Private Outpatient for Opiates, Done Right

Prescription drug abuse, especially by young people, is on the rise, and opiates like Vicodin and Oxycontin rank high on the list.  People with chronic pain all too often end up addicted to their medications.  People who got into  heroin or other opiates for recreational use or to self-medicate some psychic hurt frequently find themselves in deeper waters than they ever intended.  We meet all these people, among others, in LifeRing meetings, and one of the big concerns for them is anti-addiction medications.  In the past, the most common medication to treat opiate addiction was methadone.  Methadone continues in use, but buprenorphine (byou-pruh-NOR-feen) is the new kid on the block, and both physicians and patients are picking up on it because it's easier to administer, has fewer side effects, and less potential for abuse than methadone.  Buprenorphine is being used both to detox the person addicted to opiates and in some instances as a maintenance regime.

It isn't easy for the person who wants to address an opiate addiction to find proper care.  Apart from a few outstanding practitioners like Dr. Howard Kornfeld in Mill Valley, the patient who is without Kaiser coverage may not find any place to go.

That's slowly changing, as both physicians and patients become educated about new addiction pharmacology.  One of the bright signs of change in the field is the opening of Reliance Center in San Francisco.  Located on the third floor of the beautiful old 450 Sutter Street building, a block north of Union Square, this new outpatient clinic brings together a very high powered medical and counseling staff in a comfortable, almost living room atmosphere.

Putting physician and counselor on the same team tells me that these folks really "get it."  You need both the medical doctor and the empathetic psychological advisor to deal with an addiction.  I had the opportunity to meet and to look up the resumes of the key staff.  Dr. Carrie Schuman, Medical Director, has treated people with opiate dependence for more than 25 years.  She's a leading member of the California Society of Addiction Medicine and a member of the national addiction medicine group.  This physician knows what she's talking about when it comes to opiate addiction, and she also projects a warm, caring, nonjudgmental attitude.  On the counseling side, there's Lubov Smith, a Licensed Marriage and Family Therapist, who comes to the Reliance Center from years as Executive Director of the Henry Ohloff Centers, one of the oldest addiction treatment programs in the area.  She's bright, funny, and very knowing.  If I had an opiate addiction issue, I'd put myself into the hands of this team without hesitation.  Check them out at http://reliancecenter.com.

Professionals who include pharmacological tools in their recovery approach are often pleasantly surprised to learn that abstinence support groups exist that are open to patients who are taking these medications.  More than ten years ago, the medical director of a local treatment facility complained to me about the "G**damn 12-step sponsors who interfere with my treatment plans."  Although AA co-founder Bill W. was personally very positive about anti-addiction medications, the organization he founded contains a strong streak of anti-medication Luddites, who in many instances tell the recovering person to throw away their anti-depressants and other prescription drugs, or they're not really considered "sober."  That hasn't changed in the past ten years, judging by recent stories I've heard.  And so, when a support group like LifeRing comes along, with a more evidence-based approach, physicians' interest perks up.

In the past few years, LifeRing has mounted exhibit tables at conferences of addiction counselor groups such as NAADAC and CAADAC and at APA events (American Psychological Association).  If we can raise the money -- it costs at least $1000 to exhibit at one of these events -- we hope to exhibit next year also at ASAM and CSAM -- the American and California Societies of Addiction Medicine.  With our evidence-based supportive approach to anti-addiction pharmacology, LifeRing should get a positive reception from these professional groupings.

Goodbye Genetics, Hello Epigenetics

For the first time in history, science now has tools that can definitively answer long-standing questions about the role of genetics as the cause of diseases.  So far, the results have been devastating for believers in genetic causality.  The better we can see, the less genetic causality we find.

I've previously summarized the minimalist findings of modern genetics research for a number of psychiatric disorders, including addiction, here and here in this blog, and in my book, Empowering Your Sober Self.

Now comes another blockbuster study, this time of schizophrenia, a disease commonly believed to have a strong genetic component.  According to the November issue of Scientific American, summarizing a recent report in Nature, "three crack teams of investigators pooled genomic data from 8,000 schizophrenics of European ancestry but could lay claim to only a handful of weak genetic risk markers."

