’t know everything about addiction and recovery, I have well over 30 years experience in it. And I am also someone with lived experience. So that’s where I am coming from.
In a nutshell, I have found that treatment for substance use is deeply misunderstood by almost everyone. In its most common and traditional form it is too simplistic for the myriad issues that are underneath of and arise from substance use disorders. Historically and currently far too many programs are operated from a lived experience only foundation. In other words, many programs and recovery homes are run by those who are relatively successful in abstinent recovery, have big hearts and wonderful intentions, but do not have a broader education or specific training in all that treatment should be covering.
Fortunately, many programs and facilities are beginning to catch up. Unfortunately they are struggling to keep up with current research and evidence that should be driving treatment programs. Far too many still rely on faith based solutions. The most common faith based program is the 12 step program.
Please don’t misunderstand me. Twelve step programs have a multitude of strengths, not the least of which is a community support network all over the world. There are public meetings in almost every community in hundreds of countries around the world where people can go for support. The program itself is a structured step by step process that, if followed, can help people make big changes in their lives.
Unfortunately, it is the faith based part that people struggle with the most. The 12 step program was founded from a Christian fellowship religious movement called the Oxford Group. One of the driving principals of that organization was that only God had the power to actually solve your issues and only surrendering to God, as you understand God to be, will be the only way to make good on your shortcomings. Your shortcomings were the cause of your addiction and only God could address that, to make a long story short. The 12 step program operates on this premise to this day.
People who are in a vulnerable and desperate state tend to reach out for help. At least this is what I found when people and/or their families would come to my door for help. Desperation, shame, guilt and embarrassment were among the driving motivators. And there’s nothing more powerful than being able to finally release all of that to someone or something. Thus, a faith based approach can be very beneficial, for people who are familiar and comfortable with faith. For those who struggle with the many issues associated with religion, the 12 step program can prove to be a very inappropriate fit.
That is why there has been so much research put into how to best treat mental health and substance use. That very statement highlights the complexity involved. For instance, about 38% of people with substance use disorders struggle with mental health disorders. That is even higher when considering schizophrenia. On the other hand, about 20% of people who struggle first with a mental health disorder also struggle with a substance use disorder. I will tell you from experience, it takes much more than telling your story over and over again in a support group when your issues are this complex. And when substance use becomes your primary way of medicating and coping, it becomes engrained into your life. It takes trained experienced help to navigate alternatives.
So just from this little bit of information, you can see that just getting treatment is not a straight forward process. It takes a great deal of “matching” and even then, getting it right the first time is rare. People expect treatment to lead to some sort of success. That success usually means abstinence from substances. Most programs try to measure success as abstinence from all substances. Some more contemporary programs may consider success to be abstinence from the person’s drug of choice. Others measure goals as identified by the participant such as improvement in socialization, employment, education, living environment and so on.
So now I want to talk about another important consideration. Let’s say your loved one did get into any treatment centre that was readily available. And let’s say that facility measured total abstinence as the only indicator of success. I mention this because the more traditional and common programs out there use this very criteria.
Before your loved one even gets there: Usually the criteria to be admitted to one of these programs is total abstinence from all substances including any medical assisted therapies such as methadone, suboxone, naltrexone, etc. Some very traditional programs also require abstinence from anti anxiety and anti depressant medication as well as any cold and flu and pain medications. People are required to be abstinent from these medications and substances anywhere from 3 to 7 days. I knew of one program that did not allow anyone to attend that program if any use of crystal meth had occurred within 5 months prior to admission. That program claimed this was based on science. I could not find the science they were referring to, to warrant such a barrier. This is why proper education is so important in treatment. Lived experience helps but education provides the knowledge.
Personally, I found all of this criteria to be a huge barrier to accessing programs. The whole point of attending a treatment program in my mind was to obtain help to abstain. Apparently many programs are only there to help maintain, not initiate abstinence in a safe protected environment.
Fortunately, some facilities have progressed to include medically assisted therapies. For example many now will accept opiate agonist therapy for opioids. Some will accept opioid replacement such as slow release oral morphine. They also accept medications for mental health concerns too. This has its obvious benefits for those who are struggling with more complex health issues.
