Do I have to think like a doctor to help heroin addicts?

Hi again. I know I haven’t been posting much lately, but it’s time to get back on that horse. One thing I did in the interim was write a chapter for a volume on addiction. Which led to a strange conundrum…and some soul searching.

But before getting to that, I’ll tell you what inspired me to keep blogging for now. First, I opened Google Analytics and found that I’m still getting 200 hits per day…even after weeks with no new posts. People remain interested in our alternative and progressive approach to addiction. Wonderful! Second: I met Sandy P at my father’s memorial in California last week. And she told me she not only still exists but she follows my blog. Amazing. Sandy was my brother’s girlfriend, and Abbie, her next-door neighbour, was mine, when we were in our late teens. (When I was first getting into drugs, Abbie was my salvation. Until I took off for Asia: no Abbie, lots of drugs.) Thanks, Sandy, for a sweet hit of nostalgia.

Now about that chapter. I’ve had papers rejected by publications lots of times. It’s part of the rat race of being an academic, a researcher, submitting your best work to journals, waiting for the letter from the editor, finally getting that heart-stopping email and reading it and Oh Shit! They’re rejecting it?! Without even a “revise and resubmit!” Damn ignorant asshole editors. Too good for your shitty journal anyway… Then the anger and disappointment start to evaporate and you start thinking about what journal to send it to next. That’s the life of an academic. And that’s one reason I was glad to be done with it, and why, about eight months ago, I swore to myself I was done with academic writing.

But I caved. A colleague in Toronto, an addiction doctor, urged me to write a chapter for a book for addiction doctors, to spell out my learning model of addiction, and how it reconceptualizes the data on brain change in addiction, for the benefit of…well, addiction doctors. Because, even though they’re doctors, they don’t necessarily buy the disease model of addiction. At least they don’t necessarily buy all of it, or maybe they’re uncomfortable with it, or maybe, just maybe, the field is changing. (This particular doctor specializes in ACT for his patients.)

So I wrote the chapter. Took pieces from other work, revised them, wrote some new stuff, trying to make it accessible for all those doctors out there, because they don’t really understand human development very well and they sure don’t understand psychology very well. So, why not give them the benefit of my stratospheric perspective. (LOL) I spent a couple of weeks working pretty hard, sent it in, and soon heard back from the editor. Thank you for submitting your chapter for publication in “A prescriber’s guide to methadone and buprenorphine for opioid use disorder…” Which is when I said to myself, those ignorant editors! They got the wrong book. Or the wrong title. Or something. I can’t write a chapter that urges ditching the medical model for a damn prescriber’s guide!

As mentioned, I’ve had my work rejected by numerous publications. But this was the first time I rejected the publication. Even after I’d done all the work. Even when they said Yes, we want it! I wrote back and said, I’m sorry but I can’t contribute a chapter to a prescriber’s guide, or to anything called a prescriber’s guide. Because if the whole point of the book is to get a better handle on prescribing methadone and buprenorphine, then GO AHEAD AND CALL IT A DISEASE! Why not?

My colleague hadn’t told me that this “book for addiction doctors” would be entitled a prescriber’s guide to anything. Maybe he didn’t know. He emailed me after I withdrew my submission and said: Addiction doctors prescribe opioid substitutes to 95% of their opioid-addicted patients. Like: duh…didn’t I know that? Yes, I knew that, more or less. And I knew that opioid addicts are often in desperate need of opioid substitution therapy (OST). It helps them get off the street and sometimes stay off, it relieves the overwhelming anxiety of withdrawal, and it saves lives. As Maia Szalavitz often reports, it’s the only evidence-based treatment that saves lives. And of course that’s because heroin, especially when it’s laced with or replaced by fentanyl or its analogues, can be deadly.

So why would I avoid being featured in such a book? Maybe I should have just swallowed my whatever and revised the chapter. All those words distinguishing physiological dependency from addiction (which I maintain is a psychological process)…they would have to go. And so would that pep talk about listening to the person, not the diagnosis, and using your counselling skills, your human skills, to reach beyond just prescribing. I’d have to shelve all that. I fully advocate the use of methadone and Suboxone. I agree with other progressive addiction specialists (e.g., Mark Willenbring) that they should be easily available wherever they’re needed, free of cost, free of line-ups, free of stigma. But I’ve got nothing to contribute to that argument. Right?

Can we social-development-oriented “addiction specialists” refute the disease model and still advocate OST?

I told myself I’m trying go avoid an awkward irony: that there’s maybe one good reason to call addiction a disease. In the US and Canada it’s the only way to get addicts their medicine, their heroin substitutes. I’ve thought about this lots. But I remain concerned and confused. Maybe “medicalization” is the best we can do for people who are in a real jam, on the street or close to it, hunting for heroin day by day. Yet it maintains, in fact it strengthens, the premise that these people are sick, and it sidelines all the familial, social, economic, and cultural forces that pushed them into that lifestyle in the first place.