By contrast, says the same article, epidemiologists have been able to find significant correlations between schizophrenia and environmental and cultural conditions.  Growing up as an immigrant or as a racial minority in a big city, particularly in densely populated and troubled neighborhoods, is a significant risk factor for the disease.

These studies have given a boost to the field of epigenetics -- the study of how environmental conditions evoke or overwrite genetic predispositions.  The primitive notion that our DNA is our destiny is giving way to the understanding that our genes do nothing until they are activated.  Environmental conditions (including not only the chemicals that enter our body but also the decisions we make, the people we hang with, and the stress we undergo) determine whether a gene gets turned on or off.  Our genetic array is like a keyboard, and our interaction with the world governs what melody gets played on it.

By coincidence, a recent issue of Counselor, the magazine for addiction professionals, features an article, "Epigenetics Has Come to the Addiction Field," by Mike Taleff, Ph.D.  Taleff's main point is that it's not genetics that makes a person an alcoholic or other addict.  It is the repeated consumption of alcohol and other drugs that programs a person's genetic material to crave the drug and prioritize its consumption.

This epigenetic understanding, says Taleff, can help a recovering person shed some common myths, such as the belief that "they are somehow morally, bad, defective, or otherwise flawed.  Often, this kind of thinking gets in the way of recovery."  Epigenetics teaches, by contrast, that becoming addicted "has little to do with your moral character."  Addiction is a result of the programming that addictive substances perform on your brain.

Many questions remain to be settled before science can claim that we have a comprehensive understanding of the causes of addiction.  But progress is being made.  For decades, addictionology was stuck in the belief that the alcoholic/addict's disorder was genetically programmed. Thanks to the enormous strides made by genetic science in the past decades, with the deciphering of the human genome and the subsequent advances, we can now say with considerable certainty that genetics supplies only a weak explanation at best. Now we need to turn our eyes toward the epigenetic factors:  environment, culture, and above all the neurochemical properties of the addictive substances themselves.

Cover story

The cover of my new book -- Empowering Your Sober Self -- is going to appear as a prop in the forthcoming made-for-TV movie "Sins of the Mother."  According to the synopsis, the heroine, Kim, postpones writing her Ph.D. thesis to go live with her mother, a recovering alcoholic.  To establish the mother's character, the camera scans the books on her coffee table, and lingers on "Empowering Your Sober Self."

Just so you know, this is not a paid product placement.  A member of the film staff ran across the book in a bookstore and asked my publisher for permission to feature it as a prop.  The movie will air on Lifetime Television. Date not yet known.  The producer is Mother Road Productions Ltd in Vancouver BC.

Oh, and a review of my book, by William L. White, will appear in the next issue of Alcoholism Treatment Quarterly.  White also wrote the preface for my book, and it is expected that the review will closely track the preface.  It will not mention the cover.

What If There Were LifeRing Treatment?

[I'm cross-posting this item both here and in my LifeRing Convenor blog. Lately I've been posting a lot more to the convenor blog than here.] 

Quite a few recovering people in various treatment programs have expressed the wish that LifeRing filled more than an hour in their week.  The desire for "more LifeRing" is especially strongly felt in programs where the other hours consist of heavy-duty 12-step lectures and meetings.

Of course, there is no such thing as a LifeRing treatment program, and there probably oughtn't to be.  We are a peer-to-peer support group, and should always remain that.  So much of our fundamental approach is premised on horizontal support dynamics that the introduction of vertical relationships -- inevitable in today's insurance-dominated treatment settings -- would bring about wrenching distortions.  Still, wouldn't it be liberating if today's treatment professionals saw their role as not only facilitating 12-step involvement but also facilitating LifeRing involvement?  Whatever works best for the client?

