The Game Has Changed

By Teresa Cobleigh 

May 10th is the nation’s first Fentanyl Awareness Day, and Herren Project is pleased to join others in supporting the movement to raise awareness in the hope of saving lives. Fentanyl is now the key driver in the increase in overdose deaths. In my view, it is a game-changer that calls us to consider new tactics in addressing addiction, take harm reduction measures more seriously and re-evaluate how practices, assumptions, and stigmas may lead to unintended consequences.

What is Fentanyl

These days, everywhere you look is Fentanyl laced in every illicit substance you might seek on the street, from cocaine to pressed pills that look like Oxy and Xanax. Fentanyl is 80-100 times more powerful than morphine, a drug that can take down a 6’4” adult male in a matter of minutes, affecting the casual party-goer who might add a celebratory line to their night on the town or a party-going teenager caught unaware on a night out with friends. According to A Song for Charlie, a non-profit we are proud to partner with and formed after the fatal overdose of the founder’s son, Fentanyl has been found in 40% of confiscated street drugs. It is a cheap way for drug dealers to increase returns, and for many a middleman who “step on” their supply, it is also a way to support a habit. Fentanyl is now sought out by those addicted to opioids or already experienced this stronger class. As I am told, there are forms perceived to be “safer” for those of high tolerance, but that is risky business requiring you to trust your drug dealer, especially because the amount in a pill cannot be assumed to be evenly distributed. Sometimes you just get a lethal dose. It’s like pulling the trigger in a game of Russian Roulette. But it is not a game for child’s play. Chemical warfare seems a more fitting metaphor.

Challenging Traditional Views

In the spirit of hoping to save lives, I intend to challenge a few traditional viewpoints, so let me say at the outset that the opinions and suggestions are my own. Herren Project supports me in raising questions and promoting dialogue, so we are aligned in our overarching goal. And if it means sticking my neck out to save one life, I am grateful to have the forum. Also, I have tremendous respect for the programs and people that have helped me along the way. I have learned to face each day, one day at a time, thanks to the isms of AA. I know so much good can come out of our rooms and traditions.

Sometimes practices take longer to change. Perhaps it takes humility to know that we do not know everything about this evolving battlefield. We might need to adjust our tactics when faced with changing conditions that also may call for challenging our own assumptions. For one, stigma is never our ally, though it may come from a well-intentioned place. Our beliefs can unknowingly play into the hands of our enemy. What was relevant in the past may no longer serve today. We once based our playbook on the creeping disease of alcoholism. Now, death comes in seconds.

Why? Because on the battlegrounds of addiction, the game has changed. That game-changer is Fentanyl.

Opioids and Fentanyl in US

Meeting People Where They Are At?

For example, what does it mean to respect all recovery pathways or to meet the person where they are? To serve and protect might be the appropriate battle cry for today’s chemical warfare, and harm reduction might be an appropriate tactical strategy if we ultimately want to win this war. Consider why only a small percentage of those with substance use disorder (SUD) seek treatment. According to Dr. Nora Volkow of the National Institute of Drug Abuse, the “deleterious effect of equating treatment success with abstinence and drug use with treatment failure is that some people with SUDs are unready to give up substances completely. In fact, this is one of the main reasons people who could benefit from addiction treatment do not seek it.”

If we are to win the war in the age of Fentanyl and “meet them where they are,” we might recognize they are sometimes in the grey area between not using hard and not using anything at all. We might, then, reconsider our traditional standard of abstinence. Dr. Volkow warns that the “perfect should not be the enemy of the good.” In her view, “the magnitude of this crisis demands out-of-the-box thinking and willingness to jettison old, unhelpful, and unsupported assumptions about what treatment and recovery need to look like. Among them is the traditional view that abstinence is the sole aim and only valid outcome of addiction treatment…it shouldn’t be ruled out that some substance use or ongoing use of other substances even during treatment and recovery might be a way forward for some subset of individuals.”

Please Don’t Shoot the Messenger

Don't Shoot the Messenger sign

Consider also our practices regarding relapses. We know that extended time in treatment is associated with positive outcomes, but our practices in managing relapses might inadvertently put our loved ones in harm’s way. Expulsion from treatment or sober living may come with a professional recommendation for a higher level of care. If the patient declines that level of care, said patient may be released against medical advice (AMA, how’s that for stigma?). Outpatient, one-on-one treatment, individualized with a therapist and psychiatrist, still qualifies as treatment. Still, we often insist on what appropriate treatment needs to look like—unfortunately, transitions to outpatient care when a patient relapses in a program seldom go smoothly. A hard line of zero tolerance may result in no treatment, no housing, and no coaching just when the patient needs the support most.

According to Maia Szalavitz, who wrote the article The Science of Addiction in Health Magazine’s special addition: Understanding Addiction, What we Know and What we’re Learning: “The big part of the problem is widespread misconceptions about what addiction treatment should look like…Another common misconception about addiction treatment is that residential care is the most effective. For people who are unhoused or whose homes may be compromised …a new living situation will typically be required. However, because they may not provide adequate and individualized psychiatric care, it may be better to seek safer housing and addiction treatment separately.”

