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Not content with billions of dollars in profits from the potent painkiller OxyContin, its maker explored expanding into an “attractive market” fueled by the drug’s popularity — treatment of opioid addiction, according to previously secret passages in a court document filed by the state of Massachusetts.In internal correspondence beginning in 2014, Purdue Pharma executives discussed how the sale of opioids and the treatment of opioid addiction are “naturally linked” and that the company should expand across “the pain and addiction spectrum,” according to redacted sections of the lawsuit by the Massachusetts attorney general. A member of the billionaire Sackler family, which founded and controls the privately held company, joined in those discussions and urged staff in an email to give “immediate attention” to this business opportunity, the complaint alleges.ProPublica reviewed the scores of redacted paragraphs in Massachusetts’ 274-page civil complaint against Purdue, eight Sackler family members, company directors and current and former executives, which alleges that they created the opioid epidemic through illegal deceit. These passages remain blacked out at the company’s request after the rest of the complaint was made public on Jan. 15, 2019. A Massachusetts Superior Court judge on Monday, Jan. 28, 2019 ordered that the entire document be released, but the judge gave Purdue until that Friday to seek a further stay of the ruling.The sections of the complaint already made public contend that the Sacklers pushed for higher doses of OxyContin, guided efforts to mislead doctors and the public about the drug’s addictive capacity, and blamed misuse on patients.Citing extensive emails and internal company documents, the redacted sections allege that Purdue and the Sackler family went to extreme lengths to boost OxyContin sales and burnish the drug’s reputation in the face of increased regulation and growing public awareness of its addictive nature. Concerns about doctors improperly prescribing the drug, and patients becoming addicted, were swept aside in an aggressive effort to drive OxyContin sales ever higher, the complaint alleges.Among the allegations: Purdue paid two executives convicted of fraudulently marketing OxyContin millions of dollars to assure their loyalty, concealed information about doctors suspected of inappropriately prescribing the opioid, and was advised by global consulting firm McKinsey & Co. on strategies to boost the drug’s sales and burnish its image, including how to “counter the emotional messages” of mothers whose children overdosed. Since 2007, the Sackler family has received more than $4 billion in payouts from Purdue, according to a redacted paragraph in the complaint.“The payments were the motivation for the Sacklers’ misconduct,” the complaint says. “And the payments were deliberate decisions to benefit from deception in Massachusetts, at great cost to patients and families.”In 1998, two years after OxyContin was launched, Dr. Richard Sackler, a son of Purdue co-founder Raymond Sackler, instructed executives in an email that its tablets were not merely “therapeutic” but also “enhance personal performance,” like Viagra. Fifteen years later, he complained in another email that a Google alert he set up for OxyContin news was giving him too much information about the drug’s dangers.“Why are all the alerts about negatives and not one about the positives of OxyContin tablets?” he asked a company vice president. Staff immediately offered to replace Sackler’s alert with a service that supplied more flattering stories, according to the complaint.The redacted paragraphs leave little doubt about the dominant role of the Sackler family in Purdue’s management. The five Purdue directors who are not Sacklers always voted with the family, according to the complaint. The family-controlled board approves everything from the number of sales staff to be hired to details of their bonus incentives, which have been tied to sales volume, the complaint says. In May 2017, when longtime employee Craig Landau was seeking to become Purdue’s chief executive, he wrote that the board acted as “de-facto CEO.” He was named CEO a few weeks later.In a statement in response to questions about the redacted material, the company said that Massachusetts “seeks to publicly vilify Purdue, its executives, employees and directors by taking out of context snippets from tens of millions of documents and grossly distorting their meaning. The complaint is riddled with demonstrably inaccurate allegations.”Purdue acknowledged in the statement that it was considering acquiring the rights to sell drugs that combat addiction or reverse the effects of an overdose. It criticized the state for “casting in a negative light” the company’s exploration of a potential acquisition of an addiction treatment that was already on the market, “even though the company never actually made the acquisition.”Purdue also pointed out that OxyContin is approved by the Food and Drug Administration. It said that most opioid overdoses “now result from heroin and illicit fentanyl.”The Sackler family was once best known for its philanthropy. Its name is engraved on museums and university buildings across the world. A group of activists has called on organizations to stop accepting Sackler donations and for the family name to be stripped from some institutions. Aggressive marketing of OxyContin is blamed by some analysts for propelling the crisis that has resulted in 200,000 overdose deaths related to prescription opioids since 1999.After its 1996 launch, OxyContin rapidly became a top seller. But reports of patients abusing the drug soon followed. OxyContin contained more pain relief medication than older drugs, and crushing and snorting it was a simple way to get high fast. In 2007, Purdue pleaded guilty to federal charges of understating the risk of addiction and agreed to pay $600 million in fines and penalties. Still, the company argued publicly that OxyContin has “done far more good than harm,” and it sought to place responsibility for the bad acts on “certain of its supervisors and employees.”Privately, the complaint suggests, the Sacklers were concerned about alienating two executives, then-CEO Michael Friedman and then-legal counsel Howard Udell. Friedman and Udell each pleaded guilty in 2007 in U.S. District Court in Abingdon, Virginia, to a misdemeanor charge of misbranding OxyContin, as did a former executive. The board signed off on the three executives’ decisions to plead guilty. No member of the Sackler family pleaded guilty.Purdue paid $5 million to Udell in November 2008, and up to $1 million in November 2009, the complaint states. In February 2008, the company paid $3 million to Friedman. The complaint doesn’t mention any payments to the former executive.“The Sacklers spent millions to keep the loyalty of people who knew the truth,” the complaint alleges.Udell died in 2013. A person answering a phone number listed to Friedman declined comment.The plea deals did little to hinder OxyContin sales or the Sacklers’ hands-on management. At the direction of the board, Purdue repeatedly increased its sales force, which pushed doctors to prescribe higher opioid doses.In 2008, the same year that Purdue paid Udell and Friedman, Richard Sackler advised other family members that it was important to select a new chief executive who was loyal to the family. “People who will shift their loyalties rapidly under stress and temptation can become a liability from the owners’ viewpoint,” he allegedly wrote. A defendant in the Massachusetts lawsuit, Richard Sackler served in a number of different positions at the company before being named president in 1999 and then co-chairman of the board in 2003.The company did install five new, non-family board members in the wake of the federal investigation. But in hundreds of board votes, the new directors never opposed the family, according to the complaint. Although Purdue does not operate outside the U.S., board meetings took place at a castle in Ireland as well as in Bermuda, London, Portugal and Switzerland.When sales results disappointed, Sackler family members didn’t hesitate to intervene. In late 2010, Purdue told the family that sales of the highest dose and most profitable opioids were lower than expected, according to the complaint. That meant an expected quarter-end payout to the family of $320 million was at risk of being reduced to $260 million and would have to be made in two installments in December instead of one in November.That news prompted a sharp email question from Mortimer D.A. Sackler, whose late father, also named Mortimer, was a Purdue co-founder. “Why are you BOTH reducing the amount of the distribution and delaying it and splitting it in two?” he asked. “Just a few weeks ago you agreed to distribute the full 320 [million dollars] in November.” The complaint doesn’t say how much was ultimately paid.From 2009 until at least 2014, McKinsey helped Purdue shape its message for selling OxyContin and overcoming concerns about addiction and overdoses, according to redacted passages. The consultant told Purdue in a slide presentation that it could increase prescriptions by convincing doctors that opioids provide “freedom” and “peace of mind” and give patients “the best possible chance to live a full and active life.”Purdue staff, according to the complaint, told the Sacklers that McKinsey would study “patient pushback” to encourage hesitant doctors to prescribe opioids. In a meeting with Purdue executives, McKinsey planned how to “counter the emotional messages from mothers with teenagers that overdosed in [sic] OxyContin" by recruiting pain patients to talk about the need for the drugs.In a 2013 report, McKinsey recommended directing sales representatives to focus on the most prolific opioid prescribers because that group writes “25 times as many OxyContin scripts” as less prolific prescribers. Because prescription rates rose in tandem with visits from sales reps to doctors, McKinsey recommended increasing each salesperson’s quota from 1,400 visits a year to closer to 1,700. McKinsey estimated that targeting the most frequent prescribers could boost OxyContin sales by hundreds of millions of dollars. The quotas rose, as did total visits, the complaint states. Purdue said it planned to decrease visits relating to opioid products, and any increase was due to promoting a laxative.McKinsey also recommended Purdue fight back against efforts by a major pharmacy chain, the U.S. Drug Enforcement Agency and the U.S. Department of Justice to stop illegal opioid prescribing, the complaint states. These new rules were cutting into sales of the highest doses, which were also the most profitable, it says. The complaint doesn’t say if Purdue followed McKinsey’s recommendation. Purdue said the recommendations “actually relate to ensuring continued access to pain medicines for appropriate patients.”A McKinsey spokesman declined comment.In September 2014, Purdue embarked on a secret project to join an industry that was booming thanks in part to OxyContin abuse: addiction treatment medication. Code-named Project Tango, it involved Purdue executives and staff as well as Dr. Kathe Sackler, a daughter of the company co-founder Mortimer Sackler and a defendant in the Massachusetts lawsuit. She participated in phone calls and told staff that the project required their “immediate attention,” according to the complaint.Internally, Purdue touted the growth of an industry that its aggressive marketing had done so much to foster.“It is an attractive market,” the team working on the project wrote in a presentation. “Large unmet need for vulnerable, underserved and stigmatized patient population suffering from substance abuse, dependence and addiction.”While OxyContin sales were declining, the internal team at Purdue touted the fact that the addiction treatment marketplace was expanding.“Opioid addiction (other than heroin) has grown by ~20%” annually from 2000 to 2010, the company noted. Although Richard Sackler had blamed OxyContin abuse in an email on “reckless criminals,” the Purdue staff exploring the new business opportunity described in far more sympathetic terms the patients whom it now planned to treat.“This can happen to any-one – from a 50 year old woman with chronic lower back pain to a 18 year old boy with a sports injury, from the very wealthy to the very poor,” it said.Company documents recommended becoming an “end-to-end pain provider.” Initially, Purdue intended to sell one such medication, Suboxone, which is commonly retailed as a film that melts in the mouth. When Kathe Sackler asked staff members to look into reports that children might be swallowing the film, they reassured her. They responded, according to the complaint, that youngsters were overdosing on pills, but not the films, “which is a positive for Tango.”In 2015, Purdue turned its attention to another potential product, the overdose reversing agent known as Narcan, calling it a “strategic fit.” Purdue executives discussed how its sales force could promote Narcan to the same doctors who prescribed the most opioids. Purdue said in the statement Wednesday that it decided against acquiring the rights to sell Suboxone and Narcan.While those initiatives appear to have stalled or ended, Richard Sackler received a patent last year for a drug to treat addiction, according to the complaint. The patent application states that opioids are addictive and refers to people who suffer from substance use disorders as “junkies.”Besides being a defendant in the Massachusetts case, Richard Sackler was deposed in a lawsuit against Purdue in Kentucky, which the company settled. It’s believed to be the only time a member of the family has been questioned under oath about OxyContin and its addictive properties. The Kentucky Court of Appeals has ordered the release of his deposition, in response to a motion by STAT, but Purdue is asking the state Supreme Court to review the ruling. Hundreds of other lawsuits filed by states, cities, counties and tribes against Purdue have been consolidated in a pending case in federal court in Ohio.The Massachusetts complaint cites multiple incidents of Purdue allegedly sitting on information, sometimes for years, about doctors it had reason to believe were inappropriately prescribing OxyContin. In 2012, a Purdue employee appealed to the company’s head of sales to alert health insurers to data the company collected about doctors suspected of abusing or illegally prescribing OxyContin. The list of doctors was code-named Project Zero.“At a basic level, it just seems like the right and ethical thing to do,” the employee wrote. “Doing so could help those companies identify those physicians that may be of a concern, not just with respect to our products, but also other” pain medications. “As a result, if it reduces abuse and diversion of opioids then it seems like something we should be doing.”The idea was rejected and the employee left the company a month later, according to the complaint.Update, Jan. 31, 2019: The day after this article was published, a judge rejected Purdue's request for a further stay, and the entire complaint was made public. This story was originally published by ProPublica on January 30, 2019. ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.