For treatment professionals in Northern California, an opportunity to learn the basics of LifeRing is coming on Saturday, Sept. 19.  Thanks to sponsorship by CAADAC, the California association of addiction professionals, I'll be presenting an all-day workshop at the LifeRing Service Center in downtown Oakland.  I'll be selecting material from Empowering Your Sober Self (my new book), from the Recovery by Choice workbook, from How Was Your Week (our convenor handbook) and from other sources.  This six-hour program is aimed at treatment professionals, and six hours of Continuing Education credit, plus an hour of Professional Development credit, are offered.  However, space permitting, any interested person, including of course any LifeRing participant, is welcome to take part.  It only costs $10.

Here's a page with details about the venue, parking, meals, etc.  Hope to see you there!

On the Air with Audrey Chapman

It was my great pleasure this morning to appear via telephone on the Audrey Chapman show, broadcast in the Washington DC area on WHUR-FM at 96.3 and via the Internet at http://www.whur.com. Audrey is a relationship specialist who has written several books on love and its problems. She's active as a writer and speaker and also maintains a busy counseling practice. She talks with radio listeners every Saturday morning from 8 - 10 am (5 -7 a.m. my time), and her show is said to have a huge morning audience up and down the East Coast.

From the first words, you can see why Audrey has such a following. She's calm, she's clear, she's relaxed; she projects empathy without judgment. You immediately feel comfortable talking to her, telling her your problems. She also sees right to the heart of an issue. She couldn't have had much time to read my new book, but she clearly understood the main points. Her questions were relevant and moved the conversation forward.

Audrey thrives on the freshness and urgency of listener calls. And her callers didn't disappoint. In just a few conversations, much of the huge panorama of addiction problems in the society was laid out before us. A grown up woman was concerned with the drinking of the auntie who raised her. A mother was troubled by her teenage son's drinking. A father worried that his own drinking was leading his son into alcoholism. And so on. Addiction is an enormous problem, and there are people everywhere struggling with it.

We don't yet have LifeRing meetings in the D.C. area, but I had the opportunity to tell listeners about www.lifering.org, our website. I was pleased that Audrey asked me to stay on into the second hour of her show. There was still much more that could have been said, and I had to bite my tongue once or twice when callers pushed concepts and solutions that have very limited utility. But I loved the live interaction, and I could see myself engaged in a longer and very interesting conversation with Audrey on some other occasion. She's smart and she has an open mind and a great way with people.

Check out her website at audreychapman.com.

Empowering Your Sober Self: The LifeRing Approach to Addiction Recovery

Jacqueline Foreman (right) interviews me on Your Mental Health Talk Radio about my new book, here:

Empowering Your Sober Self: The LifeRing Approach to Addiction Recovery

The program aired July 7 2009 at 5 pm Pacific Time.

Treatment promo research results

From the treatmentgap.org website:

Most Americans know someone personally who is addicted to alcohol or drugs and they are worried about access people have to affordable treatment. And, most people support including treatment in national health care reform. These opinions are shared across the board—regardless of race, age, income and geographic location.

Results of a new national poll conducted by Lake Research Partners for the Closing the Addiction Treatment Gap initiative confirm what we suspected: Most Americans know someone personally who is addicted to alcohol or drugs and they are worried about access people have to affordable treatment. And, most people support including treatment in national health care reform. These opinions are shared across the board—regardless of race, age, income and geographic location.

Among the key findings of the national poll, conducted by Lake Research Partners:

• Three-quarters of Americans (76%) know someone personally who has been addicted to alcohol or drugs. Personal experience with addiction spans all demographic groups.

• Half of Americans (49%) do not think they would be able to afford the costs of treatment if they or a family member needed it. This concern about affordability is highest among Americans with incomes under $50,000 (67% say they would not be able to afford treatment).

• Three-quarters (75%) of Americans are concerned that people who are addicted to alcohol or drugs may not be able to get treatment because they lack insurance coverage or cannot afford it.

• Nearly three-quarters (73%) support including alcohol and drug addition treatment as part of national health care reform to make it more accessible and affordable. This support cuts across all demographic groups.

• Two-thirds of Americans (68%) also support increasing federal and state funding for alcohol and drug prevention, treatment, and recovery services.

