Update 1/11/22: Two months after I wrote this post, the COVID-19 pandemic began. Since many people in Virginia experienced financial hardship and could not afford direct pay services, but had Anthem health insurance, I applied for my private practice to become a provider. Many months later, that application was approved. However, for those who wish to protect their privacy, I continue to offer the self-pay option.

Do no harm.

People’s health care records accompany them for life. Given that substance use is stigmatized and criminalized, I urge anyone with a substance use concern or an addiction issue to self-pay if they can so no third parties – including health insurance companies – are notified.

In private practice as a direct-pay, independent counselor, I keep clinical notes that can only be accessed with a client’s release or if the records are subpoenaed for use in legal matters. I write notes to meet professional and ethical standards but they carefully include minimal details. I do my best to help protect my clients’ human rights.

Doors can close with a diagnosis related to addiction of any kind. Opportunities – invitations to join in, scholarships, employment, promotions – can be denied because most do not understand – or refuse to acknowledge – that addiction is a very human, treatable condition.

(Since my health care record includes an alcohol use disorder diagnosis, even though I have been in remission for years, I assume I will not be allowed painkillers if I’m ever in an accident and taken to an E.R. Denial of medication to people with current and former issues with addiction is tragically sad and life-threateningly dangerous, but I’ve seen it too many times locally and it’s a noted nationwide phenomenon.)

I provide individualized, responsive, comprehensive services not covered by health insurance.

Substance use disorders, challenging behaviors, and the mental illnesses that may accompany them can be complex, on-going conditions that may not remit through medical care and individual and group counseling alone. Comprehensive assistance is needed. My fees for individual and group counseling sessions include case management services, within-24-hour replies to texts, phone calls, and emails, contingency management awards, and custom-created, individualized readings, materials, and activities. These services are not reimbursed by health insurance companies.

I offer evidence-based care.

Health insurance companies specify what treatments will be reimbursed and can deny coverage for research-backed treatment. I keep abreast of the latest research on treatment for addiction. Today, right now, I can offer the very best care suggested by research that I am qualified to provide. (Medical care is the first line of treatment for addiction and may be sufficient. I am not a medical care provider.)

Clients and I are free to co-create individualized, evidence-based treatment plans designed specially for them to include the components and pacing that fit their specific needs.

I am here to help.

If I were to take reimbursement for services from health insurance companies, I would be obligated, under contract, to charge agreed-upon fees. I would commit a billing violation if I offered a sliding scale or discounted fees for low-income or no-income individuals. I have a small practice and can only offer a limited number of scholarships. I am honored and gratified that they are filled. I respect contracts and do not enter ones that compromise my ability to be of service to those in need.

Time is finite and precious.

I am 61 years old. I respect the protective intent of the vast amounts of information required to provide services covered by health insurance. I am passionate about clients and this work. I choose to spend my remaining time on the planet serving clients, not completing forms.

If the way I offer counseling services is a fit for you, please contact me. I would welcome the opportunity to work with you.

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, clients, family members, or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

I am a person with a health condition that’s commonly termed “addiction.” The primary symptom of addiction is continuing to use substances despite negative consequences. Why my behavior includes, or included, continued use is due to complex changes in my individual brain.

While some accuse me of making a “choice” to use, or selfishness for “liking to get high,” or of having moral or criminal problems, addiction research does not support these beliefs. My original use may have been of  my own volition, but with repeated, extensive use over time, my brain learned to use nearly automatically. Because alterations occurred in the organ of the brain, this condition is alternately termed a “disease,” a “medical illness,” a “brain disorder,” a “health problem,” and a “health condition.”

My brain may have been predisposed to developing addiction from trauma, mental illness, neurodevelopmental challenges – such as ADHD and autism – and/or conditions in my environment, such as abuse or poverty. Unfortunate brain changes resulting from addiction may have affected my judgment, decision-making, learning, memory, and self-control.