It’s often said that people with substance use disorder stop maturing at the age they were when they started using. If you were addicted to drugs or alcohol throughout your teens or young adulthood, you probably missed on out on learning essential life skills. That can make early recovery difficult. Not only are you adjusting to your new, sober life, but you’re also making up for lost time in learning life skills that are important for success. The good news is that most recovery programs can help you through this gap, and your sober community can help you learn these essential life skills. From conflict resolution to writing a resume and managing your finances, here are the life skills that everyone should learn in early recovery, and where you can find support for learning them. 1. How To Resolve ConflictEveryone who has relationships with other people experiences conflict. Whether it’s in your romantic life, among friends or at work, you’re bound get into disagreements now and then. When you find yourself at odds with someone, remember the communication techniques you’ve learned in recovery. Don’t attack or take things personally. Just focus on the issue at hand and working toward a common understanding.2. How To Write A RésuméMany people look for a job in early recovery, so having a resume on hand to highlight your skills is important. Many treatment centers and transitional housing programs can connect you with resources that will teach you how to write a great resume. State job programs can also help on this front.If you’re concerned about gaps in your resume, start with a bulleted section that highlights key skills. That way, you can show the skills and accomplishments that make you stand out, even if they’re not your most recent endeavors. Once you have a great resume on hand, remember that it’s important to tweak it to fit the desired skills of specific jobs that you’re applying to.3. How To Manage Time and Keep Yourself AccountableDuring treatment and transitional periods, you have a lot of structure built into your day. As you get more freedom, it’s important to learn to manage your time well, and to hold yourself accountable for this. Being on time — whether to work or for a meeting — shows that you respect the people you’re meeting with. During the early days of recovery consider making a weekly schedule. Make sure that there is time in it for the activities that help you stay sober, like meetings or yoga. Keeping yourself on schedule will help you establish new routines in sobriety.4. How To Manage Your MoneyMoney is a huge source of stress for many people. Knowing how to manage your money well can help keep stress at bay. When it comes to financial health, start with the basics: open a bank account and check your credit. From there, you can work with people that you trust to build a financial future. This might include paying past-due balances from active addiction, or saving for your own home.5. How To Create Healthy BoundariesOne of the most important life skills in recovery is knowing how to set and stick to your boundaries. There are likely certain people and places which you need to distance yourself from. You need to decide what your boundaries will be, communicate them to the people involved, and stick to the stated consequences if people violate your boundaries. Doing this can be difficult, but your recovery team is there to help, since this is critical for protecting your new, sober life.Learn more about Oceanside Malibu at http://oceansidemalibu.com/. Reach Oceanside Malibu by phone at (866) 738-6550. Find Oceanside Malibu on Facebook.
After unanimously voting to recommend a miraculous hepatitis C drug for approval in 2013, a panel of experts advising the Food and Drug Administration gushed about what they’d accomplished.“I voted ‘yes’ because, quite simply, this is a game changer,” National Institutes of Health hepatologist Dr. Marc Ghany said of Sovaldi, Gilead Science’s new pill designed to cure most cases of hepatitis C within 12 weeks.Dr. Lawrence Friedman, a professor at Harvard Medical School, called it his “favorite vote” as an FDA reviewer, according to the transcript.What the panelists didn’t know was that the FDA’s drug quality inspectors had recommended against approval.They issued a scathing 15-item disciplinary report after finding multiple violations at Gilead’s main U.S. drug testing laboratory, down the road from its headquarters in Foster City, Calif. Their findings criticized aspects of the quality control process from start to finish: Samples were improperly stored and catalogued; failures were not adequately reviewed; and results were vulnerable to tampering that could hide problems.Gilead Foster City doesn’t manufacture drugs. Its job is to test samples from drug batches to ensure the pills don’t crumble or contain mold, glass or bacteria, or have too little of an active antiviral ingredient.Recent news reports have focused public attention on poor quality control and contamination in the manufacturing of cheap generic drugs, particularly those made overseas. But even some of the newest, most expensive brand-name medicines have been plagued by quality and safety concerns during production, a Kaiser Health News analysis shows.More disturbing, even when FDA inspectors flagged the potential danger and raised red flags internally, those problems were resolved with the agency in secret ― without a follow-up inspection ― and the drugs were approved for sale.Erin Fox, who purchases medicines for University of Utah Health hospitals, said she was shocked to hear from KHN about manufacturing problems uncovered by authorities at the facilities that make brand-name products. “Either you’re following the rules or you’re not following the rules,” Fox said. “Maybe it’s just as bad for branded drugs.”The pressure to get innovative drugs like Sovaldi into use is considerable, both because they offer new treatments for desperate patients and because the medicines are highly profitable.Against that backdrop, the FDA has repeatedly found a way to approve brand-name drugs despite safety concerns at manufacturing facilities that had prompted inspectors to push to reject those drugs’ approval, an ongoing KHN investigation shows. This happened in 2018 with drugs for cancer, migraines, HIV and a rare disease, and 10 other times in recent years, federal records show. In such cases, how these issues were discussed, negotiated and ultimately resolved is not public record.For example, inspectors found that facilities making immunotherapies and migraine treatments didn’t follow up when drug products showed evidence of bacteria, glass or other contaminants. At a Chinese plant making the new HIV drug Trogarzo, employees dismissed “black residue” found to be “non-dissolvable metal oxides,” assuming it “did not pose a significant risk,” federal records show.Without a follow-up inspection to confirm drugmakers corrected the problems inspectors found, these medicines eventually were approved for sale, and at list prices as high as $189,000 a month for an average patient, according to health data firm Connecture. The cancer drug Lutathera was initially rejected over manufacturing problems at three plants but was approved a year later without a fresh inspection and was priced at $57,000 per vial.John Avellanet, a consultant on FDA compliance, said data integrity problems, like those at Gilead’s lab in Foster City, should have sparked further investigation, because they raise the possibility of “deeper issues.”Dr. Janet Woodcock, the director of the FDA’s Center for Drug Evaluation and Research, said an inspector’s recommendation to withhold approval can be “dealt with” without a follow-up. Woodcock said the agency can’t comment on specifics, and companies are reluctant to discuss them because the details of the resolution are protected as a corporate trade secret.“That doesn’t mean that there’s anything wrong with the drug,” Woodcock said.Dinesh Thakur, a former drug-quality employee turned whistleblower, called the secrecy a “red flag.” A follow-up inspection is critical, he said: “I’ve seen many times paper commitments are made but never followed through.”What worries Fox is that a faulty drug could get through and nobody would know.“In general, very few people suspect that their medicine is the problem or their medicine is not working,” Fox said. “Unless you see black shavings or something horrible in the product itself, the drug is almost the last thing that would be suspect.”The Market BeckonsIf the FDA finds problems at preapproval inspections for generics, the agency is likely to deny approval and delay the drug’s launch until the next year’s review cycle, according to industry and agency experts.In fact, just 12% of generics were approved the first time their sponsors submitted applications from 2015 through 2017.The calculus appears different for heralded new therapies like Sovaldi. In 2018, 95% of novel drugs ― the newest of the new ― were approved on the first try, the FDA said.Woodcock said the agency has “the same standards for all drugs,” but she emphasized that many of the manufacturing issues “are somewhat subjective.”For new brand-name drugs, she said, the FDA “will work very closely with the company to … bring the manufacturing up to snuff.”The manufacturer submits written responses and commits to resolve quality concerns, but the details are kept confidential.An estimated 2.4 million Americans have hepatitis C and, before Sovaldi, treatment came with miserable side effects and a strong chance it wouldn’t work. Sovaldi promised up to a 90% cure rate, though it came with an eye-popping $84,000 price tag for a 12-week course, putting it out of reach for most patients and health care systems.But corporate pressure to get such therapies into the marketplace is also considerable.Pharmaceutical firms pay hefty fees for FDA review and lobby the agency to speed products to market. For Gilead, time lost is money.“If approval of sofosbuvir were delayed, our anticipated revenues and our stock price would be adversely affected,” Gilead wrote in an SEC document filed Oct. 31, 2013, using the generic name for Sovaldi.Since its debut in 2013, Sovaldi has been widely criticized for its price but recognized as a medical breakthrough. Gilead has never recalled it.However, hundreds of patients who have taken the drug have voluntarily reported cancer or other complications to the FDA’s “adverse event” reporting database, including concerns that the treatment doesn’t always work. One in 5 Sovaldi patients and health care professionals who reported serious problems to federal regulators said the drug didn’t cure the patients’ hepatitis C.