Episode 8

[Music]
all right welcome back to another
episode of finding peaks excited to be
here again today with our
chief clinical officer jason friesma and
our chief operating officer
clinton nicholson welcome back fellas
to another episode i’ve been talking a
lot about what episode we’re on and
apparently the feedback is that i’ve
lost count
significantly so i’m no longer going to
state what episode we’re in because
i actually don’t know maybe just a sign
in the
title just like episode chair episode
yeah we’re a work in progress bear with
us
that’s pretty clear yeah super clear
yeah so today i want to
that this industry you know going all
the way back what to
introduced
from there forward started with a strong
abstinence approach to care
and this industry at least that in the
way that i’m experiencing certainly i’m
sure you guys are experiencing the same
is softening around the edges of
abstinence and moving towards a
harm reduction model
to determine outcomes and a story
comes to mind about a past patient who
was in our care several years ago
the mom continues to reach out to us on
a yearly basis just
excited and ecstatic about how well her
son’s doing
but she talks in a way that
isn’t really engaging with the
abstinence-based concepts and
so just introducing this story namely
the individual came into our program
abusing heroin intravenously
left our program has since not used
interventions
in our uh how do i be iv i’m gonna
let’s go to iv there to make this more
more uh convenient for the conversation
not using iv heroin but is holding down
his relationships has a baby in his life
you know holding down a job showing up
as a family member
not stealing from mom or anything like
this anymore
but is drinking actively drinking and
she
states it’s not an issue that you know
at parties or whatever the situation is
family gatherings that
he’s accountable showing up in all the
ways that she sees
you know um positively in the adulting
sense of things
um but has removed the heroine and so in
this regard
this story is revealing a harm reduction
principle
namely the major problem has gone away
but
use in some way continues and
so i guess with my what feels like a
poor introduction of a story there
utilizing that story
um and and coming from this large
abstinence-based approach
where are you guys at on this topic and
before i ask too many questions i’m just
going to rest it there
okay jason oh yeah
i mean this is this is a
an emerging debate or an emerging
discussion
probably to have because i do think uh
in a lot of ways creating very rigid
success models i’ve actually called it
worshipping at the altar of sobriety
time
when somebody’s perfectly sober from all
substances
um and that’s the only measure of
success
it creates an issue where if somebody
then does have some sort of slip whether
it’s a beer
or a joint or whatever and it isn’t a
return to iv heroin use
from a pure abstinence-based model
they’ve relapsed and
they’re at zero days of sobriety just
like they were
the day they last had a needle in their
arm
and i think that rigid model of thinking
takes away any nuance and it and it
says all relapses are the same all
lapses are the same
all drug use is the same and it just
turns out that
um that isn’t always helpful it it
and don’t get me wrong it has been
helpful at times to think in that way
and it can be helpful to take away
ambiguity and that is certainly the
easiest way
to take away ambiguity is just to say
all drugs are bad
any use of any drug is a relapse it’s
very black and white
there’s an easy way to measure success
in that
but i think we can be a little more
nuanced maybe in our description of what
is success like is this by all measures
this mother
that you just described would say that
her son
has successfully uh recovered from iv
heroin use now
he’s chosen to continue to use alcohol i
don’t know how he’s using it
it doesn’t really matter the mom is
saying that he’s functional his life is
going okay
um that would seem like a success
and i it would also seem a little risky
potentially too
clinton over to you over to me wow right
yeah
well um i mean i think that the big book
was very much uh
sort of um from its time right like it’s
a representative of its time which was
in a pretty conservative um not
super sophisticated scientifically um
era and it really rests a lot on the
moral
model of um of addiction and the belief
that you know there is
an element of um willpower
and that there is a sort of uh
a defect within a person that makes them
an addict
and because they have that defect
they’re an addict across the board
right like it doesn’t give you any room
for
um again like jason said for nuance or
for
differentiation or for the idea that you
know just because you are a heroin
addict physiologically does not mean
that you are an actual
alcoholic you know like those are two
different things but from a moral