Somehow these two perspectives on opioid addiction have got to come together. At least in the present social climate. But I’m at a loss as to how to help that happen.

Or maybe it’s simple. Maybe we just need one or two catchphrases to merge these two approaches: phrases like “harm reduction,” or maybe “working with the individual where they’re at.” In my next post, I’ll tell you about a treatment program in New York City where that kind of conceptualization governs everything they do. I gave a talk there two weeks ago, met some fabulous people, and learned how the field is changing. Stay tuned.











55 thoughts on “Do I have to think like a doctor to help heroin addicts?

  1. Steve K June 18, 2019 at 5:20 am #

    I personally think you’re being too rigid Marc in rejecting the medical publication for your work. It would have made for a more holistic approach to the subject. However, you are being consistent with your position on the topic of addiction. I go with the thinking that addiction is complex and involves the interaction of various bio-psych-social, and some would say, spiritual influencing factors. The development and interaction of these factors is unique to each individual and therefore requires a person-centred response, and not a “one size fits all solution”. I tend to favour the ‘middle way’ where addiction – disease vs social model- is concerned. I apply this ‘middle path’ viewpoint in my latest post on the topic of ‘the role of choice in addiction and recovery’, which was somewhat influenced by one of your previous articles on this controversial issue. Check it out here…

    • Marc June 18, 2019 at 7:32 am #

      You may well be right, Steve. Probably I am being too rigid. Not everything I write comes from a place of “knowing”.. Here I’m throwing my conundrum out to my readers and hoping for some guidance.

      So thank you for that. I’ll read what you linked to as soon as I can.

    • Nancy Minden June 18, 2019 at 1:51 pm #

      Thank you so much for posting the link Steve. I think your perspective brings resolution to many long discussions that stay stuck in dichotomous positions and thus keep hidden many new ways of conceptualizing old words and ideas.

      Thank you Marc for inviting new ways to resolve apparent dichotomies. Always a wise choice.

  2. Annette June 18, 2019 at 6:33 am #

    Marc, I think you should have submitted your chapter. You’re a thought leader here, and your role is, undoubtedly, to EDUCATE. The world is shifting – very slowly, but still, shifting in your direction. Mental health advocates are talking openly about the impact of social, economic and political structures on our (fragile) mental health, so those of us who understand this need to keep educating.

    I educate and champion Open Dialogue therapy, and I wrote about the family addiction for Mad in America recently.

    There’s a Compassionate Mental Health conference in London next week, where Sascha Altman Dubrul is speaking – lots of good things happening with OD in NY, btw (and other parts of the US.) So, be brave brother, use the opportunity to educate – your words will have greater impact in a publication which you see as counter to your views. Exactly why you SHOULD be in it. Good luck!

    • Marc July 3, 2019 at 10:07 am #

      Thank you for your insights, Annette. I finally had a chance to view the article on Open Dialogue. What a story! I don’t know about the heritability of addiction, but there is good evidence for genetic links in schizophrenia and other syndromes. In any case, the story and the message are certainly worth the read.

      And as for your advice, I think now that you were right. I should have let them have the chapter. See other comments, below, and see how I finally came to see the light myself, next post.

      • Annette July 3, 2019 at 10:37 am #

        Thanks Marc. And no shame in telling the story – I told some of it last week, at the conference – it resonated. I met Sacha and was able to tell a story from my travels which connected with his story: a magical moment.

        We can but plant a seed with our words. Who knows where and when they will take root. As Dylan wrote: “The answer is blowing in the wind.”

  3. Conor June 18, 2019 at 8:03 am #

    Mark, there are thousands of academics who can fill in that extra chapter in alignment with whatever prescribing modalities they have in mind. I think what is germane here is whether your voice could act as the thin edge of the web in providing an indispensable counter-narrative. It could be a critical Trojan Horse.

    • Conor June 18, 2019 at 8:49 am #

      *Marc…mea culpa!

      • Conor June 18, 2019 at 8:51 am #

        And *wedge.

    • Marc June 18, 2019 at 4:15 pm #

      Conor, that’s actually very compelling. Trouble is, I never perfected the Trojan Horse act. I could never keep quiet that long.

  4. Nicolas Ruf June 18, 2019 at 8:07 am #

    E.M. Forster said, “I don’t believe in beliefs”.

    • matt June 18, 2019 at 12:29 pm #

      But as human beings with minds, we have to believe in something…

      • Nicolas Ruf June 18, 2019 at 3:08 pm #

        Says who?

        • matt June 18, 2019 at 3:38 pm #

          E.M. Forster. Not believing in beliefs is a belief.

          • matt June 18, 2019 at 3:58 pm #

            Sorry…cheap shot.

            But seriously Nic…there is a lot of research on certainty, the human need to be right, “the feeling of knowing”…Robert Burton, MD writes a lot about it. One of the things that happens in moving away from addiction is a perspective shift from believing my substance is the only thing that works, to believing in something else. My higher power. My recovery method. In myself again.