Again though, most facilities are expected to have some sort of abstinence related outcome. Depending on the study you read, between 40-60% of people who complete a program remain abstinent for up to one year after discharge. That’s pretty hopeful if abstinence is your goal. There is no quantitative data that I know of that measures anything after one year. It is extremely difficult to gather that information even immediately after discharge so I suspect the numbers are approximate at best. Regardless, this leaves a disturbing counter outcome: conversely about 40-60% of people do not remain abstinent after discharge from a program.
I found this quite true throughout my career. Many of the people I worked with had to attend both inpatient (residential) or outpatient programs multiple times before their goal of abstinence was reached. This was due to many factors. Some of those factors included a poor fit between person and program. Another main factor is the nature of substance use disorder itself.
The disorder includes relapse as a natural part of recovery. Even common and traditional faith based programs recognize this fact though approaches to address it may differ from program to program.
Historically, relapse was seen as normal and not necessarily as potentially deadly as it certainly has become now. The incredible wait times and the reality of relapse has become deadlier every day. This is because of the increasingly toxic and deadly supply of illegal drugs on the street now.
So in response another unfortunately controversial approach has been bolstered in response to the overdose crisis that has occurred as a result of the increasing toxicity of street drugs. Harm reduction has been a person centred approach for decades. It became essential during the AIDS epidemic as well as to prevent the spread of other sexually transmitted diseases and the Hepatitis family of diseases. Now harm reduction is absolutely essential in saving lives as street drugs continue to become more toxic.
Harm reduction neither requires nor opposes abstinence. It is not a treatment per se for addiction in that sense. But it is an important component throughout a recovery process. Remembering that there are incredibly impossible wait times for any counselling, or residential programs and that relapse is an expected common event in the recovery process, harm reduction is absolutely necessary to keep people safe and alive.
This is the single most biggest reason advocates are calling for a safer supply. Treatment can’t treat or change a deadly supply of street drugs. Changing a failed drug policy can save thousands of lives. Dead people don’t recover as too many of us have learned.
Most families, are not informed of harm reduction as a necessary step in the protection of a loved one. In fact, traditional faith based recovery is against harm reduction. We are all seemingly told that treatment for addiction is the only answer. But I sincerely hope that you can see that treatment, while it certainly addresses substance use disorder and assists in building the ability to make significant life style changes including abstinence from substances, is not a complete answer. In short, treatment is effective but not a sliver bullet. Harm reduction must be a part of the equation. If you didn’t know before, consider that you know that now.
So what if my loved one could get or could have gotten into treatment right away? Sometimes on the extremely rare occasion, I was able to get someone into a residential program the next day. But even then, some did not complete due to lack of connection to that program. Most relapsed after discharge and re applied, some more than 2 or 3 times. Some tried various different programs before something stuck. In the meantime, we practiced harm reduction so that they would stay alive and well to try again. Now we need that safer supply more than ever.
I don’t want to leave anyone in despair here. Recovery is totally possible. So many have changed their lives after many different approaches. And I have been there to celebrate with them. I have stuck by my mantra that if it works for you, keep doing it, if it doesn’t, change it!
It’s important to know that recovery looks very different for everybody. Success is very different for everybody. I am in recovery just so y’all know. And I don’t do it perfectly all the time despite my experience and what I know. But, like me, people reach various stages of health throughout their journeys. And we do it at our pace, not yours (sorry to be blunt but this is uber important; our pace, not yours). Again this is where harm reduction plays a role when necessary. And it is important to celebrate these stages. Even if it isn’t abstinence, it’s still the journey of recovery or healing.
We all play a huge role in the recovery of our loved ones and our own healing. And we all heal with support and connection. The most any of us can do is stay connected with our loved ones the best way we know how and within our safety zones; Allow ourselves to accept the pitfalls and motivate the courage to stand back up. Then, the road to a treatment centre, and the road after, though long, can be safe, rewarding, and effective in continuing a journey of healing and recovery.
Just remember, it’s not the leaps we make, it’s the careful baby steps that help us on the path.
Resources
https://nida.nih.gov/research-topics/comorbidity/comorbidity-substance-use-other-mental-disorders-infographic
https://canadiancentreforaddictions.org/rehab-success-rates-in-canada/#drug-rehab-rates-canada
https://www.prestongroup.org/aa_docs/Oxford_Group.pdf