standpoint or that old
sort of the older models and that and
that
abstinence-based model specifically
all substances are the same you know
like addiction as addiction is addiction
is addiction
but the reality is that addiction is
really when you talk about like the
dsm-5 it’s a
it’s about how is it negatively your
substance use negatively impacting your
life
right there has to be that component to
it um
and this the um client that you were
talking about
it sounds like you know the substance
that he was using that was messing with
his life and disrupting him and
creating turmoil and chaos that was
eliminated
and now there’s another substance that
he’s using that does not have that same
effect so therefore he would not be
diagnosable
under as an alcoholic you know so
for me it um the abstinence-based
ideology is one of over simplicity
and i think that it lacks uh a certain
i think that it really does steep itself
in shame
as opposed to wellness which is what the
the more um harm reduction models look
at yeah
absolutely i think sorry interruptions
um
but i do think like looking at where aa
came from right like there is no
predecessor to it absolutely
nobody could get well and it was this
grassroots
movement in ohio if i remember right
where people
started to be able to stay sober and
then tried to figure out how they were
staying sober and this was
to me just a great honestly a great
description of how they managed to stay
sober
um and to your point it isn’t a time
capsule
um but it probably
needs to reform like any idea from the
look at sigmund freud and say all of his
ideas are absolutely true and we can’t
change any of them right
absolutely everything is about uh the id
and the ego and the superego and
there’s no other way to conceptualize
how people think absolutely
it was foundational and important and we
do use a lot of concepts from sigmund
freud and he needed to make those
um do that writing
and then we’ve grown a ton from it well
i think actually in addiction it’s one
of those fields that didn’t grow
right it found one model that worked
pretty well for a lot of people
and then because there’s so much stigma
and misinformation around addiction and
there was this sort of moralistic
component
uh that was kind of wrapped around it
socially
once once we found one decent way that
helped a few people like we just kind of
stopped
as within that field looking for other
alternatives and looking for different
ways and
really even exploring what is addiction
like what is actually what does
addiction actually mean and i think that
we’re still
kind of playing catch up to other fields
that would have like you know looking at
like psychology as an example
you know where they were able to sort of
bust through those early ideologies
and recognize very quick very quickly
that there is more to the story
and i think that we’re still pretty
early on in that process especially
because
the fact that we’re having this
conversation and harm reduction is
in a lot of circles still considered
pretty controversial well it is weird
even sitting here i’m uncomfortable i’m
going to be honest with you because i
know
certainly how i’ve been trained and how
i’ve operated for a fair amount of my
career it’s
it’s been much easier to make this
black and white issue absolutely to be
honest with you like to just
fall into that same pattern of thinking
but really with the addition of like mat
treatment like using medication to help
people
remain sober and and to be able to kind
of regain control of their lives like it
we have to begin to learn how to explore
things that are uncomfortable
even even acknowledge that
uh perhaps the the lane of this
absence-based model uh
is actually maybe even a trap that we
find ourselves in rather than
even even a path forward at times so
absolutely and
the way that i see it the the new the
the new language of a moral defect is
the science of the physiological brain
state that we call craving
uh right now so i think you know i can i
can just
feel the tension building on the other
side of the camera as it is for us too
with families being like no you’re not
telling me right now that johnny has an
iv heroin issue and he’s gonna go and
start drinking i think
there’s an important notion here to
consider that
if the craving state is iv drug use and
the end of it i guess one step back i
always have clients you know walking
around
you know our treatment center saying i
can do this on pot
do what are we talking about here and
what i hear
or the way that i translate that is that
i have this thing called ib craving
state
and i’m just going to replace that state
with pot i mean
no wonder the abstinence culture has
thrived so much because that’s an
error in thinking that it’s not going to
satiate the craving state which
leads back to the relapse of this
craving state
and so what i think is really important
here that i would certainly