            Even scientists demonstrate this when there is a paradigm shift or something they’ve believed is disproven. The immediate response is “I don’t believe it.”

            • Nicolas Ruf June 18, 2019 at 4:04 pm #

              Lots of cages look like nests at first.

              • Joanna "Nicci Tina" Free June 21, 2019 at 1:51 am #

                Amen to that!

  5. Donald Hunt June 18, 2019 at 10:09 am #

    I was watching an online ‘summit’ on kicking sugar addiction. One of the interviews was with Dr Robert Cywes. He said some really interesting things about individuals needing effective emotional management strategies to replace addictive behaviors with healthier options. Anyway, he also stated that he didn’t like the idea of “harm reduction” but instead advocates for “staged elimination” which I think might be a better strategy for what you’re talking about in this blog. I myself used that strategy to get off opiates about 9 years ago and Saboxone was part of the process. But I agree, we must keep the bigger picture in mind.

    I think you’re on the right track here. FWIW

    • Carlton June 19, 2019 at 12:52 am #

      Perhaps the term; “Staged Freedom” could also be considered?

      The freedom that is realized when a person no longer needs to maintain an addiction is a personal, private realization and is not easily described.

      Many people also find they no longer need to rely on a recovery program at some point, and that can be another realization of freedom.

      I believe most people do not return to maintaining an addiction or remaining in a recovery program because of realized freedom.

      The term could also motivate people that are struggling and give them something to look forward too.

      • Marie June 30, 2019 at 1:01 pm #

        If there was a thumbs up option, I would click it! Well put!

        • Carlton July 14, 2019 at 5:53 pm #

          Experiencing overwhelming grief and uncontrollable happiness was a re-discovered freedom.

          For instance, several years ago I had to put my beloved cat to sleep at the vets.
          I held her as she went limp. Grief overwhelmed me and I burst into uncontrollable tears. The Vet went looking for a box of Kleenex.

          Months later in reflection, I realized I was experiencing life-on-life’s terms again.

          Despite the painful and long period of grief, “To use, or not to use”.. never occurred, nor was strength, control, or resistance an issue.

          When reflecting on why a former addict like myself was not compelled, and why fear or caution were not present, the knee-jerk reaction to the idea of using was that it would have been an artificial and undesired interruption into what I was experiencing,

          The three main points being made are:

          1) Recovery like this happens. Perhaps a large percentage of former addicts would agree, but these accounts are not as readily shared or conveyed as cautionary accounts are.

          2) More accounts like this from former addicts may shed light on the understanding of addiction, while offering hope and motivation to people struggling with addiction.

          3) If a person holds on to the belief that addiction is a life-long disease, this may not occur.

  6. Lisa K June 18, 2019 at 10:54 am #

    I think maybe that article has a better future awaiting it somewhere. Possibly it was the publisher that decided to conceptualize this book as a ‘prescriber’s guide’ since that is the easiest, most facile, lowest-common-denominator way to target its market. And that your doctor friend in truth represents a hunger among ‘prescribers’ to push beyond the notion that prescribing opiate substitutes is all they can do to effectively treat addiction. As much as I recognize that medication assisted treatment is important, necessary and merciful, I also think that ‘harm reduction’ is more realistic social policy than it is treatment for individuals who suffer and would like to move beyond the obsession/compulsion in more profound and transformational ways. ‘Harm reduction’ is a way of saying: well this is all we can do, or afford to do, or are willing to do, and it’s better than what we did in the past. And when it comes to ‘step-down’, there’s less and less help available, fewer and fewer long term programs because…well, that’s more expensive than methadone, and we don’t want to spend public funds on chronic relapsers. I have seen first-hand that suboxone treatment is not the same thing as recovery, emotionally, spiritually, intellectually, socially, or physically. And I imagine that the ‘prescribers’ must be seeing that too. So…hold on to the article and maybe times are changing and a new home will appear.
    And meanwhile, you were in New York?????? a) ok i forgive you for not giving me a heads up but…. next time, i won’t. b) I need to know about this program you visited. I’m going to be a ‘certified addiction counselor’ soon and I need to find a worthwhile training internship… xo

    • matt June 18, 2019 at 1:01 pm #

      Hi Lisa

      I’m a little surprised at your view of suboxone treatment. It has been shown to cut relapse rates as much as 50% over 3 years. Anecdotally, I’ve seen hardcore heroin users quit cold turkey, but also with suboxone giving them the leg up they needed to get some momentum in their recovery. I don’t know about social, emotional, spiritual, intellectual, etc.. recovery but I have seen people get their lives back in that they are happy, healthy and taking care of all their personal responsibilities (in the emotional, spiritual, intellectual etc. domains). To me, they are “in recovery” for all intents and purposes. If they are misusing their suboxone or selling it on the street to buy a bag of dope, they’re not.