Our assumptions and attitudes — all or nothing, abstinence, how the treatment should look — feed into enemy hands. We fail to adjust to the conditions on the ground, which now warrant better safeguards if we are to maneuver through the new minefields of Fentanyl and more potent drugs on the street. The game has changed, and now you must survive the battle to win the war. Continued casualties in the battlegrounds of addiction remind us to learn from their experience. These days, Fentanyl lurks like minefields in moments of weakness, when support is gone, or you are experiencing post-acute withdrawal syndrome (PAWS), when motivation wanes (because you never really wanted eternal abstinence), or when you are trying to cope with the shame you feel from the backs of the people you love or who once supported you.


The Disease of Addiction

We know addiction as a chronic brain disease with a high relapse rate, and we might also know that 60% of us also have a co-existing mental health condition where the risk of relapse is even higher. As Maia Szalavitz puts it, “Since relapse is actually a symptom of addiction, kicking people out of treatment for having symptoms of their disorder makes little sense.”

Again, easy on this messenger.  I have wounds.

My insights are from my lived experience with treatment failure, and I’m sure I’m not the only mom who has had that heart-sinking call in the middle of the night to alert you your kid is now at large.  I have faced stigma within and among those in the industry.  It might go like this:

“Ma’am, sorry to wake you.  Courtesy call. Your son has been dismissed.”  And then this: “He must not have really wanted recovery.”  

And you might think to yourself:  Hard to sign up for eternal abstinence. Wasn’t that what my parents tried back in the day? I am a result of a failed attempt at abstinence. See, I come from generations of “lived” failure experiences. It’s in the DNA.  

 And then you might ask yourself the question: Why would I fly off to the rescue when I know full well it prevents my son from experiencing the natural consequences of his decisions?  Because the game has changed.  It’s that simple. 

“He hasn’t hit bottom. You’ve never let him.” Echoes in the ear.

And again, thinking to yourself:  Thank you for counting our weaknesses. I’ll mark the criticisms on the inside of my cape as I step off this ledge for my mission: Narcan, car, and crash-pad. Don’t forget the dog. Here I come to save the day! 

And you take off, feeling like the dastardly, rescuing enabler, co-dependent, certifiable, shameful, repeat-offending underdog that the industry might say you are.

“You are killing your son.” This from well-intentioned treatment professionals as you hit boots to the ground, cape settling in the wind.

“But do you know where he might be?

“Sorry, ma’am.”  

 “Which way did he go?”

And you are left to comb through every sleazy, drug-infested, cheap motel in south Florida — labeled, undermined, abandoned, beyond everyone’s personal boundary walls like an underdog, outcast martyr — fending alone in an all-or-nothing world where abstinence for some means failure — spit out by the treatment silos that package dogs like you as sausage links — and where stigma abounds. 

Consider This

I ask you to consider how our current assumptions and practices might play into the enemy’s hands, especially for the vulnerable transition ages, 18-24, when maturity is evolving, and the desire for eternal abstinence is low. Do we let them fail and fall, or do we adjust our sails to the new reality, embracing harm reduction more pragmatically? Perhaps it is worth opening our minds and minding our isms. Perhaps there is something we can learn from one underdog’s lived failure experience.

Did I mention that I’m down one kid who was fresh out of treatment with low tolerance and just happened to slip?  My Achilles Heel. No, the gaping hole in my heart.

white heart

Punitive measures can and have been a step in many a recovery journey, but these days being fresh out of treatment or jail and back on the street is a risky proposition. The vulnerability to overdose is greatest after a period of abstinence from opioids when tolerance is low, and Fentanyl awaits a slip like a snare for unsteady tracks.

There is now compelling evidence for the rewards-based approach called Contingency Management (CM), at least for cocaine addiction in clinical trials (see Steadman Group). The theory is that rewards activate the dopamine response levels that people with SUD crave. It is based on operant conditioning in psychology. A few treatment facilities are trying this approach with vouchers for negative UAs, proof that the addiction field is evolving.  It may be helpful to know this psychology. If addiction is chronic and perpetuates regardless of negative consequences (by definition, according to Health), tough love is not appropriate. It may insulate the family and prevent contagion to others, but it could further isolate and harm the person with SUD. Perhaps incentives are better than risky punitive measures.

Peer recovery counselors can play a critical role while the person struggling with recovery goes through a vulnerable transition period to find an alternative treatment that truly “meets them where they are.” But it may mean taking care to decouple that support from housing and treatment centers to provide continuity and a safety net. And we should heed this: “Research shows that if they can avoid overdose, most people do recover,” so says Maia Szalavitz, who gives us faith and hope and lends legitimacy to harm reduction. 

As for my lived failure experience, from where I sit in colorful Colorado, licking my wounds and trailblazing the outer flanks of the western front, there are few reinforcements to alternative routes to recovery. It seems a no man’s land in a threatening world, but maybe that’s just paranoia from breathing the fumes of legalized cannabis.

Maia Szalavitz’s article sits on my nightstand months after my last rescue mission. Thanks to her words, I have enduring hope that failure may just be part of the journey to ultimate recovery. We are lucky to be alive and grateful for help along the way, even if some came with provocative words from a different playbook. I know it was well-intentioned by good people who are only trying to help. All is now quiet on this western front, at least for the time being, and we will cherish these inward-looking moments granted, grateful because we have the chance.