Substance Use Resources

Man passed out on New Orleans street

This page has information on current thoughts on addiction including annotated book and website links.

How are alcoholism and addiction defined?

  • Alcohol use disorder is defined as a chronic, relapsing brain disorder characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences (NIH Fact sheet)

  • Addiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences (NIH Institute on Drug Abuse)

[You can scroll to the bottom of this page for links to Self Help groups and Recovery Resources]

2020 International Standards

Generally there is strong evidence that supports moving from punitive measures and criminalization of addiction to prevention and effectively supporting people living with alcohol and drug use disorders. This charge is led by the World Health Organization (WHO) and the United Nations Office on Drugs and Crime (UNODC) who released new international standards for treatment in 2020. These lay out 7 principles to guide treatment and management of drug use disorders. Aaron was abused in an opportunistic facility that took advantage of our desperation and lack of knowledge. Accountability to these principles would have protected Aaron. Straight Inc., the facility that abused Aaron, would not have survived review under them.

 

Szalavitz traces the development of the Harm Reduction movement from its beginnings in needle exchange for Hep C and HIV prevention, to using it to rethink our policies around drug use. She posits that the policies of our war on drugs not only have failed, but have done great harm in the process.

On page 156 she gives the following description:

Harm Reduction is a set of strategies and tactics which encourages users to reduce harm done to themselves and their communities by licit and illicit drug use. By allowing users access to the tools to become healthier, we recognize the competency of their efforts to protect themselves, their loved ones, and their communities.

Here is the website for the National Harm Reduction Coalition’s Principles of Harm Reduction

Strategies within Harm Reduction: The Transtheoretical or Stages of Change Model frames change in 5 stages 1. Precontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance. Motivational Interviewing is another practice theory that suggests effective interactions at each stage of change. Here are articles related to Stages of Change. These are both tools that are used to meet people where they are and direct our interactions to meet their readiness for change. Harm reduction looks for progress rather than abstinence. It has a much better evidence base than confrontation and criminalization.

The difference between Housing First and Recovery Housing reflects two poles in terms of how alcohol and substance use recovery is framed. Housing First (see link above for fact sheet) embraces a harm reduction approach whereby people are provided housing and supports without requiring abstinence with recovery being framed as progress toward increased health and wellbeing, whereas Recovery Housing (see link to primer above) generally requires abstinence as a condition of housing. A 2020 article discusses the issue of people on maintenance medication for opioid recovery.

Unbroken Brain - Maia Szalavitz

Maia Szalavitz, herself an addict in recovery, describes addiction as a learning disorder. Addiction may begin as a choice but becomes an automatic, habituated behavior that is [over]learned.

Her recommendations for transformation to recovery oriented systems and supports:

  1. Reorient policy to reset from a punitive system to one that is restorative and health oriented

  2. Begin prevention early, teaching children how to cope effectively; recognize high risk periods (adolescence)

  3. Address basic needs, both socioeconomic and difficulties with self regulation, coping styles

  4. Treat addicts with respect rather than shaming, flip the script to reframe their persistence as a strength that can also be harnessed for recovery

  5. Develop evidence based treatment that meets people where they are, identifies needs and seeks to meet them; “teaching rather than preaching”

  6. Accept and celebrate differences, develop an inclusive culture

The Biology of Desire - Marc Lewis

Marc Lewis, a neuroscientist in recovery, sees addiction as a habit of thinking which becomes compulsive, and is driven by desire. He sees the changes in the brain that happen in addiction as natural consequences of learning. The brain changes, or develops well worn pathways as the result of repetition which is how we build all kinds of habits, not just addiction. It is how we become skilled at anything.

He says recovery has to be about building a desire toward something. In essence, an addict or alcoholic has to build another pathway by finding something that motivates them and being able to step back and see that larger picture. He says that and a sense of belonging may take place in cognitive behavioral therapy, AA, NA, SMART or anything else that enables self reflection and sparks shifts in perspective.

Lewis expressed some of same potential concerns with AA that Szalavitz does.

Gene Heyman differentiates addiction from other mental illnesses because of its relationship to choices. He uses two frames for our choices, one local and and the other global. He describes local bookkeeping as focus on immediate or day to day choices, and global bookkeeping as focused on a broader view of one’s life. Addicts with a local view, tended to keep using, whereas if they shift to a global view they were more likely to quit. Therefore, he maintains that helping addicts shift to a broader perspective is important to their recovery.

High Price - Carl Hart

Carl Hart, another neuroscientist in recovery, maintains that people have to have better choices than drugs to quit. His research used contingency management - reinforcers such as vouchers or prizes, and found that these reinforcers were stronger than a 12 step program for keeping people in recovery. He speaks to the need to do something about poverty, lack of education and job skills, and comorbid social or psychological dysfunction to effectively support recovery.

I agree, Dr Hart.

Self Help Groups

Alcoholics Anonymous

AA is the most prevalent recovery program so many people have gotten sober through its 12 steps. Szalavitz also became sober in a 12 step program but expresses several potential concerns. 1st she argues it should remain nonprofessional and so should not be the core in most drug and alcohol rehabilitation programs (it is) because of a) its focus on spirituality and reliance on a higher power, b) it’s reliance on peers, and c) the moral tone lends itself to punishment and humiliation. Aaron experienced all of these in Straight which because they were paired with his abuse, took AA off the table for him. Second, she argues that AA shouldn’t be mandated, that it is effective when it is a choice. Third, she states concern over the frequently asserted need to “hit rock bottom” and be completely demoralized, which she argues has enabled the criminalization of addiction because we can say we are helping addicts/alcoholics when we punish them, but are we? Fourth, Szalavitz calls into question the central position of powerlessness in AA for youth just developing their identities and for women and minorities who have been oppressed. Her last concern is the potential for vulnerability to predators in AA. She asserts that people attending the program should be warned that not everyone in AA is safe. Yet, lest we throw the baby out with the bathwater, she also acknowledges the strong potential for recovery in AA.

SMART [Self Management and Recovery Training]

Both AA and SMART rely on abstinence and group meetings. However, SMART drops the disease model, and the ideas of character defects and higher powers. It relies instead on more cognitive behavioral and motivational interviewing strategies. Meeting leaders are trained and discussions are centered on their 4 point program 1. Build and maintain motivation, 2. Cope with urges, 3. Manage thoughts, feelings, and behaviors, and 4. Lead a balanced life.

Recovery Resources

This link will bring you to the Recovery Resources page that has information about recovery and tools to help start thinking about what recovery might look like and build anticipation of that as a positive state, as well as practical strategies to help with symptom management and coping.