TAKE 3 W/ SLP, March 2022
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[An edited version of the Take 3 w/ SLP segment read on the Recovery in the Middle Ages podcast March 25, 2022]
Correction (03/26/2022): “Take 3” did not make it into the March 25 episode. Check the April 2, 2022 episode.
I’m back with another edition of Take 3 with SLP. Take 3 is an end-of-month summary of three stories I’ve been following as I compile the Wednesday Weekly addiction and recovery news clips. What three stories are on tap for this month?
One. An update on the Purdue Pharma bankruptcy proceedings and the Sackler family.
Two. Details on the Biden administration’s plan to address the opioid epidemic and substance use disorders.
Three. Non-abstinent recovery / Recovery beyond abstinence: A summary of an SLP Insights conversation with University of New Mexico psychology professor Dr. Katie Witkiewitz on her research on alternative pathways to recovery, non-abstinent recovery and harm reduction.
But first, a few thoughts on the biggest story in the news – the war in Ukraine. Even though my focus is substance use disorders and recovery, any summary of the news seems incomplete without at least an acknowledgement of what is happening in Ukraine. I don’t have anything particularly wise or poignant to say. But I do have a brief story.
In the Spring of 1991 - the waning months of the Soviet Union - I was a student living in Budapest, Hungary. A friend had invited me to the city of Lviv in Ukraine’s far west to participate in what I was told was to be the first publicly held Passover Seder since before World War II.
I remember there was a lot of uncertainty around the table that night about the economy and the future of a soon-to-be newly sovereign nation. But there was also a lot of hope about what the future could bring.
Kind of like the story of the Exodus - the journey from bondage to liberation - that Passover commemorates (and kind of like recovery), the people with whom I shared that evening had been through so much in their lifetimes (particularly the people seated near me who had lived through World War II). They had their own stories of going from bondage to liberation. And they were hopeful.
Most of us can only watch from a distance as the war in Ukraine unfolds. We can’t control what’s happening. For most of us, all we can do is express compassion and concern. As we do so, let’s also remember to continue to have hope for the people of Ukraine and a resolution to the war.
One. Update on the Purdue Pharma Bankruptcy Settlement and the Sacklers
In December, when it looked like the parties in the Purdue bankruptcy case were close to reaching a $4.5 billion settlement, the deal fell through (Why a judge rejected a settlement with the Sackler family for their role in opioid crisis, PBS News Hour, Dec. 24, 2021).
A new settlement was reached on March 9 between the companies and the attorneys general from the 8 states and the District of Columbia who appealed the original settlement (A US bankruptcy judge approved Purdue Pharma and Sacklers’ $6 billion settlement agreement with states, Connecticut AG says, CNN, March 10, 2022). Under the new deal, the Sacklers will pay between $5.5 and 6 billion to a trust that will be used to pay the claims of states, victims of addiction, and others with claims of harms caused by OxyContin and the drug’s role in the opioid epidemic.
Importantly, the Sackler family has also agreed to a number of significant provisions:
The family will relinquish control of the company which will be re-organized as a public trust company called Knoa Pharma. Knoa will contribute future profits to address the opioid epidemic.
The Sacklers have agreed to issue an apology and release more company documents.
And finally, the family has agreed not to resist attempts to remove the Sackler family name from buildings.
One of the unresolved issues is that the Sackler’s payment is contingent on making sure they can’t be sued in the future. A federal judge ruled in December, however, that immunity from future civil liability falls outside the authority of the bankruptcy court. Purdue is currently appealing that decision.
Even if the Sacklers win on that front, they are not immune from criminal prosecution. Some people are pressuring the United States Department of Justice to pursue criminal charges. In a joint statement, several U.S. Senators argued, “steps to hold Purdue criminally accountable for its actions, but not the Sacklers, suggests dissimilar treatment for similar – or even the same – unlawful conduct” (“Senators Urge DOJ to Investigate Sackler Family Members for Role in Fueling Opioid Epidemic,” Office of U.S. Senator Ed Markey, February 16, 2022).
SLP will stay tuned to see whether criminal charges against the Sacklers are brought. It seems unlikely. As much as the family’s actions over the years seem criminal to most observers, I’m sure it’s difficult to prove criminal liability in court.
The day after the settlement was approved, victims had the opportunity to testify in a videoconference hearing the Sacklers were required to attend ('You got rich off our dead bodies' opioid victims tell Purdue's Sacklers, Reuters, March 10, 2022).
For more details, and an insider perspective on the March 10 hearing and on the history of the bankruptcy proceedings, tune into the March 11 Dopey podcast featuring an interview with author and activist Ryan Hampton. Hampton is a victim who managed to secure a spot on the creditor’s committee for the bankruptcy trial. He also recently wrote a book on the topic called “Unsettled: How the Purdue Pharma Bankruptcy Failed the Victims of the American Overdose Crisis.”
Two. The Biden Administration’s Plan to Address Substance Use Disorders and the Opioid Epidemic
On the March 4, 2022 episode of the Recovery in the Middle Ages podcast, hosts Nat and Mike mention President Biden’s announcement of a plan to address “addiction and the overdose epidemic” in his March 1, 2022 State of the State Address.
On the day of the State of the State address, the White House released a fact sheet to summarize the plan. I thought I’d provide some of the details here.