      And I’m with you on the non-notification of Dr. Lewis’s presence on the east coast. Was it something we said? 🙂

      • Lisa K June 18, 2019 at 3:39 pm #

        Hi Matt! Glad to hear from you and hope you are well. How about we have a party and not invite Dr. L?

        My views on suboxone are colored by sub-optimal results for both my ex-husband and my daughter, who I presume represent others for whom it’s no panacea. My ex is now on it and grateful; he would no doubt be a lot worse off, shooting dope or more likely dead, without it, so I’m glad for that. But he is not anywhere near happy and healthy, is still very ‘cloudy’ mentally, lacks energy, is often depressed/morose, and, was simply a more alive person when he wasn’t on it or anything else. Arguably he has a lot of other mental health issues (for which he’s also medicated) and likely a personality disorder, and has messed up so many things with so many people he’s earned his moroseness. I acknowledge suboxone can’t cure pathological self-centeredness. So, maybe he’s not a fair test case. But aren’t plenty of other addicts similarly multi-afflicted/complex cases?

        My daughter used benzos and hypnotics etc. on top of suboxone and just became more and more of a mess. She was supposed to be ‘tapering’ but, could never manage to do it–just compensated with Klonopin. (Google ‘getting off suboxone’ and you’ll find a lot of kids’ blog/video horror stories). But arguably she had not yet learned how to live such that she could get a life BACK, then. So, again maybe she’s not a fair test case either. She is now 6 yrs sober and says: I was absolutely still high/mentally fucked up on suboxone and thought I wasn’t. In any case, a life on suboxone would be the life I’d want for her, as opposed to a non-medicated one.

        When it works, that’s great. Glad it’s ‘in the arsenal’. But, if my two loved ones aren’t poster children, surely there are many others who aren’t, either. So I just get concerned about the powers that be, whether in policy or medicine or treatment world, deciding ‘harm reduction’ is an end point and all they’re responsible for, when there are so many other psychological/sociological/social/economic/cultural/educational components of addiction so often unaddressed, and long-term treatment unfunded. I hear methadone/ suboxone called the ‘gold standard’ of treatment. By itself?? Really? Other kinds of care/growth/education/therapy/neural rewiring/support are also necessary (not to mention economic and social justice) but medication is a lot cheaper and doctors would prefer they be paid rather than the therapists/yogis/psychoanalysts/coaches/shamans/whatevers. So, that’s my reservation.

        • matt June 18, 2019 at 5:15 pm #

          Hey Lisa

          Yes, let’s!!…and see how he responds? Reacts? Acts out? lol

          I’m sorry about your experience with your loved ones. I was one of those poster children that could have wall-papered a head shop. Suboxone, naltrexone, didn’t change anything. It depends on the reasons we’re using to begin with.

          I totally agree with everything you say in the last paragraph. “Harm reduction” can mean different things depending on who’s interpreting it. Does it have practical value or is it laissez-faire? Is it an expediter or an expedient? I’ve seen it really help some people and also ruin large scale programs. My own way out didn’t become evident and purposeful until my mental health issues got addressed. It had to be about more than sobriety. That’s where treatment programs and medicine often set the bar way too low.

          On the other hand, I’ve seen remarkable turnarounds for people who were about to lose everything. Naltrexone was the thing that flipped it for a guy whose issue was alcohol, Suboxone and Vivitrol helped others with opiates. It gave them an edge. But it only worked because there was the weight of intention, motivation and desperation behind that edge. Until we get that kind of “continuum of care” that addresses all the areas/issues that you listed, MAT just adds another one into the mix…and your reservation is duly noted.

          PS I’ll send you a PwrPt about a program that uses MAT/OAT in a more effective way.

    • Marc June 19, 2019 at 1:07 am #

      Hi Lisa,
      I was literally running from pillar to post while in NYC. 72 hours altogether. Then I had to get to California. Next time, I promise.

      I hope there is a better home for that chapter. I’m quite fond of it. Anybody writing a book on addiction need an extra chapter? It’s up for grabs.

      As you say, a “‘prescriber’s guide…is the easiest, most facile, lowest-common-denominator way to target its market.” Yes, exactly. Everything you say about OST here and in your next comment fits my experience to a T. (and most of an O and S)

      Ever been on methadone yourself? Yes it saves lives, definitely. And it ushers you into a shadow world where every colour is mixed with grey. Suboxone is about the same. I’ve tried both. Wanted to see how they feel. I’d prefer the Swiss way: stay on clinical heroin until it gets so damn boring that you’re fed up with the whole business.

      We make our own opioids, after all, in the privacy of our highly-evolved nervous system. This attachment to a substance, a symbol, something you can put inside the imagined “container” of your body….it doesn’t have to be like that.

      A friend of mine was so attached to the metaphor, he so needed that something inside him, that he went from oxys to methadone, cranked up the dose to about 140mg/day, got so bored of the flat landscape that he started using copious amounts of coke, then crack, then…he took off from the 32nd floor of his apartment building, without a parachute.