love for families to hear us out loud as
we talk about this
and i think it’s worth more of a
discussion here right now is
when we think about the trade-offs let’s
say we can
actually do some other drug or alcohol
in the future
that is this over here and remove this
craving state
it seems like when i think about drug
use or alcohol or
you know use anything of those sorts
that there are these two words that i
always use with clients in our care
responsibility and sustainability
right so when we’re talking about okay
well i’m going to use meth
it i mean right when it comes out of the
mouth it doesn’t feel very responsible
and we know it’s not sustainable
in our experiences due to um the
likelihood that you will begin to crave
that
and develop an addiction yeah there are
very few like weekend meth users right
that’s just not really a thing you know
um you know cocaine there’s some
there’s drugs out there that each time
we say them it doesn’t feel like we can
get
into responsible and sustainable lanes
now with
you know pot becoming legalized or at
least decriminalized across the country
it’s a common go-to
piece and we can get into it but alcohol
is the other one there
both of them have components of
responsibility and sustainability at
least in the general public sphere of
things
but what does it look like maybe to
think about responsibility and
sustainability here because it’s not
you know 10 bong rips throughout a day
that makes this
no okay to do yeah i think
you’re bringing up that craving state
really resonated with me brandon and i
really think
um if somebody’s using pot
uh in lieu of heroin um i just don’t see
that really
working right like i i think it makes
the itch worse it doesn’t scratch the
itch
it worsens the edge um and so i think
there’s a function of time a lot
often right like deal with the craving
walk through whatever is driving it
and then maybe down the road um
what would it look like to reintroduce
some of these marijuana back in
and then i frequently in in the new
approach
which is more uncomfortable i want to
acknowledge that it’s like well how will
you know
if marijuana if you want to do it and
how will you know if you’re losing
control of it or how
you know if it does seem to be leading
you back to
uh a place where you don’t want to be
into a craving state
or into being triggered and so um
and i and i don’t want to just detract
from that but like i do think
some of our unwillingness to talk about
um harm reduction is on our field
that like this is a harder nuanced
conversation it’s easier
to sit and tell a client don’t do drugs
they’re bad
avoid all that don’t go to a bar really
easy
very telly very parental
um and in the end shame based i think
maybe not shame based but aspects of it
are shame based for sure
which really complicates treatment
because a lot of
actual addiction treatment is based in
trying to eliminate shame
correct so there is this contradiction
that immediate intention that actually
is created within that model
and the treatment of that of addiction
so
um and but i mean jason’s totally right
this is as soon as you say the words
harm reduction you have cracked open a
pandora’s box of gray
like it is just there so all of a sudden
it really is based on each individual
has a unique addiction there and
therefore has a unique recovery
and our job as clinicians or as medical
providers or
is to actually try to figure out what
that is
you know so rather than giving one
answer for all of the questions we
actually have to really dig
in and figure out who these people are
what their needs are
what the motivating problems and factors
are how to actually eliminate that
craving state
and and then help them to to
figure out their own path to what their
future of recovery looks like
and that is i mean i’m tired just
thinking about it
but at the same time that’s the response
that’s the most responsible way to move
forward it might and that’s an opinion
without a doubt
and that’s that opinion in no way shape
or form is
promoting um you know substance use for
people who are in early treatment you
know or early in recovery
that’s i think the antithesis of what
we’re actually trying to say
um so there is there are edges and there
are boundaries but
they are they they don’t feel familiar
and they don’t feel and they don’t feel
nearly as
solid so yeah and the
concept of at least in the medical sense
of um
neuroplasticity brain neuroplasticity is
of the brain of course but
in and without diving too deep into the
science i mean the basic premise of
it is right that new neural pathways can
form and i think that’s the brilliance
of the time component that if you have
this craving state
the more distance you have from it and
the more neural pathways that are
developed
in front of it um or on the other side
of it you have
what seems like a new opportunity to
explore different things in a way that
was limiting in this case
