A Review of Current Talking Points in and Around Recovery
Austin McNeill Brown
Over the last few years, several talking points have emerged in the addiction and recovery space. Some of these talking points have a degree of legitimacy, some are good intentioned, and others are simply harmful. However, all of them have been formed, I assume, with good intentions. Those who have pushed these discursive elements vary from individuals with lived experience in recovery, to personal brand promoters cashing in on this unique moment in history. I do not disparage these individuals per se, but for me, it is important that we pull out these talking points from time to time, and examine the roots, meaning, and implications of these talking points. None of what I offer are going to be direct quotes, but rather, summary points derived from the techno-advocacy sphere narratives. Twitter, Facebook, blogs, and podcasts have all been utilized in this summary. This is of course, a qualitative account, and is representative of how I see and hear these points. When possible, I will try to put the best possible spin on these ideas, for I do believe that many of us truly want to see positive changes and a basic human understanding for those who are in recovery, and those who are still struggling with substance use issues. I will try to regularly post on various emergening talking points, and I encourage readers to engage with one another. So, let’s take the first one.
“Abstinence is not a realistic goal and should be removed from qualifications of success or failure.”
I am going to rate this statement as true. But with significant caveats. First let’s examine the roots of this talking point. This construction emerges from the movement to increase access to pharmacotherapy for people with opiate use disorder (OUD). It also mistakenly assumes that abstinence cannot include the use of medication. Without wading too deep in the water of race and class, I will say that the popularization of this is a talking point that is correlated highly with the rise of White opioid issues. I will also say that this point is applied largely to OUD populations. However, it has begun to creep into other discussions, namely, use management/moderation strategies. This talking point is also used within the harm reductionists strategies to make the case for more open access to harm reduction strategies. All well and good.
However, we should also examine what the possible problems with this statement may be. First, for many, particularly those with severe substance use disorders (SUD) and late-stage addiction, abstinence is the last option before death. Those involved in the justice system (rightly or wrongly) may have their very freedom dependent on the ability to achieve and maintain abstinence. This is particularly true for those outside of the OUD population. The majority of those with late-stage addiction not related to opioids, do not have options that include medications, at least, not anyoptions that work very well for very many. We must remember that OUD issues still only constitute a small part of the overall addiction issue. Ergo, what may be true and appropriate for some of the people with OUD may not be generalizable to everyone with addiction issues.
Scientifically and diagnostically, this statement is only partially true. Those who have become so biochemically dependent on a substance that they warrant the use of that substance or similar substances such as medication in perpetuity is a very, very small number, despite what five-thirty-eight may say: Linky . The sad truth is most people don’t live long enough to become so biochemically altered that abstinence is a scientific impossibility. So, this brings us to those for whom this talking point is widely applied- Those with OUD, during a poisoning crisis, who may not want to stop using substances or who may not want to taper off addiction medication. This population, like all populations who do not yet want to stop using substances, should have easy access to safer means of substance use and symptom management medication. This is, however, a different discussion and should not be confused with abstinence as a possible outcome. Additionally, we should recognize a key population who should be exempted here- Those with chronic pain. For some reason, those with chronic pain keep getting lumped in with those who use substances. This brings us full circle to the difference between those dependent on substances (mostly opioid pain relief) and those with addiction. These are two separate populations and should discursively be kept separate. Lumping them together in the discussion harms both, and benefits neither.
Let’s now talk theory. What are the theoretical implications of the statement above? As a recovery scientists and recovery theorist, I can tell you that this statement is quite true, but for scientific reasons which I will now illuminate: Abstinence tell us almost nothing about the quality of recovery. As an outcome, it is useful only in what it implies- that there was significant recovery capital brought to bear on the addiction at hand, sufficient enough to allow for abstinence and maintenance of abstinence. For how long? Generally, research extends for months to only a few years post treatment. And what is the depth of abstinence? Does abstinence include all mind-altering substances, or just the problematic ones? Since there are no objective ways to measure loss of control, abstinence remains a contentious point, that is not well-defined, and is problematic as a measure of success. What is far more useful is the measure of intrapersonal improvements (relationship to the self), interpersonal improvements (relationship to others), ecological improvements to life circumstances, and general quality of life. More on this can be found here: Linky2 Linky3
Now, let’s talk about the real world. Setting theory and science aside. Why? Because without attaching theory to practice, recovery scholarship is somewhat useless. Many of those with lived experience will affirm that they tried every possible means of avoiding abstinence through moderation. Many will also affirm that they came to abstinence only after exhausting every possible combination of substances, to alleviate their condition. Abstinence is often arrived at after years of trial and error. For those fortunate enough to survive long enough to realize that abstinence was the only way, it is an extraordinarily precious commodity. One which they have achieved, often through the hard work of self-improvement, disciplined action, and radical personal changes. For those that achieve abstinence it is one of the greatest victories in their life. The subsequent maintenance of abstinence requires lifelong ongoing vigilance. This is no small order. And, it is true, abstinence may not be possible for everyone. But it is certainly an ideal we should shoot for. Full emancipation from addiction pathology and all the related issues that go along with it is a vision that we should offer, encourage, and support. And we should aim our clinical endeavors at the overarching goal of freedom from pathology.
In the end, we should not confuse what is possible with what is wanted. This is where the comparison of addiction medication and insulin breaks down. Whether a person wants to take insulin is irrelevant. They cannot live without it. Addiction medication however, is different. It is not required by the body to survive. While cessation may increase risks of death, and those should be weighed, it is not the same as requiring such medication to metabolically survive. Additionally, imagine if you will, a person suffering from cirrhosis, or severe cardiac issues secondary to long term alcohol or stimulant use. In those situations, we would say abstinence is not only necessary, but that it is the best possible goal.
In closing, let’s review. Abstinence is a realistic goal for most. It is an ideal outcome for late-stage addictions. Just because addiction medication may be needed for some people, does not automatically invalidate abstinence as an ideal goal, or as best possible outcome. Nor are medication and abstinence at odds. For some, it simply won’t be an option because abstinence may not be wanted. But this should not deter us from striving for it, and it should not cause us to adopt talking points to that effect. Freedom from pathology should always be the clinical goal of healing. That will look different for different people, however, for those in late stage addiction, they should always be given the hope that abstinence is possible. After all, we can do a lot, from reducing harm to simultaneously helping our clients work toward abstinence. We are not wed to any ideology as professionals, nor as scientists. It is indeed a time for new ideas, for discarding old ideas that no longer work, but abstinence should not be one of those.