      The only thing I’d really want to say in a Prescriber’s Guide is: let’s move beyond prescribing. Yes, prescribe when necessary. Of course! Obviously staying alive is far better than it’s alternative.

      But staying alive isn’t the final goal. It’s the starting line.

      • Taschna September 22, 2020 at 2:05 am #

        “And it ushers you into a shadow world where every colour is mixed with grey. Suboxone is about the same. I’ve tried both”

        I can’t get over how stigmatising this passage is. Not to mention, a massive generalisation based on one person’s subjective experience.

        It bothers me that someone who purports to be in favour of OST would so flippantly invalidate the experience of those who have benefitted from it.

        • Marc October 7, 2020 at 9:19 am #

          Tascha, I don’t think my tone is flippant. Where do you see that? And yes, this is my experience of the subjective shading these drugs provide. That does not invalidate anything. Everything has its price, and the relief that comes with OST can be a huge benefit. But it’s not perfect. There’s something you give up for something gained. In my view.

          • Taschna November 27, 2020 at 11:33 am #

            Hi there,

            Am surprised you replied! What bugged me about your comment was the sense that your personal experience of these drugs could/should be extrapolated more broadly (‘an insider’s’ take if you will). Also, I don’t know about you, but the symbolism in ‘grey shadow world’ is a little stigmatising to my ears/eyes. Would you like to engage with the inhabitants of such a world? Many would not! . And finally, as you can probably guess, I personally have benefitted greatly from the availability of OST at various times in my life (one stretch with methadone, another buprenorphine, 8 years later) and am grateful that I had this option.

          • Taschna November 28, 2020 at 2:01 am #

            By the way, I definitely agree with your final sentiment here! Also appreciate the clarification vis a vis your initial comment :-).

            • Marc November 30, 2020 at 11:21 am #

              Hi Taschna. I guess you’re right: for some people the world is more flattened and “grey” — but that doesn’t apply to everyone. For others, it may simply be a return to normal, or even a source of vitality — a shedding of anxiety that permits greater heights of positive emotion, excitement, openness — good things. Thanks for catching that…yes, it was a major generalization.

              But I don’t see it as a stigma issue myself. Some people will judge you no matter what you take and no matter how it affects you. Whether it’s heroin, OST, antidepressants or whatever. There’s no point in trying to buy off the moralists with a more articulate statement about the subjective experience substances provide. Best simply to ignore them.

  7. John Runnion June 18, 2019 at 11:10 am #

    “distinguishing physiological dependency from addiction (which I maintain is a psychological process)” …
    While science uses reductionist methodologies, and necessarily so IMO, I wonder if trying to put too fine a point on the differentiation between “psychological” and “biological/physiological” doesn’t get in the way of a more holistic understanding of the addiction process and, as a corollary to that process, the path to overcoming the addiction? Calling something “psychological” (or developmental) may imply an ambiguity and unexamined distinction from those aspects which are biological/neurological. While we can certainly argue that these are interpenetrative, it seems to me that the language may carry certain unexposed and underlying implications that can circumscribe ones thinking.

    btw, have you read Never Enough by Judith Grisel? I found it very interesting and would be interested in your thoughts at some point.

    • Marc June 19, 2019 at 1:16 am #

      John, I understand that all mental processes, all developmental processes, are underpinned by biology. Of course they are! Studying the biological substrates of these processes can help in all kinds of ways. But if we conflate physiological dependency (on a chemical) with addiction, here’s what happens. Opioid addiction becomes indistinguishable from addiction to antidepressants or beta blockers for that matter. And the failure of the nicotine patch is incomprehensible. And gambling, porn addiction, and opioid addiction and coke addiction end up in completely different baskets….whereas they’re close cousins psychologically.

      That’s why I make the distinction, front and centre. And it actually adds power to our understanding of opioid addiction, because with opioids (and tobacco) you get an insidious overlap of the two. You can’t have an overlap unless you start with a distinction.

      So, my view, collapsing the distinction seriously muddies the waters.

      Haven’t read that book yet, but I’ll look for it…

      • matt June 25, 2019 at 9:33 am #

        I think the problem gets worse when we get too caught up in “what” it is instead of the “why and how”. The “insidious overlap of the two”– the psychological and the physiological– and the social and behavioral, etc., etc.. Addiction medicine or science or whatever it is, becomes too reductionist and turns a blind eye to the emergent learning and transformation that happens. The bio-psycho-social and whatever the hell else ends up in the mix. Perspective, belief, spirituality, etc. all play a role in human behavior.

        There is no theoretical elegance or scientific precision in the epistemology of addiction. At least not yet anyway. The second we start prescribing and proscribing we go to the edge of a very murky rabbit hole. Maybe instead of recovery we need to be looking at “rescribing” from what people already have to work with in order to move on in their lives.