absolutely so i think absolutely
even though we’re in a gray area time is
really important and distance from the
original craving state is absolutely
needed um
in this guard uh or in that regard in uh
particular so
uh and just real fast i mean that that
reiterates the idea that recovery is not
just
sobriety like those are two very
different things like not using
substances
is not the same as recovery uh recovery
is about
changing all of those aspects of your
life the the social aspects the
interpersonal aspects the intra-personal
aspects
managing and creating a life that in
which you function completely
differently
which is reflected in the new and the
way that your brain is functioning
right because of neuroplasticity that
transformation is somehow made permanent
and more meaningful and you actually
do live a different life
i think that’s a great point i mean i i
do think of
people that i’ve met along the way who
maybe have been sober
for years and years and years and go to
three aaa meetings a day and are no more
pleasant to be around when than when
they were drinking
yeah they’re sober but they’re not in
any sort of recovery
yeah that’s a thing yeah and
so it brings me to a future topic
medication assisted treatment
programming that um we’ll definitely
play out in a future
uh episode but one of the things that dr
volkow with nida
the national institute on drug abuse
came out
many years ago in regards to suboxone
this is around i think 2006 or so and
felt as if this was a cure to craving
states
so there’s tension on the mat side of
things that i’m
looking forward to talking to but just
kind of leave the viewers with as a tail
end of this conversation
um that’s limiting in our thought about
this that we can apply
an a drug objectively to all subjective
craving states for
intravenous opioid users and in
relationship to suboxone
that for me doesn’t seem reasonable that
it can’t be the silver bullet that we
depend on as an industry moving forward
it’s something within the tool kit that
we can utilize
um in all of this but i don’t feel like
suboxone
in general or you know supplicate and
the like are accounting for the
subjective experience of craving states
and this is why we get such a separation
from the young adult being
entirely not successful on mat
programming where you get you know
middle-aged 33 years old or higher
largely seemingly
becoming successful on those protocols
so
i don’t know exactly what my question is
here but i feel like
it seemed like you were doing an outro
yeah
yeah maybe maybe it’s an outro here um
well you’re kind of reiterating the idea
that
um you know silver bullet responses
regardless of what they are whether
they’re
based in a medication model or whether
they’re based in an abstinence model
there is no silver bullet the real the
real work and the real
repair is done over time and it’s uh
actually done within the brain you know
that’s where the majority of the repair
work is and it takes time
it takes dedication it takes treatment
it takes
counseling it takes um
several different dynamics and variable
variables are involved
in actually healing the brain so the
silver bullet mentality in general and i
think this goes for either
abstinence-based or for harm reduction
models is
i think that’s maybe what we actually
need to walk away from yeah
absolutely it’s crazy because inside of
me
as we talk about this i i want to like
put the disclaimer out there that like
people don’t walk out of peaks
with the recommendation of like start
smoking marijuana right
i would explore your path absolutely not
uh
have your wife pick you up with a
six-pack and see how it goes like that
because of that time element people
aren’t walking out after a stabilization
program right and right into that like
there’s a there’s that element see and
that’s my own
discomfort with this whole conversation
but i feel like i need to say it yeah
and it is a part of this outro that i
that you rightfully pointed out i’m
cautioning
both sides of the the polar sides of the
conversation that this isn’t pure
harm reduction this isn’t pure
abstinence that we have to sort of live
in this gray area
to arrive at better outcomes for the
individual for the family systems that
are suffering throughout this process
and so um hopefully we’ve been able to
provide a little bit of insights
into the tension in this relationship
you could probably experience it in just
us discussing out loud that there is
tension in this
um uh topic and that definitely the goal
isn’t to just
you know turn around and start using you
know drugs and alcohol by
any means in this regard it’s it’s
sensitive but it’s something worth
talking about and this industry does
need to
talk about it and i’m excited that we’re
able to deliver
small pieces of it today so thanks again
for joining us here
at the finding peaks and we look forward
to
the next episode with you all thank you
thanks