It’s important to keep in mind that this information is from a brief fact sheet. It’s more of a high-level summary than a detailed description. It's also important to keep in mind that the fact sheet comes from the White House, which means these are the administration’s talking points.
There is no better way to evaluate a government’s priorities than to look at the allocation of dollars. Of the $40 billion mentioned in the fact sheet, $23.5 billion is slated for public health approaches to reduce drug use and its consequences. Another $17.5 billion is aimed at law enforcement efforts to reduce the supply of illegal drugs. That’s about 57% toward public health initiatives and programs, and 43% toward the Sisyphean effort of reducing supply.
The fact sheet list three major categories of spending.
“Removing barriers to treatment” – Eliminating obstacles that get in the way of prescribing medication assisted treatment (MAT) such as buprenorphine for opioid use disorder; extending COVID rules for prescribing MAT via telehealth; expanding MAT in the federal prison system; and developing standards and model state legislation for hospital emergency department care for addiction and overdose.
“Reducing harm and saving lives” – Federal funds for syringe exchanges, fentanyl test strips and the procurement and distribution of opioid overdose reversal medication such as naloxone; convening a steering committee of people with lived experience to provide guidance and input on future harm reduction efforts; working with states and local communities to elevate harm reduction best practices.
“Stopping the trafficking of illegal drugs” – Targeting drug traffickers by establishing the U.S. Council on transnational organized crime and creating enhanced targeting and data sharing among law enforcement agencies.
[This just in: Faces and Voices of Recovery’s statement on final FY 2022 Federal Budget, Faces and Voices of Recovery, March 22, 2022]
Three. Non-abstinent recovery / recovery beyond abstinence
In last week’s RMA episode, one of things guest Evan Haines (“Can America Recover?: Reimagining the Drug Problem”) discussed was how to define success in recovery and the importance of looking at factors beyond abstinence.
The topic is very apropos for me given that my recent SLP Insights interview with University of New Mexico psychology professor Dr. Katie Witkiewitz discusses the importance of defining success in recovery as something broader than just abstinence. In addition to her work on the role of mindfulness in alcohol and substance use disorder treatment, Witkiewitz’s work also examines non-abstinent recovery.
In the interview, we speak about her research and about the new book she and Jalie A. Tucker edited titled “Dynamic Pathways to Recovery from Alcohol Use Disorder.”
“We endeavored to challenge the assumption that sustained abstinence was a necessary and sufficient condition for AUD recovery and underscored the strong empirical basis for a broadened definition of recovery that focuses on improvements in valued areas of living, functioning, and well-being. Further, we brought together experts in the field to identify and discuss new empirical research that is needed; what theories, treatments, and policies need to be reconsidered or adapted; and how this collective body of work can make a difference in helping individuals and communities.”
Dr. Katie Witkiewitz and Jalie A. Tucker,
Dynamic Pathways to Recovery from Alcohol Use Disorder: Meaning and Methods
Witkiewitz makes the case for developing a definition of recovery that is broader than abstinence. She notes that a person can be not drinking or using drugs and still be miserable. For that reason, we need better measures of success in recovery that capture how well a person is fulfilling work and family responsibilities, their relationships with others and the extent to which they are living what Witkiewitz often refers to as “a life worth living.”
In a paper titled “What is Recovery?” Witkiewitz and her co-authors examine emerging definitions of recovery including that of the U.S. Substance Abuse and Mental Health Administration’s (SAMHSA) definition which does not mention abstinence at all. SAMHSA defines recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”
Witkiewitz also argues the treatment industry’s emphasis on abstinence is a barrier that keeps people from seeking help. Her research has shown that roughly half of people who could benefit from treatment do not want to stop drinking. “What the treatment industry has is not what people want,” according to Witkiewitz.
Witkiewitz also points to evidence indicating that the research focus on people who are in formal treatment programs has an inherent selection bias that keeps the research from capturing the experiences of people who recover without treatment. For example:
Over 70 percent of “problem resolutions” with alcohol occur outside the context of treatment.
For people who recover without formal treatment, a return to low-risk drinking is a more common outcome.
“Individuals with more severe alcohol use disorder appear to practice some degree of self-selection into treatment and may require several change attempts before achieving stable change.”
Even though Katie’s work focuses largely on alcohol use disorders, in the interview she discusses research that looks at harm reduction and moderation with cocaine and other drugs.
In the concluding paragraph of Dynamic Pathways, Witkiewitz and Tucker offer the following: “There are many pathways to recovery…we encourage the field to embrace this heterogeneity and embark on new research, community action and policymaking to support the many pathways to recovery.”
I often wonder whether I might have asked for help earlier or achieved abstinence sooner if I had been aware of treatment alternatives that didn’t require abstinence, at least initially. And wouldn’t it be a better business model for the treatment industry to open their doors to the larger population of people who want help, but do not necessarily want to give up drinking or using entirely?
The idea that someone can be in recovery and still drinking or using at some level is undoubtedly and understandably controversial, but as someone who has decided abstinence is right for me, I think there is value in looking at the research evidence on multiple pathways to recovery, particularly if doing so will lead to helping a larger segment of the population who could benefit from treatment
And that, my friends, is Take 3 with SLP. I’ll be back next month. Until then, be well Monksters and stay tuned!
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