I have reasons for using alcohol and/or other drugs. You may or may not approve of my reasons, but they are meaningful to me, often because substances help me with emotional or physical distress.

Please don’t equate my use of alcohol and other drugs with “abuse,” nor with the term’s inferred – and stigmatizing – sexual and physical violation. Humans have used substances for 10,000+ years. If we count caffeine, nicotine, and alcohol, nearly all Americans are drug users. If we count being overweight or obese, more than two thirds of Americans have trouble limiting their intake of substances. Neither I, nor they, are substance “abusers.”

This is subtle but I need you to hear me: Substances are not the problem. Problems are the problem. Substances can solve problems – that’s why we use some substances as medicines. Substances can help people feel good, feel better, or do better.

My intention was to use alcohol and other drugs for my reasons and without harm to myself or to you. The majority of people who take or use substances do not become dependent upon them, i.e. experience physical symptoms without the substances, or become addicted to them, i.e. persist with using them despite adverse consequences. I expected to be like most people. I did not mean for this health condition to occur, nor do I choose or want it to continue. I deeply regret any hurt or hardship my having this condition has caused you.

Abstinence is not the solution to the problem of addiction. When I abstain, whether through my own attempt or mandated by authorities, I am under the neurobiological force of addiction, possibly under the physical force of dependence, and under the mental and physical forces of unmet purposes that substances served. These forces interact and magnify, causing anguish that’s nearly unbearable. This is why I continue to use, or return to use – what you call “relapse.” You perceive my return to use as evidence of self-indulgence, of lack of self-discipline. I experience my return to use as self-mercy.

If you want to help me recover from this health condition, we need to focus on what might be termed “the unbearability.” First, you can help me protect my health and safety if I’m still using by connecting me with harm reduction resources. Second, please get me medical care. Extensively-researched medications exist to ease the neurobiological, physical, and mental burdens of this illness. A physical exam and lab work can help detect other conditions that may be weighing down my system.

If I’m newly attempting to cut down or abstain, or am mandated to abstain, I don’t feel very good. Abstinence from some substances puts me in mortal danger. In an emergency, help me get to medical professionals. With urgency, help me make appointments and help me get to them. If I can trust you and you are a safe person for me, I might even ask you to go into appointments with me to help ask important questions and to take mental or written notes on the guidance I receive.

If there are policies or laws in the way of me getting medical care, I either can’t or dare not advocate for myself. I usually don’t have adequate resources to hire legal representation. And if I speak up, I risk punishment from authorities or shunning by society. Protest injustice on my behalf and on behalf of others denied health care for health conditions.

According to research, sometimes medications and medical care are all I need to achieve stability from this health condition. What was unbearable may now be bearable. If I’ve received medical care and am still suffering, I may benefit from counseling. Research suggests individual counseling if I can get it, and skills-focused (not general) group counseling if individual counseling isn’t available, I can’t afford it, or I find working together with others helpful to me.

Since addiction is a brain condition, counseling can’t specifically and directly treat areas of the brain affected by addiction. I need counseling that takes into account the workings of my brain, not my personal, moral, or spiritual selfhood. I may or may not choose to look at those subjects in the future. Right now, I need assistance with using my own mind as a tool to work with having this health condition.

Given what neuroscience research has revealed about addiction, the essence of effective counseling for addiction builds toward this: If I can become aware that I am feeling emotions, and name them, that simple act of consciousness activates both the “heart” and “mind” functions of my brain. I now have access to the innate essence of both – termed “Wise Mind” in dialectical behavior therapy, or, more generally, “inner wisdom.” From my inner wisdom’s state of attention, awareness, functionality, and self-kindness, I can learn and apply myriad skills that may help me consider what might be helpful for me to say or do next – or not say or not do.

If I’ve received medical care, then counseling, and I am still troubled, I may need what’s termed “support.” If you can help me figure out what’s working for me, and what’s not, and help me access resources to increase what’s working and decrease what’s not, that, too, lightens the load of what has been unbearable.

