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Heroin Recovery A Systemic Approach
Welcome to Part Five of the series Heroin Use and Recovery in Delaware. It makes sense to expend just as much energy on recovery as was utilized in prevention.
Part Two History of Heroin and Delaware
Part Four Heroin Addiction and the Self
Well, I got a candle
And I've got a spoon
I live in a hallway
With no doors and no rooms ….
Someone save me, if you will
And take away all these pills
And please, just save me if you can
From the blasphemy in my wasteland
Someone save me
Someone save me
Somebody save me
Somebody save me
Please don’t erase me
(Save Me. Shinedown)
The song, Save Me, performed by the group Shinedown, talks about the internal battle users goes through once they have made the decision to get clear of the drug and they have the realization that they need help. The last line of the song is key for society to understand, “Please don’t erase me.” Too often we are looking for solutions to social problems the recommended strategy benefits future generations. In the case of Delaware’s ability to address addiction issues, the structure does not currently exist, so the plans need to include short term and long range goals. While heroin addiction is a national problem, it is a very personal issue involving real people that should not be dismissed as insignificant or a lost cause.
I have been told many times, if I am going to present a problem then I have an obligation to recommend a solution. If I do not, then I become part of the problem. With no alternative course of action the status quo remains the most viable option to those who are in control. Some may argue over my qualifications to present a plan of action because of my earlier confession of not being a social services, law enforcement, or drug rehabilitation expert. I believe there is an advantage gained by having someone from outside the established norm of experts to be a valued and active partner in the discussion. Diversity of thought and skills are beneficial assets to the project. However, as diversity consultant and author R. Roosevelt Thomas Jr. points out, “Diversity for its own sake has little meaning. Its value lies in the effect it may have on the ability to accomplish objectives, and that is a matter of context.” (Thomas 189) To that end, what I bring to the table years of research experience, a vested interest in the issue, and a willingness to collaborate with those who have a different knowledge and skill set. In addition, I have a good grasp of self-identity and disability through my work as a diversity consultant and an Americans with Disability advisor.
My primary goal for this project has been to facilitate a discussion on how a society can help a person who wants to break free from their addiction? First, there has to be some part of the individual user that wants change. They have to start questioning their lifestyle and choices. Singer songwriter Pink (Alecia Beth Moore), a former drug user, highlights in her song Sober.
Will I ever feel this good sober?
Tell me, No no no no no pain
How do I feel this good sober? (Moore)
The song is asking if there is life beyond the substance abuse. The idea of sobriety can come from many places, the court/penal system, family and friends, a near death experience, or becoming tried of the lifestyle. Adam Smith and other moral philosophers believed one of the primary motivators in life is the attempt to increase pleasure and the avoidance of suffering. In Part VI of The Theory of Moral Sentiments, he introduces this topic. “As he grows up, he soon learns that some care and foresight are necessary for providing the means of gratifying those natural appetites, of procuring pleasure and avoiding pain, of procuring the agreeable and avoiding the disagreeable temperature of heat and cold. In the proper direction of this care and foresight consists the art of preserving and increasing what is called his external fortune.” (Smith VI.I.3) Smith believed we gravitate to the things that give us pleasure while shying away from the things that cause us pain. The pain can be physical, mental or a combination of both. The pain of continuing the addiction has to reach a point where the limited pleasure received is no longer sufficient. But, they have the tools available to them to deal with the pain without the crutch drugs.
In any case, there has to be a significant emotional event within the self before change can start to happen. That does not mean the individual has to “hit rock bottom”, which is a dangerous myth in itself. If we  wait until the drug can do no more harm, then it may be too late; non-repairable criminal activity or health issues may have already taken hold. A key component is the user has to have some personal motivation for change. They alone know what their significant emotional event is. But the recognition of the significant emotional event happens after the moment has past. At some point, the individual has to accept the need for change, and create his or her own opportunity. The State needs to ensure the systems are in place to support the individual’s effort.