The finding that three quarters of Americans know someone personally who has been addicted to alcohol or drugs confirms what many recovering people find through personal experience: when you broach the subject, practically every person you talk to has a story about someone who is or was addicted.

Not researched in this study, which was funded by treatment industry interests, is how many Americans know someone for whom addiction treatment did not work. The industry not only has an affordability gap, it has a credibility gap.

They laughed at him

A little while ago, a gentleman -- let's call him "Guy" -- phoned to say that he had just read my book and wanted to start a LifeRing meeting. Guy said he is more than 20 years clean and sober in AA, and is one of the better known AA speakers in his region.

He happened to go to his favorite recovery bookstore, and this title, Empowering Your Sober Self, "jumped out at me." He bought it and over the next 24 hours read it straight through. He said he had been reading recovery literature for nearly 30 years and nothing had resonated with him enough to pick up the phone and call the author, until this book.

He said he liked AA enormously but after more than 20 years, he felt it was always the same thing, and it wasn't going anywhere, and he wanted the challenge of moving forward. The LifeRing concept really spoke to him.

He wanted to start a LifeRing meeting in his area, and he outlined a plan to go speak with some head people at a number of treatment programs with which he was familiar, having often spoken there, in order to get a room and referrals. Of course, I encouraged him, but at the same time I cautioned him that his enthusiasm might not be shared by some of his AA friends.

And so it was. At the first program where he spoke with the chief, he was told that the facility's board of directors was unlikely to go with anything other than 12 step.

He then took the book to his home group, and presented a share about the "A" and the "S" -- the addict self and the sober self. He said, "They laughed at me." They agreed about the "A" but they couldn't wrap their minds around the concept that there was an "S" -- a sober self -- inside the alcoholic's head. His talk met with sarcasm and ridicule.

It reminds me of Gandhi's famous saying:

"First they ignore you, then they ridicule you, then they fight you, then you win."

To his everlasting credit, Guy wasn't intimidated. He's going to speak to other treatment professionals. I shared with him that a number of senior people in 12-step programs have been expressing interest in the LifeRing option. He's now reading How Was Your Week in order to prepare for the convenor role. He's making plans to come visit Northern California in September so he can see LifeRing meetings first hand.

A Reader Writes With More Reading

One of the readers of this blog was kind enough to email me with the following information, which I pass on as received:

mr. nicolaus,

i'm a regular reader (& sometime commenter) of your "new recovery" blog. i'm writing to draw your attention to a few items i think might be of interest to you:

1 - the april/may 2009 issue of "Free Inquiry" magazine ran a great piece by Steven Mohr entitled "Exposing The Myth of Alcoholics Anonymous"; "Free Inquiry" is the first American publication to take AA head-on in a long, long time & the article is thorough & even-handed (unfortunately, you have to pick up a hard copy as the contents aren't available online)

2 - Dr. Harriet Hall (www.sciencebasedmedicine.org, www.skepdoc.info) ran a blog post on the above article & gave an MD's view of the article & the organization (http://www.sciencebasedmedicine.org/?p=490); i thought that might be of interest as well

3 - at my request, Dr. Hall visited & commented on a blog post at www.mentalhelp.net (http://www.mentalhelp.net/poc/view_doc.php?type=weblog&id=700&wlid=5&cn=14); the "editorial comment" to her post was -- putting it mildly -- elusive & openly condescending to any lay critique of AA; again, i was hoping this might be of interest of to you & that you might want to lend your voice to the discussion.

in any case, i thank you for your time & wish you all the best with your book. i'll be visiting the blog & www.unhooked.com regularly.

warmest regards,

peter [Name withheld]

donewithaa.wordpress.com

Choice Theory Conference

It was my privilege yesterday to attend the Choice Theory Education Conference at the Hilton in Sacramento. I staffed a LifeRing literature table there, met with LifeRing convenors and future convenors, attended some of the sessions, and met some of the leading figures in the choice movement.

Georgellen Hofine, one of the oldest students of Choice Theory founder Dr. William Glasser (photo), personally welcomed me to the gathering. LifeRing keynote speaker and DVD author Dr. B. J. Davis was the closing speaker on the conference program, and I much enjoyed listening to his presentation and chatting with him informally.