“The FDA approved these products after a rigorous inspection process, and we are confident in the quality/compliance of these products,” Gilead spokeswoman Sonia Choi said.Problems at Foster CityGilead’s Foster City facility has been cited for an array of problems over the years. In 2012, FDA inspectors said the facility had failed to properly review how the HIV drugs Truvada and Atripla became contaminated with “blue glass” particles; some of that tainted batch was distributed. The company “made no attempt to recover” the contaminated drugs, according to FDA inspection records.Gilead had just filed its application for Sovaldi’s approval when FDA inspectors arrived at Foster City for an unrelated inspection in April 2013. Inspectors slapped the facility with nine violations in what’s called a 483 document and said that the reliability of the site’s methods for testing things like purity were unproven and that its records were incomplete and disorganized, according to FDA inspection documents.As a result, the FDA initially rejected two HIV drugs, Vitekta and Tybost. Gilead had to resubmit those applications, and it would take 18 months before the FDA approved them in late 2014.On Sept. 19, 2013, FDA officials met to discuss Sovaldi with Woodcock, agency records show. Meeting minutes show inspectors recommended hitting Gilead Foster City with a formal warning letter based on the April inspection. (A warning letter is a disciplinary action from the FDA that typically includes a threat to withhold new approvals or place a foreign facility on import alert and refuse to accept its products for sale in the U.S.)At the same meeting, FDA inspectors said their recommendation to approve Sovaldi would be “based on” removing an unnamed drug ingredient manufacturer from the application and “a determination that Gilead Foster City has an acceptable cGMP [current good manufacturing practices] status.”Records show the FDA didn’t issue a warning letter or otherwise delay the approval process when Foster City failed its inspection.Instead, the Sovaldi preapproval inspection started four days later and lasted two weeks. At the end, inspectors issued Foster City another 483, this time with 15 violations, formally outlining problems and requiring a written plan to fix them. Inspectors said they couldn’t recommend Sovaldi’s approval.FDA officials gave Gilead two options during an Oct. 29 teleconference: Remove Foster City, a “major testing site” for Sovaldi, from the application, and use a third-party contractor instead; or use Foster City but hire another firm to monitor the site and sign off on its testing work.Gilead was optimistic. “Based on recent communications with the FDA, we do not expect these [inspection] observations to delay approval of sofosbuvir,” the company said in its Oct. 31 SEC filing.Gilead chose to replace the Foster City plant with a contract testing site, federal records show. By December, Sovaldi was approved for distribution, and the company soon announced its $1,000-per-pill price tag.Not Just GenericsRecent media reports, and the ongoing recall of the widely used blood pressure medicine valsartan, have led consumers ― and members of Congress ― to question whether generics are manufactured safely. Valsartan pills made in China and India were found to contain cancer-causing impurities.Branded-drug quality, in large part, has been spared from congressional scrutiny. But many factories ― overseas and in the U.S. ― make branded and generic drugs.In January 2018, FDA inspectors hit a Korean manufacturing plant that makes Ajovy, a migraine drug, with a warning letter. With the problems still unresolved in April, an agency reviewer recommended withholding approval. When they returned in July, inspectors wanted to give the plant the worst possible classification: “Official Actions Indicated.” Among other problems, inspectors found that glass vials sometimes broke during the manufacturing process and that the facility lacked protocols to prevent the particles from getting into drug products. The FDA’s Office of Manufacturing Quality eventually downgraded the inspection to just “Voluntary Actions Indicated.”The drug was approved in September 2018 and priced at $690 a month. FDA records indicate no further disciplinary action was taken. Teva, the maker of Ajovy, did not respond to requests for comment.Similarly, when FDA inspectors visited a contract manufacturing facility in Indiana used to make Revcovi, which treats an autoimmune disease, they noted that a redacted drug lot had failed a sterility test because the vials tested positive for a bacterium called Delftia acidovorans, which can be detrimental even in people with healthy immune systems, studies show. But the drug-filling machine stayed in use after the contaminant was discovered, the FDA determined. Inspectors recommended withholding approval.The drug was approved in October 2018 even after another inspection turned up problems, with a list price of $95,000 to $189,000 per month for an average patient, according to health care data firm Connecture.Revcovi’s manufacturer, Leadiant Biosciences, said through an outside public relations firm that its contract manufacturer’s written responses to the FDA observations were considered “adequate” by two FDA offices, adding, “We do not have any more information to share with you at this time as pharmaceutical manufacturing processes are confidential.”Problems with drugs can take years to discover ― and then only after patients are injured. So, many health researchers say, more caution is warranted.“They’re doing so few of these [FDA] inspections pre-market,” said Diana Zuckerman, president of the nonprofit National Center for Health Research. “The least they can do is listen to the ones they’re doing.”This story was originally published at Kaiser Health News on November 5, 2019
In the lead-up to the 2020 elections, the Journalist’s Resource team is combing through the Democratic presidential candidates’ platforms and reporting what the research says about their policy proposals. We want to encourage deep coverage of these proposals — and to do our part to help deter horse race journalism, which research suggests can lead to inaccurate reporting and an uninformed electorate. Our criteria for the proposals we’re covering is simple: We’re focusing on proposals that have a reasonable chance of becoming policy, and for us that means at least 3 of the 5 top-polling candidates say they intend to tackle the issue. Here we look at candidates’ proposals to address the opioid epidemic. Candidates are divided in their approaches; while nearly all favor increasing funding for and access to treatment for opioid use disorder, fewer candidates support harm reduction policy interventions, such as safe injection sites and needle exchanges. A few candidates incorporate broader criminal justice-level changes or physician-level interventions into their policy proposals.Candidates favoring increased funding for and access to treatmentMichael Bennet, Joe Biden, Cory Booker*, Pete Buttigieg, John Delaney, Amy Klobuchar, Bernie Sanders, Tom Steyer, Elizabeth Warren, Marianne Williamson*, Andrew YangCandidates favoring harm reduction interventionsMichael Bennet, Cory Booker, Pete Buttigieg, Amy Klobuchar, Bernie Sanders, Elizabeth WarrenCandidates favoring action against pharmaceutical companiesMichael Bennet, Cory Booker, Pete Buttigieg, John Delaney, Tulsi Gabbard,  Amy Klobuchar, Bernie Sanders, Elizabeth Warren, Andrew YangCandidates favoring interventions that target physician prescribing behaviorJohn Delaney, Amy Klobuchar, Andrew YangCandidates favoring decriminalization of possession of opioidsPete Buttigieg, Andrew YangWhat the research saysAccess to treatment: Medication-assisted treatment is an evidence-based treatment for opioid use disorder; it has been shown to reduce the risk of overdose death for people who use opioids. Methadone, buprenorphine and naltrexone are types of medication-assisted therapy for opioid use disorder. These medications reduce symptoms of craving and withdrawal. A systematic review and meta-analysis of medication-assisted treatment find that people receiving such treatment were less likely to die of an overdose or other causes than their peers with opioid use disorder who did not receive medication-assisted treatment.Harm reduction: Harm reduction initiatives attempt to reduce the risks associated with using drugs. Such initiatives include needle exchange programs, widespread distribution of the opioid overdose antidote naloxone and supervised injection facilities. Supervised injection facilities, also known as safe injection sites or supervised consumption facilities, are not legal in the U.S. They exist legally in other countries, such as Canada and Australia, however.Several studies have demonstrated a positive link between safe injection site use and entry into treatment. Safe injection sites also provide benefits to people who use drugs in the form of sterilized equipment and supervision to mitigate the dangers of overdose.Over a dozen studies have linked needle exchanges with lower rates of hepatitis C and HIV infection among people who inject drugs.A systematic review of research on take-home naloxone programs, which provide people at risk of opioid overdose with kits including the antidote, concludes that “there is overwhelming support of take-home naloxone programs being effective in preventing fatal opioid overdoses.”The pharmaceutical industry: Big Pharma’s role in marketing opioids spurred physicians to prescribe more opioids, research shows. This, in turn, fueled the opioid epidemic the country faces today. Policies targeted toward Big Pharma include proposals to hold industry players liable for their role in the opioid epidemic with criminal penalties and fines.Decriminalization: The rationale behind decriminalization of the personal use of narcotics is that criminal penalties essentially criminalize substance use disorder. Proponents of decriminalization argue that such drug use should, instead, be met with evidence-based treatment. There is not much research on the effects of decriminalization because it’s rare. However, in 2001, Portugal decriminalized personal acquisition, possession and use of illicit drugs. Research indicates that drug-related deaths have fallen since the southwestern European country decriminalized illicit drugs.Physician-level interventions: These interventions target prescriber behavior. Examples include physician education programs, guidelines or restrictions on the quantity of opioids physicians can prescribe, and prescription monitoring programs that allow physicians to view patients’ prescription history to avoid overprescribing or illegitimate prescribing. While education and prescribing policies have curtailed prescribing habits, prescription monitoring programs have been less successful, studies indicate.Key contextIn late 2017, the U.S. Department of Health and Human Services declared the nation’s opioid crisis a “public health emergency.” The problem has been building for over a decade, spurred by sharp increases in prescriptions for opioids, commonly used to treat both short-term and chronic pain.About 233.7 million opioid prescriptions were filled each year, on average, from 2006 to 2017, according to a March 2019 study in JAMA Network Open that looks at