At this point of the discussion, I am going to ignore the addict for a minute and focus on a subject I touched on in an earlier section, which is the social stigma that is attached with the terms “addict” and “addiction”. In a report to Cable News Network (CNN) Dr. Adi Jaffe talks about the challenge stereotyping has on a recovering addict’s ability to fully integrate back into society. “Do drugs really "fry" your brain? Once an addict, always an addict? Is there such a thing as an "addiction gene"? The subject of addiction is plagued by myths and misinformation that were created to scare our children away from drugs. But these haven't succeeded, and have actually made it harder for addicts to seek treatment and to return to a normal life.” (Jaffe) As a researcher at the University of California Los Angeles (UCLA), he explains how a social stigma is one of the top reasons for a recovering addict to relapse. Twelve years after CNN published this report, the stereotypes of addictions and addicts are still firmly in place.
Much of our societal views of addiction are driven from our moral understanding of the subject. The American philosophy John Dewey explains how morality can be translated into norms. “For practical purposes morals mean customs, folkways, established collective habits. This is a common place of the anthropologist, though the moral theorist generally suffers from an illusion that his own place and day is, or ought to be, an exception. But always and everywhere customs supply the standards for personal activities. They are the pattern into which individual activity must weave itself.” (Dewey 75) In the case of addiction, the norm has been to look at the addict as evil. Social media discussions portrait drug users as a drain on our social services. In movies/TV, they are often depicted as outcasts, homeless, uneducated, and criminals. The news looks at them as criminals that need to confine to prisons. Instead of looking at the disease, the focus is on the moral failing of the individual. These perspectives highlight a lack of understanding of the underlying issues involved with addiction. Just as with any stereotype, there is a grain of truth blended in with the fiction. This understanding addiction has to change and be replaced with a social contract where the expectation is recovery.
A huge component of the societal paradigm shift is education about the process of recovery, which means redefining the public understanding of drug abuse. The new comprehension will involve replacing the demonization of heroin and the addiction with a focus on the road to healthy and the humanness of the user. There is an interesting balance, which has to maintained, between prevention and recovery. A program has to bring attention to the dangers of the addiction while highlighting the ability to move beyond. At the same time, there also has to be an understanding of the consequence of use, while placing the emphasis on the behavior without the moral judgment of the user. This is hard to do when a stakeholder is dealing with a family member or an intimate friend who has not accepted that they have a problem.
The NIH has design a detailed drug abuse treatment (Figure 3) schematic, which is comprehensive. If you look at most states, the recovery plan include the usual suspects. You have sections for family and friend, another piece that covers the medical, legal/support type groups, and finally transitional support.
The NIH schematic missing is the coordinated partnership of stakeholders that exists in the prevention of drug use. In the prevention framework (Figure 4), the listed partners include a number of Federal agencies to include the Department of Education, Homeland Security, the Department of Health and Human Services, Department of Defense, Justice Department and the White House. For Delaware prevent group includes Delaware Health and Social Services, Department of Education, Department of Services for Children, Department of Safety and Homeland Security, Governor’s Advisory Council, Criminal Justice Council, and a number of non-governmental groups and institutional of higher education. With recovery, the prevailing attitude is that addiction is a medical or judicial problem. I am arguing the groups involved with prevention need to be involved with recovery. Their role in avoidance is just as important to the recovery. With the intent of the process is to help the person reconnect with their self without the filter of heroin. Missing from this coalition of prevention and recovery are two key shareholders. They are the health insurance industry and businesses.
The health insurance industry has to be an active partner in this process. For those who do not qualify for public assistance programs, insurance companies determine the level and location of the care an individual is able to receive. For the most part the industry has remained actively silent on the subject, providing only superficial assistance. Treatment and rehabilitation programs are expensive. Early intervention would make fiscal sense, the cost to insurance companies increases the longer the addiction goes on. Chronic health issue develop with repeat exposure, so any short term gain they may see as a result of inactivity with be lost over time.