Choice Theory advocates Resa Stendel Brown and Jack Harnden spoke about the application of Choice Theory in education. Author Mike Rice gave a talk on addiction. B. J. Davis, in addition to his own discussion of Choice Theory in addiction treatment settings, introduced a DVD showing how Reality Therapy (an earlier name for Choice Theory) was applied in a prison setting.

I took time out to meet and chat with convenors of the LifeRing meetings in Placerville and one of the Sacramento locations. One of the conference participants expressed determination to start a LifeRing meeting in Lodi. Two of the treatment professionals in attendance spoke of plans to start LifeRing meetings at their centers in the Sacramento area.

It was a very positive crowd, including quite a few people with an interest in addiction recovery, and I should have brought more books, as Empowering Your Sober Self sold out by noon.

The only shadow over the event was the news that Dr. Glasser himself, who had been scheduled as keynote speaker, had been admitted to the hospital with a cardiac issue. There is as of this writing no further news on his condition.

LifeRing in New Living (NY)

An excerpt adapted from Chapter 2 of my new book (Empowering Your Sober Self) appears in the April issue of New Living, a free 20-p health and wellness newspaper published in Stony Brook NY and distributed in the New York City area and Long Island.

This chapter from my book contains a set of tips and exercises designed to help the person who wants to stop using addictive substances to move across the gap from contemplation to action. They include visualization, laughter, self-forgiveness, reframing, exercise, and other attitude-builders. I wrote a 900-word excerpt for the paper.

The editors took some minor liberties with the chapter. They took the sentence, "Becoming drug or alcohol-free can exhilarate you and enable you to accomplish great things in life," and added the phrase "... and perhaps, more importantly, give you gratitude and humility, two spiritual qualities hard to find in most people."

OK, I may not be the most original writer in the world. But I try not to stoop to moth-eaten cliches like "gratitude and humility." But it's good to have the article in the paper, with a plug for the book, and a plug for the two LifeRing meetings in Long Island; and I guess there's a small price to pay for that. I am humbly grateful.

Class war in California counseling

In California you need a license to fix cars, cut hair, paint fingernails, give massages, and much else. But not to provide addiction treatment. You can be a high school dropout with a history of petty crime and mental hospital stays, and you may find work as a counselor treating people who suffer from addiction. There are in fact a substantial number of high school dropouts working as front-line counselors in the field today.

Yet, at the same time, the addiction counseling industry insists, almost with one voice, that addiction is a disease. Just like diabetes, atherosclerosis, hypertension, and the rest. Now, if addiction is a disease, then addiction treatment must be a branch of medicine. No?

How many other branches of medicine do you know where the front-line treatment providers -- the physicians and RNs who hold the patient's recovery in their hands -- are high school dropouts? Or high school graduates, without more? Or have junior college degrees, only? There are none. Addiction treatment is way out of line, far, far below the standard of the rest of medicine -- if in fact it deserves the name "medicine" at all.

To be sure, there are quality treatment programs where addiction professionals are held to the same high standard as other providers. At the Kaiser Chemical Dependency Recovery Programs, for example, there is supervision by an MD, and each of the counselors has a professional license or certification as a Licensed Clinical Social Worker, Marriage and Family Therapist, Registered Nurse, or a similar qualification that requires graduate level education and thousands of hours of supervised training. But these islands of quality are, unfortunately, just islands.

Several organizations in California have been trying for years to pass legislation that would require standards of training, education, licensure and certification for addiction counselors comparable to those in other clinical professions. The current effort is Senate Bill 707. It is a complex piece of legislation and I won't try to analyze it here in detail. What's most interesting about it, really, is the controversy that surrounds it.

On the one hand, there are voices crying that it doesn't go far enough. Today's email, for example, brings a post from Dennis W., a member of the board of one of the counselors' organizations, complaining that the draft bill is so watered down as to be useless. It puts counselors with a GED and 350 hours of counseling experience on the same level as those who have a master's degree in addiction studies. He says that the bill in this form "will continue to keep the addiction service profession in California the sub-standard field that all other states in the US look down upon."