  8. Eric Nada June 18, 2019 at 11:37 am #

    Marc, I could feel my heartbeat increase as I was reading your article as you are touching on the aspects of the addiction discussion that I challenge so passionately. I, too, advocate for the use of opioid replacement therapies when appropriate. That said, I tire of attempts at fundamentally describing addiction (or other emotional pathology, for that matter) as primarily medical. Like you, I view addiction as separate from (though sometimes exacerbated by) physiological dependence, and don’t conflate the two. I understand the importance of using medial therapies (detox process/OD/MAT) when dealing with the physiology of dependence, but differentiate this from the emotional phenomena of depending on external means to regulate what we should learn to regulate internally, as a definition of addiction. I fear that as long as medicine is so profitable, there will always be an effort to explain emotional processes through its limited and personally disempowering lens.

    • Marc June 18, 2019 at 1:22 pm #

      Hi Eric. Your last sentence offers a really important perspective. But it’s not just the profit. It’s the coziness of a mutually approving club that wields this unchallenged authority. There’s a lot I didn’t say in my post. But, to be brief, these guys weren’t even talking to me about addiction. I sent a number of emails to the editors, and to my colleague, to try to reconcile things. For the first two weeks, they didn’t even reply, which is rare when you’re being courted for a book chapter. In fact, unheard of. I got frustrated and gave up.

      My brother’s a doctor. And he’s a good one. I love him and I love what he does for people. But the “prescribers” shingle epitomizes what goes wrong when addiction treatment is medicalized. Yes, provide MAT when needed. But don’t make it this glorious gift to the diseased — because that’s all you guys are willing, or able, to offer. Maybe I was rigid, but In my own defense, I would have given them that chapter if the book had almost any other title. “Prescriber’s Guide…” I just couldn’t go there.

      • Eric Nada June 18, 2019 at 2:32 pm #

        “Unchallenged authority,” yes. And it puts you in the presumably uncomfortable position of either being a somewhat dissenting but possibly refreshing perspective within a discussion surrounding an otherwise unchallenged paradigm, or not wanting to add to the discussion that you use your work to advocate against. It’s a difficult decision and one that I trust you to make appropriately.

        I assume you might know the work of Bessel van der Kolk, author of The Body Keeps the Score. (So you might be aware of this). But he was asked to weigh in during the writing of the latest DSM edition. He did so, espousing a developmental model vs. a medial one and his work was left out completely as it didn’t fit with the medical/medication forward model.

      • Alison June 23, 2019 at 12:34 pm #

        Marc this is a beautiful line:Yes, provide MAT when needed. But don’t make it this glorious gift to the diseased —
        Day in and day out I listen and follow tons of “disadvantaged “people only to hear more and more that they realize over time MAT keeps them from addressing human factors w addiction ….AND pinpointing Trauma! Trauma trauma… especially people in poverty …..
        Just watched on tv PBS New Jersey morning show of a New Jersey “leader” yelling “addiction is a disease there is something wrong with THESE people”
        We gave enough research to show this these people are diseased”
        This creates more judgement and stigma in the end ….it ruined my Sunday morning

        Marc I tried to get to your nyc talk I had on calendar!🙁 but job duties prevented me!
        I wanted to come hear new fresh ideas cause the poor people are still being forced to residential long term or MAT

        But a positive note NY finally passed allowing paroles access to medical marijuana! People were going back to prison for using weed!
        Torn apart from their families only to re trauma them and their kids….
        Now we just gotta get medicaid to pay for medical marijuana.
        So now parolees can use it but can’t afford it!

        Marc I support you decision not to submit your piece!!!!!!

  9. matt June 18, 2019 at 1:18 pm #

    I don’t quite understand why you would not offer your unique perspective to anyone, especially physicians, and especially since they asked for the chapter to begin with. There are so many physicians who would be exposed to your ideas who may of had no idea they existed.

    • Marc June 18, 2019 at 1:25 pm #

      I know, Matt. Maybe I was wrong to withdraw the chapter. But see my reply to Eric, above. It was a PRESCRIBER’S GUIDE. How on earth could I fit my perspective with the thrust of that book? I would have had to trim and edit and revise and cut and rephrase and tone down my main message…a lot…and frankly I didn’t feel like rewriting the whole damn piece.

  10. Nicolas Ruf June 18, 2019 at 3:12 pm #

    How can there be psychological without biological?

    • Marc June 19, 2019 at 1:18 am #

      There can’t. Why would you even ask that? See my reply to John above!