Businesses can play an important role in this process, because in this country, employment is critical in the creation of identity, and past drug use is a barrier to full employment. By full employment, I mean a person is working in a job and receiving a paycheck appropriate for their skills. Drug addiction is a recognized disability under the ADA. However, as the Department Of Justice website explains, the ADA is not an excuse to come to work under the influence. “Casual drug use is not a disability under the ADA. Only individuals who are addicted to drugs, have a history of addiction, or who are regarded as being addicted have an impairment under the law. In order for an individual's drug addiction to be considered a disability under the ADA, it would have to pose a substantial limitation on one or more major life activities. In addition, the individual could not currently be using illegal drugs.” (DOJ) The educational process for business has to counter the old stereotypes such as “once an addict always an addict” and replace it with an understanding of the disability.
Additional employers also can influence the level of coverage provided by the insurance industry. The larger the company/organization the increase leverage they have when negotiating benefits for this employees. If it is an important issue for the employee, it will become important to the insurance provider. Even small to medium companies can have an impact. Especially if the unify their voices through such groups as their local Chamber of Commerce.
Employers have to be educated on the disease, recovery and life beyond the drug. They are the ones who can close the gap in the ADA that creates a dangerous Catch 22 for addicts who are gainfully employed. The idea Catch-22 is captured in a book by the same name. The author, Joseph Heller, tells the story of the no win situation a WWII bomber pilot felt he was in. In this exchange the lead character, has just learned the number of required mission to rotate back home has gone from 45 to 50, at the time he had completed 44. Here he is talking to the base physician to see if he can be certified as crazy to be grounded.
Yossarian looked at him soberly and tried another approach. “Is Orr Crazy?”
“He sure is,” Doc Daneeka said.
“Can you ground him?”
“I sure can. But first he has to ask me to. That’s part of the rule.”
“Then why doesn’t he ask you to?”
“Because he is crazy,” Doc Daneeka said. “He has to be crazy to keep flying combat missions after all the close calls he’s had. Sure, I can ground Orr. But, first he has to ask me.”
“That’s all he has to do to be grounded?”
“That’s all. Let him ask me.”
“And then you can ground him? Yossarian asked.
“No. Then I can’t ground him.”
“You mean there’s a catch?”
“Sure there’s a catch,” Doc Daneeka replied. “Catch-22. Anyone who wants to get out of combat duty isn’t really crazy.” (Joseph Heller 52)
The following is from the U.S. Commission on Civil Rights’ Website, Sharing the Dream: Is the ADA Accommodating All? Chapter 4: Substance Abuse under the ADA. While recognizing addiction as a disability there are limitations on the protections recovering addicts have in relation to the ADA.
The ADA provides that any employee or job applicant who is “currently engaging” in the illegal use of drugs is not a “qualified individual with a disability.” Therefore, an employee who illegally uses drugs—whether the employee is a casual user or an addict—is not protected by the ADA if the employer acts on the basis of the illegal drug use. As a result, an employer does not violate the ADA by uniformly enforcing its rules prohibiting employees from illegally using drugs. However, “qualified individuals” under the ADA include those individuals:
- who have been successfully rehabilitated and who are no longer engaged in the illegal use of drugs;
- who are currently participating in a rehabilitation program and are no longer engaging in the illegal use of drugs; and
- who are regarded, erroneously, as illegally using drugs.
(Commission on Civil Rights)
So where is the Catch-22? At first glance, the law says if you are currently using the drug then there are no protections. But if you have completed or are participating in a rehabilitation program than you are disabled. The term that is creating the confusion case is “currently engaging”. Which is defined by the EEOC in Section 8.3 of the A Technical Assistance Manual on the Employment Provisions (Title I) of the Americans with Disabilities Act.