On the other hand, the bill has been the target of a barrage of attacks charging that it goes too far. If it passes, say these voices, program costs will rise, programs will go out of business, and counselors by the thousands will be out of jobs. What's that about?

The current newsletter of one of the other addiction professionals' organizations explains:

Simply put, associations representing program owners are attempting to defeat the measure by “scaring” counselors from supporting it. The truth is, they’ve opposed every bill put forward to recognize your professionalism. More than half of the states have licensure and none of their treatment systems were shut down due to licensure or certification. Standards for counselors improves salaries, raises treatment outcomes and reduces the strains on public sector treatment as addicts seek treatment from private practitioners.

So there you have it. It's class war. On one side, the counselors who aspire to professional status and to the salaries, benefits, and respect that come with it. On the other side, associations representing owners of treatment programs whose profit rate depends on filling their staff rosters with people who have little education, training, or other claims to professional advancement.

Now you can begin to understand a little more clearly why much of the addiction industry is so heavily invested in the 12-step approach. The 12-step approach does not require much in the way of professional education. If you've done the steps and you can repeat a basic set of slogans for any occasion, you're qualified to "carry the message" to others. Of course, you're not supposed to be getting paid for doing that, but you're being paid so little as a counselor that you might as well be doing it for free. If Karl Marx were looking at this, he might say that the 12-step organizations continuously generate a "reserve army of labor" for the treatment industry -- a flood of workers willing to work for substandard wages and under substandard conditions. And this "reserve army" necessarily depresses the wages and conditions of the whole labor force. No wonder, then, that the owners' associations oppose the counselors' campaign to pass laws that would upgrade professional standards.

Don't drink that marshmallow

The marshamallow experiments are famous by now, thanks in large part to Daniel Goleman's Emotional Intelligence books, and their relevance to addiction seems obvious.  In 1968, Stanford psychology prof Walter Mischel presented four-year olds with a marshmallow and the choice: Eat it now, or wait 15 minutes and get two.  The kids who could delay the gratification ended up, a decade and more later, with higher SAT scores, higher graduation rates, better jobs -- in short, twice as many of the marshmallows life had to offer.  

It was often believed that the kids who could delay gratification did so thanks to more "will power."  Mischel -- according to a helpful and informative summary in this week's New Yorker, by Jonah Lehrer -- analyzed what this "will power" really consisted of.  He paid very careful attention to what went through the delaying kids' minds as they resisted the bait.  They succeeded because they had methods of distracting their minds from the lure.  They covered their eyes, or played hide-and-seek under the desk, or sang songs.  "Their desire wasn't defeated -- it was merely forgotten."  The key, Mischel found, was not to resist the marshmallow -- that didn't work --- but to avoid thinking about it.  

In further experiments, Mischel found that children could be taught cognitive tricks that helped them distract themselves.  Even reducing the intensity of the temptation by pretending that the marshmallow was only a picture of a marshmallow or that the marshmallow was really a cloud worked for some children.   

Mischel and other researchers Lehrer quotes are skeptical of finding a genetic basis for the ability to delay gratification.  Too many genes are involved in even the simplest aspects of personality.  The cutting edge of research lies in classroom curricula that teach self-distraction, and in educating parents to cultivate simple cognitive skills in children.  Says Mischel:

"We should give mashmallows to every kindergartner... We should say, 'You see this marshmallow"  You don't have to eat it.  You can wait.  Here's how.'"

No Such Thing as a Bad Person Addicted to Alcohol

Had the pleasure today to hear and meet Charles D. Appelstein, author of No Such Thing as a Bad Kid and other works expounding the strength-based approach to working with at-risk youth.  

Charlie was keynoter  at the 12th annual Northern California Tobacco, Alcohol, Drug Educator and Youth Development Conference at UC Berkeley, where I staffed a LifeRing exhibit table.  He's a fun speaker, gets the audience laughing, chanting, and singing, all the time delivering key points of a message that is in many respects revolutionary.  