      • Nicolas Ruf June 19, 2019 at 9:36 am #

        Well. I thought it was your distinction! Your response to John makes no sense to me. Maybe if we talked about open v closed systems? Or brought homeostasis into the discussions?
        So let’s take the research that shows things like place preference and ICSS in test subjects that have been force-fed drugs but change their drug taking patterns when circumstances (social, environmental) change as opposed to those subjects that have freely chosen to administer the substance(s) whose patterns of use do not change when external circumstances change. Aren’t we seeing disruption of system stability v maintenance or reestablishment of it? Do you change the behavior to fit the circumstances or change the circumstances to fit the behavior? If psychological states have to have brain state representations, plasticity or lack of it has to explain the process – down to 5% charge on ipad

        • Marc July 2, 2019 at 11:25 am #

          Hi Nick. As usual, I am having a hard time decoding your comment. I’ve read it about four times so far… To put it simply, what aspect of my response to John do you find incomprehensible?

          Systems thinking, notions of homeostasis and so forth, can be applied either to biological OR psychological processes. So what’s the deal? At one level of analysis, human cognitive events are best described as psychological and at another level of analysis as biological events. But surely ALL psychological processes are also manifestations of underlying biological processes. I mean you can observe changes in the EEG or fMRI when people are surprised or frightened or trying to solve problems or reflecting on their errors.

          Certainly some phenomena are much easier to describe one way or the other. I mean, racism and religious orthodoxy have biological substrates, I’m sure (since everything does), but we don’t have the concepts or the technology to analyze them that way. So we discuss them as psychological processes — that is their so-called “focus of convenience”. When it comes to addiction, I’m saying that what goes on is best described in psychological terms, because thinking, learning, rumination, self-regulation, self-esteem…all these “psychological” processes go into the mix. Whereas, with chemical dependency, there isn’t much to say at the psychological level. The best indicators of withdrawal include stomach cramping, changes in heart rate, rapid respiration, muscle tension and other signs of arousal, etc, etc. When you “withdraw” from beta blockers, there is no perceptible psychological process, except perhaps as a RESULT of the physical discomfort. So that’s why I’m making the distinction I’m making.

          Does that make sense?

  11. *D June 18, 2019 at 4:13 pm #

    Hello Marc,

    I have read all your books, your blog and been on this mailing list a long time. I married someone who struggled many years with narcotics additions but he now has it behind him for the time being. I myself drink. I drink a lot and have for a long time. There have been no consequences for any of it as I “function quite highly”. Do you know anyone in your field of academic neuroscience that is trying to help those that need help with alcohol the way you help heroin addicts? Who is the leader is that field? What are the most progressive and science based treatments out there? I am willing to try anything and I have already tried many things.
    Thank you so very much,

    • Marc June 19, 2019 at 1:21 am #

      There are so many therapeutic approaches to addiction…dozens in fact. And I think you’re best off choosing a therapist rather than an approach, because talking with someone who you feel you can connect with makes all the difference.

      I offer addiction psychotherapy. See the tab on the menu bar, far right. But so do a lot of other folks, and most of them advertise online. Good luck with it!

      • Alison June 24, 2019 at 12:20 am #

        I ditto what Marc says.
        And check out Rocketman refreshing how
        he tells his story of addiction …. very human
        Shows how he was shaped as a child …

  12. shaun June 24, 2019 at 8:07 pm #

    My dearest Marc,

    I apologize for not having the time to catch up- It’s 12:30 in Lisbon and I..Well, I’ll leave that for an e-mail or skype. But I have to add something here without reading the other comments – apologies to those of you who have responded, it just a time issue.

    Firstly, I know you had valid reasons for not publishing and I respect 100% your decision (obviously). And as usual you demonstrated your commitment to doing what is ethically right for you rather than what is easy.

    If it was me, I would think something like this: In a prohibitionist world, methadone is often the best a person can get, and it may save their life, especially if done right. In an ideal world people would be able to access diamorphine easily and cheaply, and live in circumstances where the use of heroin is not made more salient by the setting they live in.

    But in this world of chaos and stigma and the belief that people like us are ‘evil’ (to quote the preamble of the single convention), methadone is the best opioid agonist of known concentration and quality many will ever be able to access.

    Unfortunately, in the US, methadone programmes are not evidence based and are more a method of social control than an attempt to help people. In order to get the methadone, a prescription is needed – so who will give the methadone? Prescribing a medication does not equal a disease – as we have jointly said, some people just do better on opioids.

    I imagine two scenarios:
    ONE: a well-meaning doctor who has learned it all from the book of NIDA, Chapter Volkow, TIP63: Patient has life-long disease of brain that compromises free-will. They will manipulate and lie. I will insist that the pee in a cup, don’t give take home doses until they have jumped through multiple hops for xxxweeks, have medication discontinued if they test positive and they will have to sing Kumbaya to the group three times a week to get their prescription at the clinic every day for the first xx months between the hours of “too late” and “too early”. Chance of getting on with life, zero.

    TWO: Having read Marc’s chapter start by seeing a person who, for whatever reason, has learned to use heroin as a valid way dealing with life. Through collaboration and honest dialogue, with voluntary additional services that they may or may not request, I will prescribe their methadone without fuss and making them seem like I’m doing them the world’s biggest favour. I will offer take-home doses as soon as stable dose is achieved and not wield their autonomy like a weapon that can be removed if the so much as blink wrong. I would help them find the right dose, and keep them on it as long as they want without pressure and expectation.