For some, addiction is a chronic condition. My condition is in remission now, but if a flare-up happens, I would welcome your help in getting evidence-based care.

You will have to fight for me. Even professionals who should know better – the science is right here for all to see – will call me an “alcoholic,” scorn my “choice” to drink again, and admonish me to “become a better person” to make my alcoholism go away. You will have to fight to keep misinformation and mistreatment from breaking my heart, my mind, my life.

I am a person. I am not an osteopororitic because I have been diagnosed with osteoporosis. I am a person in which a troubling health condition has occurred.

I am a person with addiction. Addiction is a health condition that responds to evidence-based treatment. I do not and cannot speak for all people with addiction, but my lived experience matters. In America today, evidence-based treatment for addiction is hard to get. When I am unwell, I am your sister citizen, at your mercy. I ask for your help in continuing to receive evidence-based treatment for addiction. I ask for your help in getting evidence-based treatment to persons who have what I have.

Maia Szalavitz and Keith Brown contributed to this article.

This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

One way I urge us to help all our citizens is to question the legality, effectiveness, and humanity of criminalizing the medical illness of addiction.

Here is a summary of my findings:

Many of our citizens with opioid use disorder are arrested, incarcerated, or given the forced choice of drug court or jail. Many receive limited or no treatment, or are denied the first-line, evidence-based treatment for opioid use disorder, methadone and buprenorphine. Some drug courts ban the use of medications for opioid use disorder. At the national level, the Department of Justice’s Civil Rights Division has begun an initiative to remove discriminatory barriers to treatment for those in the criminal justice system. Incarceration does not decrease substance misuse. Treatment is 7 times cheaper than incarceration.

Here are highlights of my literature review of research on opioid use disorder and the criminal justice system:

“A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use.”

– Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, November, 2016, Page 4-1

On-going, long-term maintenance on methadone or buprenorphine are the only two treatments currently known to reduce mortality from opioid addiction by 50 percent or more.

– Pierce et al., Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England, Addiction, 2015

– Sordo et al., Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies, British Medical Journal, 2017

Naltrexone, whether oral or extended release naltrexone, branded as Vivitrol and marketed directly to drug court judges by its manufacturer, does not result in decreased mortality rates for people with opioid use disorder.

– Degenhardt et al., Excess mortality among opioid-using patients treated with oral naltrexone in Australia, Drug and Alcohol Review, 2014

– Jarvis et al., Extended-release injectable naltrexone for opioid use disorder: A systematic review, Addiction, 2018

“[H]ealthcare providers, criminal justice officials, and the media should consider the potential for overdose when prescribing or promoting Vivitrol treatment.”
– Saucier et al., Review of Case Narratives from Fatal Overdoses Associated with Injectable Naltrexone for Opioid Dependence, Drug Safety, 3/20/18

Persons recovering from, or receiving supervised treatment for addiction to alcohol or drugs, are often qualified as disabled individuals according to the American with Disabilities Act. Courts, drug courts, probation departments and prisons may not treat individuals with opioid use disorder differently from other individuals who are allowed to take medications as prescribed.

– Letter to the New York State Office of the Attorney General from the U.S. Department of Justice, October 3, 2017

80% of people with opioid use disorder who attempt abstinence-based behavioral treatment or detoxification relapse.

– Gavin Bart, M.D., Maintenance Medication for Opiate Addiction: The Foundation of Recovery, Journal of Addictive Diseases, 2012

“The majority of patients who discontinued BMT [buprenorphine maintenance therapy] did so involuntarily, often due to failure to follow strict program requirements, and 1 month following discontinuation, rates of relapse to illicit opioid use exceeded 50% in every study reviewed.”

– Bentzley et al., Discontinuation of buprenorphine maintenance therapy: perspectives and outcomes, Journal of Substance Abuse Treatment, 2015

People are more likely to fatally overdose prior to beginning maintenance medication and upon ceasing it than are those with continuous treatment. Cornish et al. caution, “Clinicians and patients should be aware of the increased mortality risk at the start of opiate substitution treatment and immediately after stopping treatment.”