"Current" drug use means that the illegal use of drugs occurred recently enough to justify an employer's reasonable belief that involvement with drugs is an on-going problem. It is not limited to the day of use, or recent weeks or days, in terms of an employment action. It is determined on a case-by-case basis. (EEOC)
Here is the problem, you have an employee who has worked for less than a year  and has addiction to heroin (or any other drug). This individual has made that critical first decision to get clean. He/she arranges to go to a detoxification center with follow on care with an outpatient facility. He/she asks the employer for a leave of absence to go to the detoxification center and the aftercare program will not interfere with his/her work hours. The leave of absence should be no more than seven days. This employee can be fired for violating the company’s drug-free workplace policy, because to be admitted into a detoxification facility you must be going through withdrawals, which means that he/she fits the EEOC definition of current use, thereby they are not covered by the ADA.
Even after completing, a rehabilitation or detoxification program there is no clear guidance for employers to determine what the line of current use is. In the Decision of Mauerhan v. Wagner Corporation, the 10th Circuit wrote.
No formula can determine if an individual qualifies for the safe harbor for former drug users or is “currently” using drugs, although certainly the longer an individual refrains from drug use, the more likely he or she will qualify for ADA protection. Instead, an individual’s eligibility for the safe harbor must be determined on a case-by-case basis, examining whether the circumstances of the plaintiff’s drug use and recovery justify a reasonable belief that drug use is no longer a problem.
Among the factors that should be considered will be the severity of the employee’s addiction and the relapse rates for whatever drugs were used. (Mauerhan v. Wagner Corporation)
The lesson is, if you are a heroin user, employed, the use has not interfered with your ability to perform the tasks at your job, and you want to keep your job, try to stay out of trouble for a year. During that time make sure you work 1250 hours so you are then qualified for job protections under the Family Medical Leave Act (FMLA), then apply for a leave of absence. This is not the message we should send. To avoid this troublesome scenario educating the employers is so important. I am not advocating a free pass for workplace misconduct, however if the employee self identifies as to having a problem before there are any documented employment actions, then it would be prudent to allow for the time off to receive assistance. The lack of employment will only increase the chances of relapse and delaying treatment can on have deadly consequences.
Given the understanding of the self established in the last section and how the drugs interact with the self, the approach to rehabilitation has to come from an understanding the multiculturalism that is involved. It is viewing the whole person, the addiction and the environment, how to create a self when the drug has been a central player. Referring the NIH website, “No single treatment is appropriate for all individuals. Matching treatment setting, interventions, and services to each individual's particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.” (NIH) There has to be an appreciation of the culture the individual comes from. The societal norms drive how a person perceives and interacts with the world. If the recovery process does not address the unique aspects of the person, any plan of action will appear foreign to the client. The National Center for Cultural Competence at Georgetown University has developed the concept of cultural competencies for healthcare providers. The benefits to the clients they lists apply to the recovery process.
Benefits to the Patient/Consumer
1. Patients/consumers who have positive experiences with cultural brokers will be more likely to continue to access services, which potentially improves health outcomes and reduces health disparities.
2. Patients/consumers will recognize the health care setting’s commitment to deliver services in a manner that respects and incorporates their cultural perspectives.
3. Patients/consumers may be motivated to seek care sooner when they know that providers understand and respect their cultural values and health beliefs and practices.
4. Patients/consumers may be able to communicate their health care needs more effectively and better understand their diagnoses and treatment.
5. Patients/consumers who benefit from this approach may also encourage others within their community to access and use services. This approach has the potential to positively impact the health of the entire community. (National Center for Cultural Competence)
The treatment and integration program for a 50-year-old male from Wilmington Delaware is not going to look the same for a 20-year-old female in Ellendale Delaware. Their motivations and reasons for sobriety are going to be different. In 1725 the philosopher Immanuel Kant wrote, “Act in such a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means, but always at the same time as an end.” (Kant 98) When viewing each person within the process, they must not be seen as the process, they are participants of.