    I would, as you have written, “provide a scaffolding” of methadone “to support a vision of future self”, rather than use methadone as a straight jacket to constrict their right to breath.

    I have just finished writing up the results of South Africa’s first methadone prescribing service that I co-designed and implemented with my colleagues. For the first time ever in the global South we started with low-threshold, high tolerance, harm reduction informed service rather than a regimented programme that is more social control than person centred well-being. Despite being time limited to 18 months the people achieved a retention of 20% more than expected and people’s lives changed significantly for the better.

    I’m sure your reasons were great for not submitting, but if we had more better-informed prescribers, maybe they would be demanding the changes the world needs to stop seeing people who use drugs as drug-seeking addicts and junkies, but as people who have found a way to make their way through life and who deserve to make their choices and access what they need without being forced to rely on unregulated street drugs and live in constant risk of dying.

    • Alison June 24, 2019 at 10:43 pm #

      Shaun your description of methadone clients was poetic…
      Lol “too early” “too late”…. thanks for making me laugh cause most days I’m crying over the rigidness of methadone “maintenance “
      I even think that word is annoying ….

    • Gina June 25, 2019 at 12:43 pm #

      Brilliant commentary, as always, Shaun. I think you hit the nail on the head when you said prescribing medication doesn’t equal disease. Some people just do better on opioids. I am convinced this is true and I’m so glad that Marc has written about that very topic. Although I side with others who think Marc may have been too rigid in resisting publication in this book, I find no fault with the attempt to remain consistent with his principles.

      Alison, I love that “too early” and “too late” line, as well! I chuckled in recognition when I read it because I’ve been down that road with my daughter enough times.

    • Marc June 29, 2019 at 10:23 pm #


      I wrote Shaun an email (no reply yet — hey Shaun, did you read it? — he happens to be the busiest person on the planet….so I forgive him) saying that his comment, above, hit me over the head hard enough to turn me around: 180 degrees. In a nutshell, I think I made the wrong decision. Matt, this applies to your comment too. As you both point out, very gently in fact, i’ve been too pig-headed about this.

      Back-track: many of the comments here have been incredibly insightful — smart, knowledgeable, giving me a fresh perspective, grist for my mill. And they’ve come down roughly 50-50. About half of you (who’ve expressed a clear opinion) endorsed my decision to pull back and half of you thought I should have stayed in the ring.

      But Shaun’s comment hit the hardest. Partly because of how he worked out the two scenarios, and how achingly accurate the staging seemed to be.

      Okay, Shaun, when you put it that way, of course I need to do my best to support scenario #2. Help give doctors whatever message I can give them to use OST as a scaffolding rather than a prison cell.

      The day I saw his comment, about a week ago, I’d already spent nearly two hours with a client of mine. We went over our 1-hour time frame because…I guess because I had the time, so did she, and her story had me nailed to my chair. It was overwhelmingly painful.

      As I often say, context makes all the difference. The confluence of these two events — listening to Sally’s (fictional name) story and then reading Shaun’s comment — was so powerful that I felt compelled to write one of the editors (my colleague, actually) and ask him to accept my chapter after all, with most of the revisions he might request as well as a few of my own.

      All this amounted to a personal journey that seems important enough to warrant a separate blog post. I’ll put that up tomorrow or the day after.

      • Shaun Shelly June 30, 2019 at 4:33 am #

        Hey Marc, I am humbled – I have just sent a brief and unsatisfying response to your e-mail.
        Yes, I am busy at the moment – and I miss having the time to engage with the people I have come to know on the web (your blog, the various list serves and facebook). I have to choose my moments, and I’m really grateful that this influenced your decision, but I think you were already in two minds… Love and respect to you and your contributors – Shaun

        • Marc July 3, 2019 at 10:19 am #

          Hey Shaun, I’m humbled too. You saw things so clearly and expressed a reality that I needed to see, using your awesome perspective and your skill at spinning an argument that penetrated the fortress of my biases and presuppositions. It worked. See the next post for details.

          Whatever you’re so busy doing this week, next week, next month, next year, wherever you happen to be pitching your intelligence and passion, you help people in addiction like no one else.

  13. Marcodevin November 13, 2019 at 2:58 am #

    Nice Blog

    Thanks for sharing the information

  14. Selena Valentine November 15, 2019 at 2:14 am #

    My son was badly affected by alcohol abuse, we gave him so much counselling and made him sober for 2 years. Again he was relapsed and it was very worse. We moved to the recovery center in our city as an outpatient and they really treated us well and suggested the treatments that best fits for him and he is now fully recovered and staying sober for the past 8 years. I am very happy to share this and I love this blog too!

    How To Help Your Loved One Overcome Their Addiction Issues?

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