– Sordo et al., Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies, British Medical Journal, 2017

– Anders Ledberg, Mortality related to methadone maintenance treatment in Stockholm, Sweden, during 2006–2013, Journal of Substance Abuse Treatment, 2017

– Cornish et al., Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK General Practice Research Database, British Medical Journal, 2010

Individuals with opioid use disorder who are newly released from prison are at high risk of overdose death.

– Binswager et al., Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009, Annals of Internal Medicine, 2013

Incarcerated individuals with opioid use disorder should be treated with methadone and buprenorphine while they are incarcerated. “[R]esults suggest that comprehensive MAT [medication-assisted therapy] treatment in jails and prisons, with linkage to treatment in the community after release, is a promising strategy for rapidly addressing the opioid epidemic nationwide.”

– Green et al., Postincarceration Fatal Overdoses After Implementing Medications for Addiction Treatment in a Statewide Correctional System, JAMA Psychiatry, 2018

For those with opioid addiction in the criminal justice population, maintenance medication can reduce rates of re-incarceration by 20% or more.

– Larney et al., Effect of prison-based opioid substitution treatment and post-release retention in treatment on risk of re-incarceration, Addiction, 2011

To stay in remission from opioid use disorder, people must remain on methadone or buprenorphine for extended periods of time, sometimes life-long. According to SAMHSA’s guide, “Medication-assisted treatment should continue as long as the patient desires and derives benefit from treatment. There should be no fixed length of time in treatment. For some patients, indefinite medication-assisted treatment may be clinically indicated.”

– Federal Guidelines for Opioid Treatment Programs, SAMHSA, 2015

“Medication-Assisted Treatment (MAT) is an evidence-based substance use disorder treatment protocol, and BJA [Bureau of Justice Assistance, U.S. Department of Justice] supports the right of individuals to have access to appropriate MAT under the care and prescription of a physician. BJA recognizes that not all communities may have access to MAT due to a lack of physicians who are able to prescribe and oversee clients using antialcohol and anti-opioid medications. This will not preclude the applicant from applying, but where and when available, BJA supports the client’s right to access MAT. This right extends to participation as a client in a BJA-funded drug court.”

– Adult Drug Court Discretionary Grant Program FY 2017 Competitive Grant Announcement, U.S. Department of Justice, 2016

“Examining any two-year post-program recidivism (defined as an arrest, conviction, or incarceration), over one third (37.6%) of graduates and almost all program terminators (95.3%) had two-year post-program recidivism ( p < .001). [my emphasis]. For the overall sample, age, outpatient treatment, marital status, number of times treated for a psychiatric problem in a hospital, substance use (i.e., past-30-day cocaine use and intravenous opiate use), number of positive drug tests, and receiving any sanction/therapeutic response were associated with two-year post-program recidivism.”

– Shannon, et al., Examining Individual Characteristics and Program Performance to Understand Two-Year Recidivism Rates Among Drug Court Participants: Comparing Graduates and Terminators, International Journal of Offender Therapy and Comparative Criminology, 4/1/18

“The analysis found no statistically significant relationship between state drug imprisonment rates and three indicators of state drug problems: self-reported drug use, drug overdose deaths, and drug arrests.”

– More Imprisonment Does Not Reduce State Drug Problems, The Pew Charitable Trusts, 3/8/18

Treatment is up to 7 times less expensive than incarceration.

– NIDA, “Is drug addiction treatment worth its costs?”, 2018

Watercolor painting by Jesi Pace-Berkeley

The above includes data I used for a talk I gave on the opioid crisis on Tuesday, March 13, 2018. I reviewed common beliefs about opioid use in the U.S., and compare those beliefs to what research reports. I published highlights from my background research for the talk as Opioid Crisis: What People Say vs. What the Research Says.

Last updated 5/15/18

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.