opioid prescriptions filled in retail pharmacies across the U.S.Prescription painkillers have a high risk of abuse -- across the academic literature, rates of misuse among patients taking opioids for chronic non-cancer pain average between 21% and 29%. Research indicates that as of 2013, more than 2 million people in the U.S. had prescription opioid-related opioid use disorder.Prescription opioids can also pave the way for illegal drugs like heroin. Eighty percent of people who have used heroin have previously misused prescription opioids, according to an August 2013 analysis of national survey data collected from 2002 to 2011.As opioid use and misuse has increased, deaths linked to the drugs have increased. In 2017, opioids were involved in 47,600 drug overdose deaths, accounting for nearly 70% of all overdose deaths nationwide that year.Recent researchAccess to treatment:A review of randomized controlled trials comparing medication-assisted treatment of opioid use disorder to placebo or no medication finds that medication-assisted treatment “at least doubles rates of opioid-abstinence outcomes.”A study of 151,983 adults in England treated for opioid dependence between 2005 and 2009 finds that the risk of fatal drug overdose more than doubled for individuals who received only psychotherapy compared with those who received medication-assisted treatment.Harm Reduction:Two reviews -- one published in Drug and Alcohol Dependence in 2014, and one published in Current HIV/AIDS Reports in 2017 -- indicate that supervised consumption facilities promote help people access treatment. The more recent review looks at 47 studies published between 2003 and 2017 on supervised drug consumption facilities. The authors find a handful of studies that demonstrate a positive link between safe injection site use and starting treatment.One of these studies compared enrollment in detoxification programs among those who used Vancouver’s supervised injection facility the year before and after it opened in 2003. Researchers find the facility’s opening was linked to a 30% increase in detox program use, which, in turn, was linked to pursuing long-term treatment and injecting at the facility less often. A later study of the injection facility focused on use of detox services located at the facility. It finds that 11.2% (147 people) used these services at least once over the two years studied. The authors conclude that supervised injection facilities might serve as a “point of access to detoxification services.”A 2006 study of 871 people who injected drugs finds no substantial increase in rates of relapse among former users before and after the Vancouver site opened. However, the researchers also find no substantial decrease in the rate of stopping drug use among current users before and after the site opened. Another study of 1,065 people at this facility published in 2007 finds that only one individual performed his or her first injection at the site.Though supervised injection sites are illegal in the U.S., one opened underground in 2014. Researchers interviewed those who used the underground site during its first two years of operation and their findings were published in 2017 in the American Journal of Preventive Medicine. The site’s users were asked the same set of questions about their use patterns every time they injected drugs at the site. The authors conclude that the site offered several benefits, including safe disposal of equipment, unrushed injections and immediate medical response to overdoses. The authors add that if the site were sanctioned, it might be able to offer additional benefits, including health care and other services.Big Pharma:Research suggests that physicians targeted with marketing from pharmaceutical companies prescribe opioids at higher rates than doctors not exposed to their marketing.Several studies use data from the Centers for Medicare and Medicaid Services’ Open Payments database, which tracks payments made by drug and medical device companies to physicians. That information is used to analyze how relationships between physicians and drug companies are linked to prescriptions written.These studies define opioid-related payments as cash payments -- for example, speaking fees associated with promoting a drug -- and payments-in-kind -- free meals pharmaceutical representatives provide to doctors’ offices, for instance. These studies find that physicians who receive opioid-related payments tend to prescribe more opioids.A study in PLoS One from December 2018 looks at physicians who received opioid-related payments, some in 2014 and some in 2015, compared with doctors who never received such payments. The authors find that physicians who received opioid-related payments had a larger increase in the number of daily doses of opioids dispensed, as well as in total opioid expenditures, prescribing pricier opioids per dose.Another study looking at the same data offers further detail. The study, published in Addiction in June 2019, focuses on 865,347 physicians across the country who filled prescriptions for Medicare patients from 2014 to 2016. “Prescribers who received opioid-specific payments prescribed 8,784 opioid daily doses per year more than their peers who did not receive any such payments,” the authors write.Other research geographically links opioid marketing and opioid-related overdose mortality. The paper, published in JAMA Network Open in January 2019, analyzes county-level prescription opioid overdose deaths and county-level opioid marketing payments.The authors find that deaths from prescription opioid overdoses increased with each standard deviation increase in opioid marketing as measured by dollars spent per capita, number of payments to physicians per capita and number of physicians receiving payments per capita. Standard deviation indicates the variation of a given value from the average. “Opioid prescribing rates also increased with marketing,” the authors write. They note that the higher prescription rate might be why overdose deaths increased.Physician-level interventions:An August 2018 study published in Science highlights the role physician education might play in addressing the nation’s opioid crisis. The intervention was simple: When a patient died of an opioid overdose, the county medical examiner sent the prescribing physicians a letter notifying them. The authors conducted a randomized trial of 861 physicians whose patients overdosed. The intervention group received the letter, which included a safe prescribing warning consisting of these recommendations:Avoid co-prescribing an opioid and a benzodiazepine.Minimize opioid prescribing for acute pain.Taper long-term users off opioids.Avoid prescriptions lasting for three consecutive months or longer and prescribe naloxone, an opioid overdose antidote.The control group received no communication.Physicians in the intervention group cut their opioid prescribing by 9.7% -- as measured by milligram morphine equivalents in prescriptions filled -- in the three months after the letter was sent. These physicians also started fewer patients on opioids and wrote fewer high-dose prescriptions than the control group.Prescribing policies and guidelines also have successfully curbed physicians’ distribution of opioids.In October 2017, the Michigan Opioid Prescribing Engagement Network released opioid prescribing guidelines for nine surgical procedures to clinicians participating in the Michigan Surgical Quality Collaborative, a statewide initiative to improve surgical care.Researchers compared opioid prescribing before and after these guidelines were released, analyzing data from 11,716 patients across 43 hospitals collected from February 2017 to May 2018. They find that prescriptions declined, on average, from 26 pills to 18 pills per month after the guidelines were released.Patients also took fewer of the pills they were prescribed. As measured by patient-reported survey data, opioid consumption following surgery dropped from 12 pills to nine, “possibly as a result of patients anchoring and adjusting their expectations for opioid use to smaller prescriptions,” explain the authors of the August 2019 New England Journal of Medicine study. Although patients received smaller prescriptions and used fewer pills after the guidelines were published, there were no substantial changes in the patients’ satisfaction and pain scores.Similar to the study of Michigan’s opioid prescribing guidelines is a February 2018 study in the American Journal of Emergency Medicine that tracks the effects of an emergency department opioid prescribing policy. The policy resulted in declines in opioid prescriptions. Compared with the control emergency department, the two intervention hospitals had a more pronounced decline in opioid prescribing. The authors conclude that emergency department-based policies might help reduce opioid prescribing.Prescription drug monitoring programs, which allow physicians to view patients’ prescription history to avoid overprescribing or prescribing opioids to people who don’t actually need them, have been shown to be less effective. A January 2018 study of national data published in Addictive Behaviors finds that there were not statistically significant differences in the likelihood that physicians would prescribe opioids for chronic pain when comparing states with prescription drug monitoring programs with those without.Further readingGeneral overviewModeling Health Benefits and Harms of Public Policy Responses to the US Opioid EpidemicAllison L. Pitt, Keith Humphreys and Margaret L. Brandeau. American Journal of Public Health, October 2019.The gist: “Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation.”Safe injection sitesAttendance at Supervised Injecting Facilities and Use of Detoxification ServicesEvan Wood, Mark W. Tyndall, Ruth Zhang, Jo-Anne Stoltz, Calvin Lai, Julio S.G. Montaner and Thomas Kerr. New England Journal of Medicine, June 2006.The gist: A study of Vancouver’s supervised injection facility finds “an average of at least weekly use of the supervised injecting facility and any contact with the facility’s addictions counselor were both independently associated with more rapid entry into a detoxification program.”Injection Drug Use Cessation and Use of North America's First Medically Supervised Safer Injecting FacilityKora DeBeck, Thomas Kerr, Lorna Bird, Ruth Zhang, David Marsh, Mark Tyndall, Julio Montaner and Evan Wood. Drug and Alcohol Dependence, January 2011.The gist: “These data indicate a potential role of SIF [supervised injecting facilities] in promoting increased uptake of addiction treatment and subsequent injection cessation.”"A Little Heaven in Hell": The Role of a Supervised Injection Facility in Transforming PlaceEhsan Jozaghi. Urban Geography, May 2013.The gist: “Participants' narratives indicate that attending InSite [Vancouver’s supervised injection facility] has had numerous positive effects in their lives, including changes in sharing behavior, improving health, establishing social support and saving their lives.”Process and Predictors of Drug Treatment Referral and Referral Uptake at the Sydney Medically Supervised Injecting CentreJo Kimber, Richard P. Mattick, John Kaldor, Ingrid Van Beek, Stuart Gilmour and Jake A. Rance. Drug and Alcohol Review, May 2009.The gist: Researchers conducted 1.5-year study at a supervised injection site in Sydney. They find that 16% of clients at the site referred to treatment by health and social welfare professionals went on to receive it, leading the authors to conclude that the center “engaged injecting drug users successfully in drug treatment referral and this was associated with presentation for drug treatment assessment and other health and psychosocial services.”Inability to Access Addiction Treatment and Risk of HIV Infection Among Injection Drug Users Recruited from a Supervised Injection FacilityM.