When a teacher or counselor begins work with troubled kids -- also "trouble kids" -- the key thing is attitude, Charlie began.  The successful attitude, he said, is "I believe in you.  You are a great kid.  You can do great things."  This attitude transfers to the kid; it makes the kids feel good about themselves, it gives them hope, and it inspires them to change for the better.

Afterward we chatted about addiction treatment, and I told him that LifeRing was one of the strength-based approaches in this field.  He expressed great interest.  We also exchanged books; he gave me his and I gave him mine.  

I also had the opportunity to chat with Tom Herman of the State Department of Education, Dr. Alex Stalcup of the New Leaf Treatment Center, Ralph Cantor of the local County Office of Education, and a number of substance abuse program administrators, teachers, cops, and others in and around K-12 education who are concerned with the drug issue.  The message that there's a secular, strength-based addiction recovery support network out there was welcome news to many ears.  

First call

Had the first telephone call today from an arms-length reader of Empowering Your Sober Self, my new book.  A counselor in San Diego called on the 800 line to say he had a number of clients who were not responding to 12-step and this looked like just the right approach for them.  Wanted to know were there local meetings (not yet) and how they could connect with us (online).  "Very glad to see you exist.  This is much needed."

Seattle police chief tapped as 'Drug Czar'

Rumors last month that Rep. Jim Ramstad was headed for the post of 'Drug Czar' proved unfounded, as Pres. Obama has reportedly nominated Seattle Police Chief Gil Kerlikowske for the post, instead.  Kerlikowske has earned generally positive reviews, but it's too early to say, if he's confirmed by the Senate, what he's likely to do as top commander of the 'war on drugs.'  Obama is on record that this 'war' has been a colossal failure.  There's grounds for hope that Kerlikowski will redirect the mission of this cabinet-level office more toward treatment, prevention, and a public health approach, rather than the nightstick-and-prison medicine that has prevailed.  For an eloquent statement advocating such a change in mission, read Victor Capoccia's op-ed in the Baltimore press, here.  Capoccia is head of the Closing the Addiction Treatment Gap initiative.  

Well said, in Washington

The Bush years, by wide consensus, were a dismal era for science.  But by a strange paradox, some bright stars emerged in what is normally a dismal field under any administration: addiction science.  

One is the brilliant Nora Volkow, who brings a rare mix of research experience, clear thinking, and leadership ability to the National Institute on Drug Abuse (NIDA).  

Another is Mark Willenbring, Director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA).  In a letter to the current New Yorker (the one with the cartoon of Obama as George Washington on the cover), Willenbring precisely skewers a piece that this normally astute mag published in its December 1 issue.  The article, titled "Special Treatment," by Amanda Fortini, featured a Los Angeles area deluxe treatment facility.  

After a string of well-worn 12-step platitudes about addiction and the difficulties of recovery, the owners of the facility claimed that in essence treatment could make no difference, everything depended on the addicted person's motivation.  So why bill the client for clinical services on top of the normal cost of luxury room and board? 

Willenbring's letter goes directly for the jugular.  He writes that the piece:

... shows the irony that paying more does not guarantee access to the most current therapies... The program that Fortini describes appears to base its services on a treatment model that is more than thirty years old .... Although clients may or may not receive some benefit, they are vulnerable to unnecessary relapse risk if more contemporary treatments are not also made available.  For example, research funded by the National Institutes of Health has identified several medications that reduce relapse in early recovery from alcohol dependence.  Newer behavioral approaches, such as cognitive-behavior therapy and motivational interviewing, also increase recovery and provide alternatives to the traditional Twelve Step approach (which in updated form is also effective).  This menu of services makes possible truly individualized treament and  increases client choice and engagement, but only if people have access to it.

The treatment program Fortini described in her article was so clinically clueless and bereft of ideas that the piece might have been a subliminal parody.  It isn't often that I get to cheer somebody in Washington for saying the right stuff.  Could this be the beginning of a change we can believe in?  