It has been said that changing the physical environment is important to any sustained modification of behaviors. Larsen said, “relapse is common if there are not changes to the physical environment or the behavioral motivations that prompted the abuse and first place.” (Larsen 233) This is sometimes easier said than done. Without jobs, housing, and viable means of self-support changing the environment becomes challenging. If the social perception and stereotypes do not evolve then the message being sent and enforced is efforts of recovery are fruitless. If nothing changes than nothing changes.
You have stayed with me through 5 different Hubs of history, policy, and suggestions for the future, for that I thank you. Listening to other perspectives and understanding their view is the first step in any sustainable systematic change. Without open discourse from competing positions then chances for growth are limited. In closing this piece, I want to leave you with several thoughts.
The first point is an understanding that all negatives can be made into a positive. This may sound like a cliché, but it is a matter of choice. You can decide to antipathetic and cynical or you can look for way to grow and help others learn from your experience. When dealing with a person who has not made the choice yet for recovery it is a hard concept to remember.
Beware of the wonder drugs that will fix the problem. Remember drugs like cocaine, morphine, and heroin all started as pharmaceutical wonders of their day. Prescription drugs are a tool, but they too can become the problem of abuse. The long-term answer to this problem is self-identity and the elimination of the need for the drug.
A question that is often asked, especially during tough economic times is why should we go through the trouble and expenses for something that impact a minority part of the population? One answer is it makes fiscal sense. When you compare the cost of prevention and recovery with expense of untreated abuse, it becomes a solid investment. Often continued abuse leads to other health conditions and possible negative and expensive interaction with the judicial system.
Drug addiction treatment is cost-effective in reducing drug use and its associated health and social costs. Treatment is less expensive than alternatives, such as not treating addicts or simply incarcerating addicts. For example, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs approximately $18,400 per person.
According to several conservative estimates, every $1 invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft alone. When savings related to health care are included, total savings can exceed costs by a ratio of 12 to 1. Major savings to the individual and to society also come from significant drops in interpersonal conflicts, improvements in workplace productivity, and reductions in drug-related accidents. (NIH)
The other reason I will point is a moral obligation as a member of a modern society. Some would counter with “I am not my brother’s keeper.” Meaning I am not responsible for the actions of others. In reality, heroin addiction impacts the society as a whole; it will take the whole society to address the problem. Recovery programs are not charity or a hand out; they are a pathway for people to return to being.
It was the British author Douglas Adams’ cynical view about humans that portraits the issue of heroin addiction. “Human beings, who are almost unique in having the ability to learn from the experience of others, are also remarkable for their apparent disinclination to do so.” (Adams) The problem with heroin has been known for a number of decades. The addictive nature of all opiates has been well documented for centuries, yet we still are having a problem with them.
Recovery for some is a life long journey, for our State, it is a problem that is not going away overnight. If the people/politicians are looking for quick fix solution to the growing problem, none exists. Our history of action and inaction has been leading us to this point where we have no choice but recognize the problem since 1874. In Delaware we have ignored the problem for at least 12 years, so turning the tide is going to take time. Time should not be the excuse for inaction or delaying action. Dr. King points the importance of never depending on time to work out a problem.
First is the myth of time advanced by those who say that you must wait on time; if you ‘just wait and be patient,’ time will work the situation out. ………. Even a superficial look at history shows that social progress never rolls in on the wheels of inevitability. It comes through the tireless effort and the persistent work of dedicated individuals. Without this hard work, time itself becomes an ally of the primitive forces of irrational emotionalism and social stagnation. (King p 213)
It is only through continuous effort will the perceived need for the drug will diminish. I will leave you with one more question:
Question: How do you walk 200 miles?
Answer: One-step of the time. But, you have to keep walking.