-J.S. Milloy, Thomas Kerr, Ruth Zhang, Mark Tyndall, Julio Montaner and Evan Wood. Journal of Public Health, September 2012.The gist: Many who use supervised injection facilities have the desire to access treatment. This study surveyed 889 people who were randomly selected to be surveyed at Vancouver’s supervised injection facility. “At each interview, ∼20 percent of respondents reported trying but being unable to access any type of drug or alcohol treatment in the previous 6 months,” the authors write. The main barrier to access, respondents said, was waiting lists for treatment.Big PharmaThe Promotion and Marketing of OxyContin: Commercial Triumph, Public Health TragedyArt Van Zee. American Journal of Public Health, February 2009.The gist: In the first six years it was on the market, Purdue Pharma spent about six to 12 times more to promote OxyContin than it had to promote another long-lasting opioid. The paper describes various marketing strategies including promotional giveaways and Pharma-funded medical education programs.Industry Payments to Physicians for Opioid Products, 2013-2015Scott E. Hadland, Maxwell S. Krieger and Brandon D. L. Marshall. American Journal of Public Health, September 2017.The gist: This study examines payments pharmaceutical companies make to physicians to market opioid products. The authors find that 375,266 opioid-related payments that weren’t related to research work were made to 68,177 physicians over the study period. The authors estimate that about 1 in 12 physicians in the U.S. received a payment from a pharmaceutical company to promote their opioid medications during the 29-month study period. The bulk of the money went toward speaking fees or honoraria, but the most common expense was food and beverages – 352,298 payments totaling $7,872,581.Association of Pharmaceutical Industry Marketing of Opioid Products to Physicians with Subsequent Opioid PrescribingScott E. Hadland, Magdalena Cerdá, Yu Li, Maxwell S. Krieger and Brandon D. L. Marshall. JAMA Internal Medicine, June 2018.The gist: “Whereas physicians receiving no opioid-related payments had fewer opioid claims in 2015 than in 2014, physicians receiving such payments had more opioid claims,” the authors write.Physician-level interventionsDifferences in Opioid Prescribing Practices among Plastic Surgery Trainees in the United States and CanadaDavid W. Grant, Hollie A. Power, Linh N. Vuong, Colin W. McInnes, Katherine B. Santosa, Jennifer F. Waljee and Susan E. Mackinnon. Plastic and Reconstructive Surgery, July 2019.The gist: Plastic surgery trainees were asked about their opioid prescribing education, factors contributing to their prescribing practices and what they would prescribe for eight different procedures. The authors find that, of the 162 respondents, 25% of U.S. plastic surgery trainees received opioid-prescriber education, compared with 53% of Canadian trainees. For all but one of the eight procedures, U.S. physicians prescribed significantly more morphine milligram equivalents than their Canadian counterparts.Source listCaleb Alexander, professor and co-director of the Center for Drug Safety and Effectiveness. Johns Hopkins University.Michael L. Barnett, assistant professor. Harvard T.H. Chan School of Public Health.Chinazo Cunningham, professor. Albert Einstein College of Medicine.Scott Hadland, assistant professor. Boston University School of Medicine.David N. Juurlink, scientist. Sunnybrook Research Institute.Thomas Kerr, associate professor. The University of British Columbia. For more, check out JR’s long read on the opioid prescribing problem, our summary of research on where opioids are prescribed the most and our tip sheet for reporting on fentanyl and synthetic opioids.This piece adheres to suggestions offered by the National Institute on Drug Abuse’s media guide, which recommends language that avoids the potentially stigmatizing term “addict” in the context of substance use. It states: “In the past, people who used drugs were called ‘addicts.’ Current appropriate terms are people who use drugs and drug users.”*Dropped out of race since publication date.This article first appeared on Journalist's Resource on December 9, 2019 and is republished here under a Creative Commons license.
New draft alcohol guidelines, released today, recommend healthy Australian women and men drink no more than ten standard drinks a week and no more than four on any one day to reduce their risk of health problems.This is a change from the previous guidelines, released in 2009, that recommended no more than two standard drinks a day (equating to up to 14 a week).(If you’re unsure what a standard drink looks like, use this handy reference.)The guidelines also note that for some people – including teens and women who are pregnant or breastfeeding – not drinking is the safest option.Read more: Drink, drank, drunk: what happens when we drink alcohol in four short videos What Are the New Recommendations Based On?The National Health and Medical Research Council looked at the latest research and did some mathematical modelling to come to these recommendations.It found the risk of dying from an alcohol-related disease or injury is about one in 100 if you drink no more than ten standard drinks a week and no more than four on any one day.So, for every 100 people who stay under these limits, one will die from an alcohol-related disease or injury.This is considered an “acceptable risk”, given drinking alcohol is common and it’s unlikely people will stop drinking altogether. The draft guidelines take into account that, on average, Australian adults have a drink three times a week.Why Did the Guidelines Need Updating?Recent research has shown there is a clear link between drinking alcohol and a number of health conditions. These include at least seven cancers (liver, oral cavity, pharyngeal, laryngeal, oesophageal, colorectal, liver and breast cancer in women); diabetes; liver disease; brain impairment; mental health problems; and being overweight or obese.Some previous research suggested low levels of alcohol might be good for you, but we now know these studies were flawed. Better quality studies have found alcohol does not offer health benefits.Read more: Health check: is moderate drinking good for me? The new guidelines are easier to follow than the previous guidelines, which gave recommendations to reduce both short-term harms and longer-term health problems. But some people found these confusing.Although most Australians drink within the previously recommended limits, one study found one in five adults drank more than the guidelines suggested and almost half could not correctly identify recommended limits.Although women tend to be more affected by alcohol than men, at the rates of consumption recommended in the guidelines, there is little difference in long term health effects so the guidelines apply to both men and women.The recommended limits are aimed at healthy men and women, because some people are at higher risks of problems at lower levels of consumption. These include older people, young people, those with a family history of alcohol problems, people who use other drugs at the same time (including illicit drugs and prescribed medication), and those with physical or mental health problems.The guidelines are currently in draft form, with a public consultation running until February 24.After that, there will be an expert review of the guidelines and the final guidelines will be released later in 2020. There may be changes to the way the information is presented but the recommended limits are unlikely to change substantially, given they’re based on very careful and detailed analysis of the evidence.What’s the Risk for People Under 18?The draft guidelines recommend children and young people under 18 years drink no alcohol, to reduce the risk of injury and other health harms.The good news is most teenagers don’t drink alcohol. Among 12 to 17 year olds, only 20% have had a drink in the past year and 1.4% drink weekly. The number of teenagers who have never had a drink has increased significantly in the last decade, and young people are having their first drink later.Read more: Three ways to help your teenage kids develop a healthier relationship with alcohol However, we know teenagers are more affected by alcohol than adults. This includes effects on their developing brain. We also know the earlier someone starts drinking, the more likely they will experience problems, including dependence.The idea that if you give teenagers small sips of alcohol it will reduce risk of problems later has now been debunked. Teens that have been given even small amounts of alcohol early are more likely to have problems later.What’s the Risk for Pregnant and Breastfeeding Women?The guidelines recommend women who are pregnant, thinking about becoming pregnant or breastfeeding not drink any alcohol, for the safety of their baby.Read more: Health Check: what are the risks of drinking before you know you're pregnant? We now have a much clearer understanding of the impacts of alcohol on the developing foetus. Foetal alcohol spectrum disorder (FASD) is a direct result of foetal exposure to alcohol in the womb. Around one in 67 women who drink while pregnant will deliver a baby with foetal alcohol spectrum disorder.Foetal alcohol spectrum disorder is characterised by a range of physical, mental, behavioural, and learning disabilities ranging from mild to severe – and is incurable.Worried About Your Own or Someone Else’s Drinking?If you enjoy a drink, stick within these recommended maximums to limit the health risks of alcohol.If you have trouble sticking to these limits, or you are worried about your own or someone else’s drinking, call the National Alcohol and other Drug Hotline on 1800 250 015 to talk through options or check out these resources online.Read more: Did you look forward to last night's bottle of wine a bit too much? Ladies, you're not alone Nicole Lee, Professor at the National Drug Research Institute (Melbourne), Curtin UniversityThis article is republished from The Conversation under a Creative Commons license. Read the original article.