Congratulations to Barack Obama

As a college student at Wesleyan in '61 (or was it '62?) I joined with other white students to team with groups of black students from Howard University in an effort to integrate lunch counters in Glen Burnie, a suburb of Baltimore.  In some places we sat indefinitely without being served; in one, we were served coffee with salt in it; at another they locked the doors as we approached.  When we picketed the segregated local movie theatre, a mob of white men surrounded us as sheriffs watched.  A providential cloudburst scattered the crowd and allowed us to escape.  

On the night of election day in 1964, I arrived at the civil rights movement headquarters in Jackson, Mississippi, to begin a few months of volunteer work.  Nearly everyone was glued to the TV set to see whether the Democratic Party would seat the elected black delegates running under the banner of the Freedom Democratic Party.  The answer was, no.  

These and other memories came upwelling as I watched the inauguration of Barack Obama.   The party that wouldn't seat elected black delegates had nominated a black man for president.  A man whose father would not have been served at DC area restaurants 60 years ago was taking the oath of office.   Indeed, there has been some changes.

This morning's San Francisco Chronicle editorializes that Obama's new approach is "grounded in sobriety and hard work."  The "sobriety" that's meant here is, I assume, the metaphorical kind -- a pragmatic, realistic attitude -- and not the literal kind, meaning abstinence from alcoholic drink.  Yet there's a connection to reflect on, here.  

For me, personally, my time of active engagement in the civil rights movement was largely a time when my alcoholism (acquired in my freshman year in college) was in remission.  Engagement in life-changing work was hugely more interesting than drink.  My drinking habit only bloomed large during the years of reaction that followed, when it seemed that everything we had done was being undone.  Pessimism, despair, lack of hope were the atmosphere in which this illness flourished.  And I'm not the only one.  Is it an accident that the drug problem grew larger in rough proportion as conditions for the poor and middle class in America stagnated and deteriorated?  

Barack Obama's own history with alcohol and other drugs offers a refreshing contrast to that of his predecessor in office.  Obama has freely and openly admitted experimenting with drugs as a youth, but then stopped; he is trying to quit, or has quit, smoking.  What a contrast to the history of "W," whose claimed mid-life alcohol salvation story is widely believed to be a sham that covered up more than it revealed, notably a long history of cocaine use, some say.  

I've not yet seen anything in the way of Obama's statements so far that gives a clue to his specific policies on alcoholism and other addictions.  The federal government has many levers to pull and many dollars to spend in this area.  On general principles, I assume that Obama will support the recent extension of parity in the treatment of mental health and addiction treatment.  I assume that the federal agencies in this area will continue to be funded.  

The open questions in my mind are (a)  War on Drugs, and (b) Federal excise taxes on spirits and tobacco.  We need "change we can believe in" in the "war on drugs," a criminal exercise in hypocrisy and racial/economic persecution that is long overdue for radical reform.  An even more telling mark of Obama's mettle will be whether he supports Congressional action to raise the excise taxes on liquor and tobacco.  Public health advocates have long maintained that raising these taxes is the single most effective measure to reduce the social impact of these two most murderous addictive drugs.  Needless to say, the pillars of corporate greed stand deeply dug in on this issue.

The largest opening in the clouds under this new administration will be in the area of improving living standards and reducing inequities for the poor and middle class.  If the real and emotional environment of ordinary people in this country becomes infused with progress and hope, the problems of alcohol and other drugs will recede as if of their own accord.  It will take some time, but if the new administration succeeds in this largest and most difficult of goals, we will, in fact, see a new era of "sobriety" in both senses of the word.

Congratulations to President Barack Obama, and best wishes for the future.

P.S.  To date, the White House Office of National Drug Control Policy remains under an interim head, Patrick Ward, a Bush appointee who has held the post a bit over a year.  Obama's choice of Rep. Jim Ramstad to become the new Drug Czar has run into heavy fire for Ramstad's ties to abusive "faith-based" programs, his policy positions on prevention, and his ties to a massive investor fraud.  Read Maia Szalavitz's blog blast and the Drug Policy Alliance editorial.  Ramstad is not change, he's MOTSOS.