1. I am using “we” in the collective sense meaning society and the stakeholders to an individual user.
2. The one-year mark is an important milestone. If a person works for one year and has been on the job for 1250 hours they may have protections under the Family Medical Leave Act (FMLA)
3. When the drug was introduced
Department of Justice; Civil Rights Division; Disability Rights Section. QUESTIONS AND ANSWERS: THE AMERICANS WITH DISABILITIES ACT AND HIRING POLICE OFFICERS. http://www.ada.gov/copsq7a.htm. March25, 1997 (Access February 18, 2015)
Department of Justice: National Drug Intelligence Center. Delaware Drug Threat Assessment. Product No. 2002-S0379DE-001. http://www.drugabuse.gov/publications/research-reports/heroin/scope-heroin-use-in-united-states. Page last Updated November 2014. (Accessed December 20, 2015)
Dewey, John. Human Nature and Conduct: An Introduction to Social Psychology. The Modern Library. 1926
Equal Employment Opportunity Commission (EEOC). A Technical Assistance Manual on the Employment Provisions (TITLE I) of the Americans with Disabilities Act. http://askjan.org/links/ADAtam1.html#VIII. January 1992 EEOC-M-1A. ADA Technical Assistance Manual Addendum (10/29/02). (Accessed March 29, 2015)
Heller, Joseph. Catch-22. Simon & Schuster. 1989 (Original 1955)
Jaffe, Adi, Special to CNN. 5 damaging myths about addiction. http://www.cnn.com/2012/09/13/health/jaffe-addiction-myths/. Updated 1:31 PM ET, Thu September 13, 2012. (Accessed March 1, 2015)
Kant, Immanuel. Translated by H. J. Paton. Groundwork of the Metaphysics of Morals. Harper Torchbooks. 1964 (originally published 1785)
King, Martin Luther Jr. The Essential Writings and Speeches of Martin Luther King Jr; I have a Dream. Editor James M. Washington (New York: First Harper Collins Publishing. 1986)
Larsen, Laura, editor. Drug Abuse a Sourcebook. Omnigraphics Inc. 2000
Moore, Alecia Beth, Marcella Araica, and Kara DioGuardi. Sober. Funhouse. LaFace Zomba. 2008
National Center for Cultural Competence. Georgetown University Center for Child and Human Development. Georgetown University Medical Center. Bridging the Cultural Divide in HealthCare Settings: The Essential Role of Cultural Broker Program. DEVELOPED FOR: National Health Service Corps Bureau of Health Professions Health Resources and Services Administration. 2004
Smith, Adam. The Theory of Moral Sentiments. 6th edition. http://www.econlib.org/library/Smith/smMSCover.html. London: A. Millar. 1790, original publication date 1759. (Accessed March 8, 2015)
Smith, Brent and Anthony Battaglia. Save Me. Performed by Shinedown. Album Us and Them Published by Lyrics © Sony/ATV Music Publishing LLC, Warner/Chappell Music, Inc., Universal Music Publishing Group, O/B/O APRA AMCOS. 2005
Thomas, R. Roosevelt Jr. Building a House for Diversity. AMACOM American Management Association. 1999
Figure 1: Cooking Heroin. Heroin FAQs; Frequently Asked Questions About Heroin. About.Com. http://alcoholism.about.com/cs/faq/a/blheroinfaq.htm. 2015 (Accessed April 10, 2015)
Figure 2: Public Service Image of Brain on Drugs. http://chej.org/2011/09/this-is-your-brain-this-is-your-brain-on-pvc/brain-on-drugs/. (Accessed March 11, 2015)
Figure 3: Components of comprehensive drug addiction treatment. NIH. http://www.drugabuse.gov/publications/teaching-packets/understanding-drug-abuse-addiction/section-iii/4-components-comprehensive-drug-addiction-treatm
Figure 4: Drug Prevention Infrastructure Map. University of Delaware. With Funding by Delaware Health and Social Services. Division of Substance Abuse and Mental Health. State of Delaware. http://www.cas.udel.edu/cdhs/ddata/Documents/Delaware%20Prevention%20Infrastructure%20Map_2014.pdf.