In recovery circles, there is a lot of focus on treatment. Admitting you have a drug or alcohol problem and being willing to seek treatment is a massive step on the journey toward health. Finding the right treatment center that can meet your individual needs can help you create a solid foundation for recovery. Still, the 30, 60 or even 90 days that you spend in treatment are just a drop in the bucket compared to the rest of your life. To really succeed in sobriety, you need to focus on recovery after treatment. Whether you’ve recently finished treatment or are floundering a bit in early recovery, having a plan for recovery after treatment can help you get on the right track. Here’s what you can do to protect your sobriety after treatment ends. Have Realistic ExpectationsIt would be wonderful if people could go to treatment for a set amount of time and emerge entirely cured from their substance use disorder. Unfortunately, that’s not realistic. The past traumas, underlying mental health issues and other factors that contributed to your substance abuse are still with you, even in recovery. The key difference is that you’re now able to deal with them in healthier ways. You can talk to professionals, go to a meeting, meditate or exercise when you’re overwhelmed, rather than using. Still, you have to accept that sometimes you’re not going to feel great. Life can still be challenging even in recovery, so be prepared for there to be bumps in the road, no matter how transformational your treatment experience was. Utilize Step-down Programs and Transitional HousingMany people who go through treatment had their lives interrupted by their addiction. You might have experienced job loss, homelessness or credit challenges. Some people never learned to cope with the challenges of adult life without turning to drugs and alcohol. No matter what, reentering the “real world” after treatment can be daunting. That’s where step-down programs and transitional housing can help. If you went to an inpatient treatment program, it can be shocking to go from a structured environment to being on your own. To ease that transition, “step down” through treatment options, including outpatient and evening programs. Consider living in transitional housing, where you can pursue a job or education while still having some structure and accountability. Grow Your Sober CommunityAfter you leave treatment, you might feel a bit lonely. Many of the people that you spent time with during active addiction aren’t safe to be around now that you’re building a sober life. Your friends who didn’t experience addiction might still be hurt by your past actions, or cautious in reestablishing their relationship with you. Your new sober community can help fill the gaps. Attend meetings, go to alumni events at your treatment center, and make friends with others at your sober living. Although putting yourself out there can be scary, the benefits of having sober friends invested in your success are well worth it. Focus On The Long TermWhen you’re in treatment, your attention is on the next 30 days. However, to stay sober over a lifetime you have to focus on the big picture, one day at a time. You might experience days where you’re coping with cravings. You’ll likely have frustrations that your life isn’t coming together as quickly as you would like. By staying focused on your long-term goal of surviving and thriving in recovery, you can better handle the ups and downs of early recovery. Staying sober is a lifelong commitment. During early recovery, you can set the foundation for that, by building your community, establishing healthy habits, and learning which practices are most helpful for you. You’ll learn to recognize triggers and how to avoid them. And you will realize the importance of reaching out for help. Over time, all of this will strengthen your sobriety and help you live the life that you want live, without drugs or alcohol. Learn more about Oceanside Malibu at http://oceansidemalibu.com/. Reach Oceanside Malibu by phone at (866) 738-6550. Find Oceanside Malibu on Facebook.
A recent study showed that North Americans are becoming less tolerant of uncertainty.The U.S. presidential impeachment inquiry has added another layer of uncertainty to an already unstable situation that includes political polarization and the effects of climate change.As a clinical psychologist in the Washington, D.C. area, I hear people report being stressed, anxious, worried, depressed and angry. Indeed, an American Psychological Association 2017 survey found that 63% of Americans were stressed by “the future of our nation,” and 57% by the “current political climate.”Humans dislike uncertainty in most situations, but some deal with it better than others. Numerous studies link high intolerance of uncertainty to anxiety and anxiety disorders, obsessive-compulsive disorder, depression, PTSD and eating disorders.While no one person can reduce the uncertainty of the current political situation, you can learn to decrease intolerance of uncertainty by implementing these scientifically sound strategies.1. Commit to Gradually Facing UncertaintyEven though humans encounter uncertain situations every day, we often avoid feeling the discomfort of facing the uncertainty.When unsure how to best proceed with a work assignment, you might either immediately seek help, over-research or procrastinate. As you prepare for the day, uncertainty about the weather or traffic is quickly short-circuited by checking a phone. Similarly, inquiries about family or friends’ whereabouts or emotions can be instantly gratified by texting or checking social media.All this avoidance of uncertainty leads to relief in the short run, but lessens your ability to tolerate anything short of complete certainty in the long run.Tolerance for uncertainty is like a muscle that weakens if not used. So, work that muscle next time you face uncertainty.Start gradually: Resist the urge to reflexively check your GPS the next time you are lost and aren’t pressured for time. Or go to a concert without Googling the band beforehand. Next, try to sit with the feelings of uncertainty for a while before you pepper your teenager with texts when he is running late. Over time, the discomfort will diminish.2. Connect to a Bigger PurposeRita Levi-Montalcini was a promising young Jewish scientist when fascists came to power in Italy and she had to go into hiding. As World War II was raging, she set up a secret lab in her parents’ bedroom, studying cell growth. She would later say that the meaning that she derived from her work helped her to deal with the evil outside and with the ultimate uncertainty of whether she would be discovered.What gives your life meaning? Finding or rediscovering your life purpose can help you deal with uncertainty and the stress and anxiety related to it.Focusing on what can transcend finite human existence – whether it is religion, spirituality or dedication to a cause – can decrease uncertainty-driven worry and depression.3. Don’t Underestimate Your Coping AbilityYou might hate uncertainty because you fear how you would fare if things went badly. And you might distrust your ability to cope with the negative events that life throws your way.Most people overestimate how bad they will feel when something bad happens. They also tend to underestimate their coping abilities.It turns out that humans are generally resilient, even in the face of very stressful or traumatic events. If a feared outcome materializes, chances are you will deal with it better than you could now imagine. Remember that the next time uncertainty rears its head.4. Bolster Resilience by Increasing Self-CareYou have probably heard it many times by now: Sleep well, exercise and prioritize social connections if you want to have a long and happy life.What you might not know is that the quantity and quality of sleep is also related to your ability to deal with uncertainty. Exercise, especially of the cardio variety, can increase your capacity to cope with uncertain situations and lower your stress, anxiety and depression. A new review study suggests that regular exercise may even be able to prevent the onset of anxiety and anxiety disorders.Possibly the best tool for coping with uncertainty is making sure that you have an active and meaningful social life. Loneliness fundamentally undermines a person’s sense of safety and makes it very hard to deal with the unpredictable nature of life.Having even a few close family members or friends imparts a feeling that “we are in this all together,” which can protect you from psychological and physical problems.5. Appreciate That Absolute Certainty Is ImpossibleNothing is certain in life. The sooner you start thinking about that fact, the easier it will be to face it.Moreover, repeated attempts at predicting and controlling everything in life can backfire, leading to psychological problems like OCD.In spite of civilization’s great progress, the fantasy of humankind’s absolute control over its environment and fate is still just that – a fantasy. So, I say to embrace the reality of uncertainty and enjoy the ride.[ You’re smart and curious about the world. So are The Conversation’s authors and editors. You can read us daily by subscribing to our newsletter. ]Jelena Kecmanovic, Adjunct Professor of Psychology, Georgetown UniversityThis article is republished from The Conversation under a Creative Commons license. Read the original article.
About ten years ago, I got one of those letters. It was painful to read it but once I had a drink, my pain turned into indignation. I folded the letter multiple times till it ended up a tiny square, which I shoved into a shoebox where it lives till this day, next to old birthday cards and love notes from exes. I’m talking about my first Intervention Letter. If you’ve never gotten one of these, then you were probably not destroying your family’s life successfully enough! I’m kidding, of course, and not everyone gets an Intervention Letter; some of us also get a serious talking-to; most of us get ultimatums and threats; and all of us get tears. This is what it’s like to have a family while high or drunk. Not fun. But it’s even less fun for the families—they are some of the most tortured, miserable, angry, confused people entangled in their misery by love. It’s no wonder that resentment is ever-present, fuelling many misguided attempts to help circumvent addiction. Why misguided? Because those attempts rarely get anyone better. And a person going to a rehab to please their loved ones has less of a chance of staying clean than a person going on her own account. On top of it, the families are still often left without any solid tactics in place on how to keep their loved one sober, how to prevent relapses, and how not to fall back into the muck of co-dependency. There are programs designed to help families but many of them advocate “tough love” and aren’t terribly effective. So Intervention Letters and ultimatums are common. Instead of Ultimatums and Threats, CompassionFortunately, there might be a better way—specifically the CRAFT way. According to one definition, “Community Reinforcement and Family Training (CRAFT) teaches family and friends effective strategies for helping their loved one to change and for feeling better themselves. CRAFT works to affect the loved one’s behavior by changing the way the family interacts with him or her.” At first look, CRAFT’s techniques might appear contra-intuitive as a lot of its teachings seem to advocate dismissing the addictive behavior—complaining, arguments and demands are discouraged. In fact, on the cover of the popular book on CRAFT, Get Your Loved One Sober, the tagline reads “Alternatives to Nagging, Pleading, and Threatening.” Instead of tough love, CRAFT advocates gentle love—and that approach seems to be working.According to one trial by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), CRAFT was more effective than Al-Anon and Johnson Institute Intervention. CRAFT had a 64 percent success rate of getting the person with addiction into treatment compared to 30 percent for Johnston Institute and 10 percent for Al-Anon. Johnson Institute is a model that’s based on confrontation that is supposed to motivate the person with addiction to enter treatment. Al-Anon, similar to CRAFT, teaches detachment with love, but it is also a 12-step-based program which includes the sometimes-problematic concept of Higher Power and advocates a certain kind of passivity, which might not be conductive to strengthening the very fragile fabric of families dealing with active addiction. In contrast, CRAFT focuses on attending to your own needs along with steering the problem user toward treatment, which often happens organically as the patterns of interaction change. CRAFT’s mission is to help reduce the loved one’s alcohol and drug use, whether or not the loved one has engaged in treatment yet. CRAFT discourages enabling, encourages problem solving, employs reward systems and aims to empower the beaten-down, frustrated family members. CRAFT doesn’t approve of breaking the family apart and its goal is to not only keep it all intact but also get everyone better. A family member who’s part of CRAFT is taught to change her/ his reactions—from negative to positive—in response to the triggers from the person with addiction. For example, a husband coming home late after a night of drinking with his buddies again won’t get a lecture for being late for dinner, as he usually does in that situation, because the wife will have been instructed to take care of her own needs, and she will have eaten the dinner on her own. Observing and AdaptingAs part of CRAFT, the family members are asked to observe and monitor the addictive behavior of their loved one—this means noting what situations might cause the person to reach for another drink, what creates conflict, and observing any patterns in behavior. With time, as these patterns become obvious, the family member changes the approach—from aggressive to more passive and compassionate—and in that more loving way, upsets the predictable trajectory of maladaptive interactions with the addicted person. Instead of yelling at someone and accusing her of being a liar, the family member might say, “I know you haven’t been going to work all this time and I am hurt that you’re lying to me. Let’s talk about it in the morning after you sleep it off.” A calm, reasonable way of dealing with the situation will most likely elicit a reaction that’s not combative. Eventually those kinds of interactions will become a norm and change will occur.It’s not exactly “kill them with kindness” but it’s a similar principle. When you expect Intervention Letters—like I did—and you’re stuck in a hamster wheel of constant conflict, getting something completely opposite might just shock you into action. Receiving praise for sticking to commitments—even something as small as coming home on time—or staying sober for a string of days, is more effective than having those subtle changes ignored or taken for granted. No, we don’t need to applaud every nice thing a person with addiction does but in the beginning, perhaps it makes sense to do so. People who are just starting to get sober are very much like babies—deregulated emotions, lack of impulse control—and praise goes a longer way than punishment does. Punishment tends to prolong trauma where praise leaves the person wanting to earn it again, which leads to repeating the desirable action. A Better Alternative to Tough LoveMy family has always taken the “tough love” route and my addiction did contribute to me eventually separating from my husband. I imagine if we were a part of CRAFT program, things could’ve gone differently. I lived through ultimatums and anger and once I was kicked out of my house. I’ve often felt alone and ashamed and angry with myself for disappointing everyone. I thought I was worthless and my loved ones’ attitude confirmed that. But I don’t think they knew any better. So many of us with addiction still live in an episode of Intervention; we have never been shown a kinder, better way. 
8.30.2019On March 30, 1981, 25-year-old John W. Hinckley Jr. shot President Ronald Reagan and three other people. The following year, he went on trial for his crimes.Defense attorneys argued that Hinckley was insane, and they pointed to a trove of evidence to back their claim. Their client had a history of behavioral problems. He was obsessed with the actress Jodie Foster, and devised a plan to assassinate a president to impress her. He hounded Jimmy Carter. Then he targeted Reagan.In a controversial courtroom twist, Hinckley’s defense team also introduced scientific evidence: a computerized axial tomography (CAT) scan that suggested their client had a “shrunken,” or atrophied, brain. Initially, the judge didn’t want to allow it. The scan didn’t prove that Hinckley had schizophrenia, experts said — but this sort of brain atrophy was more common among schizophrenics than among the general population.It helped convince the jury to find Hinckley not responsible by reason of insanity.Nearly 40 years later, the neuroscience that influenced Hinckley’s trial has advanced by leaps and bounds — particularly because of improvements in magnetic resonance imaging (MRI) and the invention of functional magnetic resonance imaging (fMRI), which lets scientists look at blood flows and oxygenation in the brain without hurting it. Today neuroscientists can see what happens in the brain when a subject recognizes a loved one, experiences failure, or feels pain.Despite this explosion in neuroscience knowledge, and notwithstanding Hinckley’s successful defense, “neurolaw” hasn’t had a tremendous impact on the courts — yet. But it is coming. Attorneys working civil cases introduce brain imaging ever more routinely to argue that a client has or has not been injured. Criminal attorneys, too, sometimes argue that a brain condition mitigates a client’s responsibility. Lawyers and judges are participating in continuing education programs to learn about brain anatomy and what MRIs and EEGs and all those other brain tests actually show.Most of these lawyers and judges want to know such things as whether brain imaging could establish a defendant’s mental age, supply more dependable lie-detection tests or reveal conclusively when someone is experiencing pain and when they are malingering (which would help resolve personal injury cases). Neuroscience researchers aren’t there yet, but they are working hard to unearth correlations that might help — looking to see which parts of the brain engage in a host of situations.Progress has been incremental but steady. Though neuroscience in the courts remains rare, “we’re seeing way more of it in the courts than we used to,” says Judge Morris B. Hoffman, of Colorado’s 2nd Judicial District Court. “And I think that’s going to continue.”A Mounting Count of CasesCriminal law has looked to the human mind and mental states since the seventeenth century, says legal scholar Deborah Denno of Fordham University School of Law. In earlier centuries, courts blamed aberrant behavior on “the devil” — and only later, starting in the early twentieth century, did they begin recognizing cognitive deficits and psychological diagnoses made through Freudian analysis and other approaches.Neuroscience represents a tantalizing next step: evidence directly concerned with the physical state of the brain and its quantifiable functions.There is no systematic count of all the cases, civil and criminal, in which neuroscientific evidence such as brain scans has been introduced. It’s almost certainly most common in civil cases, says Kent Kiehl, a neuroscientist at the University of New Mexico and a principal investigator at the nonprofit Mind Research Network, which focuses on applying neuroimaging to the study of mental illness. In civil proceedings, says Kiehl, who frequently consults with attorneys to help them understand neuroimaging science, MRIs are common if there’s a question of brain injury, and a significant judgment at stake.In criminal courts, MRIs are most often used to assess brain injury or trauma in capital cases (eligible for the death penalty) “to ensure that there’s not something obviously neurologically wrong, which could alter the trajectory of the case,” Kiehl says. If a murder defendant’s brain scan reveals a tumor in the frontal lobe, for instance, or evidence of frontotemporal dementia, that could inject just enough doubt to make it hard for a court to arrive at a guilty verdict (as brain atrophy did during Hinckley’s trial). But these tests are expensive.Some scholars have tried to quantify how often neuroscience has been used in criminal cases. A 2015 analysis by Denno identified 800 neuroscience-involved criminal cases over a 20-year period. It also found increases in the use of brain evidence year over year, as did a 2016 study by Nita Farahany, a legal scholar and ethicist at Duke University.Farahany’s latest count, detailed in an article about neurolaw she coauthored in the Annual Review of Criminology, found more than 2,800 recorded legal opinions between 2005 and 2015 where criminal defendants in the US had used neuroscience — everything from medical records to neuropsychological testing to brain scans — as part of their defense. About 20 percent of defendants who presented neuroscientific evidence got some favorable outcome, be it a more generous deadline to file paperwork, a new hearing or a reversal.But even the best studies like these include only reported cases, which represent “a tiny, tiny fraction” of trials, says Owen Jones, a scholar of law and biological sciences at Vanderbilt University. (Jones also directs the MacArthur Foundation Research Network on Law and Neuroscience, which partners neuroscientists and legal scholars to do neurolaw research and help the legal system navigate the science.) Most cases, he says, result in plea agreements or settlements and never make it to trial, and there’s no feasible way to track how neuroscience is used in those instances.The Science of States of MindEven as some lawyers are already introducing neuroscience into legal proceedings, researchers are trying to help the legal system separate the wheat from the chaff, through brain-scanning experiments and legal analysis. These help to identify where and how neuroscience can and can’t be helpful. The work is incremental, but is steadily marching ahead.One MacArthur network team at Stanford, led by neuroscientist Anthony Wagner, has looked at ways to use machine learning (a form of artificial intelligence) to analyze fMRI scans to identify when someone is looking at photos they recognize as being from their own lives. Test subjects were placed in a scanner and shown a series of pictures, some collected from cameras they had been wearing around their own necks, others collected from cameras worn by others.Tracking changes in oxygenation to follow patterns in blood flow — a proxy for where neurons are firing more frequently — the team’s machine-learning algorithms correctly identified whether subjects were viewing images from their own lives, or someone else’s, more than 90 percent of the time.“It’s a proof of concept, at this stage, but in theory it’s a biomarker of recognition,” Jones says. “You could imagine that could have a lot of different legal implications” — such as one day helping to assess the accuracy and reliability of eyewitness memory.Other researchers are using fMRI to try to identify differences in the brain between a knowing state of mind and a reckless state of mind, important legal concepts that can have powerful effects on the severity of criminal sentences.To explore the question, Gideon Yaffe of the Yale Law School, neuroscientist Read Montague of Virginia Tech and colleagues used fMRI to brain-scan study participants as they considered whether to carry a suitcase through a checkpoint. All were told — with varying degrees of certainty — that the case might contain contraband. Those informed that there was 100 percent certainty that they were carrying contraband were deemed to be in a knowing state of mind; those given a lower level of certainty were classified as being in the law’s definition of a reckless state of mind. Using machine-learning algorithms to read fMRI scans, the scientists could reliably distinguish between the two states.Neuroscientists also hope to better understand the biological correlates of recidivism — Kiehl, for instance, has analyzed thousands of fMRI and structural MRI scans of inmates in high-security prisons in the US in order to tell whether the brains of people who committed or were arrested for new crimes look different than the brains of people who weren’t. Getting a sense of an offender’s likelihood of committing a new crime in the future is crucial to successful rehabilitation of prisoners, he says.Others are studying the concept of mental age. A team led by Yale and Weill Cornell Medical College neuroscientist B.J. Casey used fMRI to look at whether, in differing circumstances, young adults’ brains function more like minors’ brains or more like those of older adults — and discovered that it often depended on emotional state. Greater insight into the brain’s maturation process could have relevance for juvenile justice reform, neurolaw scholars say, and for how we treat young adults, who are in a transitional period.The Jury Is Still OutIt remains to be seen if all this research will yield actionable results. In 2018, Hoffman, who has been a leader in neurolaw research, wrote a paper discussing potential breakthroughs and dividing them into three categories: near term, long term and “never happening.” He predicted that neuroscientists are likely to improve existing tools for chronic pain detection in the near future, and in the next 10 to 50 years he believes they’ll reliably be able to detect memories and lies, and to determine brain maturity.But brain science will never gain a full understanding of addiction, he suggested, or lead courts to abandon notions of responsibility or free will (a prospect that gives many philosophers and legal scholars pause).Many realize that no matter how good neuroscientists get at teasing out the links between brain biology and human behavior, applying neuroscientific evidence to the law will always be tricky. One concern is that brain studies ordered after the fact may not shed light on a defendant’s motivations and behavior at the time a crime was committed — which is what matters in court. Another concern is that studies of how an average brain works do not always provide reliable information on how a specific individual’s brain works.“The most important question is whether the evidence is legally relevant. That is, does it help answer a precise legal question?” says Stephen J. Morse, a scholar of law and psychiatry at the University of Pennsylvania. He is in the camp who believe that neuroscience will never revolutionize the law, because “actions speak louder than images,” and that in a legal setting, “if there is a disjunct between what the neuroscience shows and what the behavior shows, you’ve got to believe the behavior.” He worries about the prospect of “neurohype,” and attorneys who overstate the scientific evidence.Some say that neuroscience won’t change the fundamental problems the law concerns itself with — “the giant questions that we’ve been asking each other for 2,000 years,” as Hoffman puts it — questions about the nature of human responsibility, or the purpose of punishment.But in day-to-day courtroom life, such big-picture, philosophical worries might not matter, Kiehl says.“If there are two or three papers that support that the evidence has a sound scientific basis, published in good journals, by reputable academics, then lawyers are going to want to use it.”10.1146/knowable-082919-1 Eryn Brown is a freelance writer and editor whose work has appeared in the Los Angeles Times, the New York Times, Nature, and other publications. Reach her at erynbrown.writer@gmail.com. This article originally appeared in Knowable Magazine, an independent journalistic endeavor from Annual Reviews. Sign up for the newsletter.
Michael Lee will always lead me back to the inextinguishable part of the self where the ones we’ve lost are alive in another form. There’s a tension here: how painful it is to dial the number of a memory instead of a person, but how precious it is to dial any love at all, to celebrate and learn from. Some people have chiseled their initials into our bones. So too have we named the scaffolds of our being after important experiences, often trials, perhaps hardships or compulsions. These are the thoughts Michael Lee’s new collection of poems awakened for me. Published by Button Poetry,The Only Worlds We Know draws on almost a decade of poem writing. Michael has a talent for thoroughly examining grief, shame, and despair until they shift from disorienting to orienting. Things have happened to us. We did things we regret. We have lost. Now it’s our duty and privilege to make meaning out of the past. If we’re doomed to see through a particular waterfall of emotion, at least we can become masters at recognizing shapes. This theory also applies to awe, which billows again and again inside The Only Worlds We Know. Audiences may be familiar with Michael from his work in the national slam poetry scene. He has a trio of performances on YouTube which average out to about 500k views each. I suspect this is due to his tendency to articulate feelings that are widely felt, something on full display in his new collection. In this interview we explore the stories within and behind The Only Worlds We Know, and the vibrant perspective of a poet who is attuned to both his perceptions and their limits. I’d love to start this interview with talking about your sobriety. You mention in your book you have a decade. What about currently?Eleven years as of September.Hell yeah, congratulations. Thanks, man. How long do you have, by the way?Three and a half years.That’s what’s up. That’s what’s up. Could you tell me about the title of your book, “The Only Worlds We Know,” and how it manifests in that first poem? A big chunk of the book was written within nine months of sending out the draft. I was on a roll. I looked at it and thought, “Okay, this book no longer centers on the death of my best friend. It’s a lot bigger than that.” So [the title] tried to capture the new direction. And I wanted to capture...well it’s like being in recovery, right? You have two options. You can either get clean or you can die. But there is also a nebulous space in your head where there are a lot of questions and wonder. The title comes from that first poem which has the line, “If the bullet were just a tool of grammar / in the language of the unspeakable, / would it not be a conjunction, / would it not be the word “and” / for doesn’t it connect us to the only two worlds we know?” The piece opens the book because it sets the stage for talking about life and death. But I dropped the word “two” because I was looking beyond life and death, at longing, nostalgia, and place, how our sense of place is shaped by longing, by death, by nostalgia. Did this new surge of work offer fresh perspective on ideas or themes you had been engaging for a while?Distance from the height of addiction, or from the height of grief does offer perspective. Poems like “Out There,” “Row,” and “Tapestry in Five Parts” were written in the last year. With “Out There,” the longer you are in recovery the more you are going to see people who aren’t able to figure it out, who go back out there. Or, recovery can happen in episodes. For a year you go to two meetings a week, you have a sponsor, but then that formula doesn’t work for you the next year. I wanted to explore some of the dark spots where you go in sobriety. One of the oldtimers in my homegroup used to say, “I don’t always miss the drink or the drug but I do miss the chaos,” and I’ve always identified with that and tried to capture it tonally in poems. Some of the distance has allowed me to explore not just the nostalgia for this person or this moment in my life I lost, but how this thing, while it almost destroyed me, it was consistent. Even if it was terrible, I knew what the terrible was going to be. I needed it, and there have been dark times in my sobriety where I have longed for it. Imagined throwing it all away.The book struck me in how it approached some of these subjects indirectly, talking about the emotions that challenge recovery, and the ones that precipitate addiction in the first place. You said something earlier about wonder. I do see magical realism in some of these poems. Do you agree and if so, how is it functioning for you?Great question. The beginning of this book was written at the end of 2011. I was living in Norway, a couple years sober. It’s the first time I’m away from my recovery groups and I’m in this magical place I’ve always wanted to go, surrounded by mountains, living in this 300-year-old house with a bunch of Norwegian musicians. But I had mono so I couldn’t do much. My spleen was so enlarged I could hardly walk. I dug into the library down the street which was about as far as I could walk. I kept checking out as many books as I could and one of them was 100 Years of Solitude by Gabriel Garcia Marquez. Ah, OK, I can see that.I was reading Garcia Marquez and a lot of Larry Levis, Cormac McCarthy, Roberto Bolano. So I was getting a lot of wonder, magical realism, lyrical narrative, and grit all while being in this miraculous place. For me, my sense of wonder is also partially why I first started to use. Wow.My using was sped up because one of my best friends was killed, the same year my grandfather died, and I was already 14 which is a shitty age to be anyway. Yeah, of course. Everything is terrible when you’re 14. The world was too much to contend with, both in its terror and in its beauty. I felt so much and the best way to deal with that was to numb it, even the good. I’m sad? Give me a drink. I’m happy? Give me a drink. I didn’t have the language to express what I was feeling and that’s part of why I was drawn to poetry. It gave me some tools to survive with. I’m glad you picked up on the magical realism. When you talk about things like death and addiction, facts and numbers don’t really get people, especially in this era of information. You can say 100 people died in a plane crash. You can say 5,000 people were killed in an attack by some country’s military. 75,000 people died in the US from overdoses last year. Numbers have stopped meaning something to most people when there is death all the time. Most people don’t feel any different response to the 100 people in a plane crash and the 75,000 people who died from overdoses because it isn’t numbers that move us, those don’t fully register, it’s storytelling and narrative that shape our responses to death, to tragedy. So I try to get at the emotion of it and go beyond data and create a mythology. I had heard Just Yesterday a couple years ago. It’s always been a poem for me to turn to when thinking about the work of memorializing the dead and writing about the dead. To me, it seems you’ve been doing this work for a while. I see it in this book and I like the placement of that poem before “Secondly, Finally.” You sort of inspect or interrogate what it means to memorialize the dead and the responsibility that comes along with it. What do you think?This is something I wrestle with a lot in this piece, especially in talking about the death of my friend because A, he’s gone and cannot tell his own story, B, we were children, and C, he was a black child and I am a white writer, so there are levels of potential appropriation and co-option I’m trying to be cognizant of. What story needs to be told? Who is the one to tell it? I mean, it’s essentially a function of whiteness to co-opt the stories of people of color, particularly stories that chronicle death or pain. And that co-option is violence. So there are a number of layers I’m contending with in terms of telling the story and what parts. Especially the way I finish the poem, talking about the body and its relationship to his death, talking about keys and doors. That’s not something I necessarily have the answers to. It’s nerve-wracking to tell. I’m in some contact with his cousins and his aunt. In some ways I’m terrified about what they might think of the book. Do I do any justice at all? Do I open the wounds further? Do I close them? As far as placement after “Just Yesterday,” putting them together, I wanted to get at this feeling of, “Look, I can write this whole book that has a great focus on loss and the lost and the ways in which they died. At the same time, is it worth it? Does it do anything?” I hope it does. It did for me.Let’s turn to the subject of memory, which is woven throughout the book. I heard on a Radio Lab podcast like six years ago that remembering--the way it works biologically--it’s a process of rewriting that introduces errors. So the things you remember the most have the most errors because you keep rewriting them. Memory and its disintegration, such as in the poem “Self-Erasure as Applied to My Memory,” is another focus of your book. Any thoughts on this?Memory plays a huge role in the book and in why I used, right, trying to forget certain things. But absolutely, the longer you get from any event the more the story begins to change. That’s just how memory works. I specifically remember seeing the Northern Lights as a kid in Northern Minnesota. My grandfather pointed at the sky and said, “That’s where we’re from,” and I was like, “...the sky!? What do you mean?” But he was like “no, Norway, that’s where our family is from.” This is such a fantastic moment and I wonder if it actually happened. Part of me is like this is too poetic to be true. But I remember it! I have to think: at this point does it matter for my development if this moment is actually true? That story has shaped me in profound ways. It’s partly why I wanted to go back to Norway on this sort of journey of cultural reclamation. Whether or not it happened doesn’t really matter anymore. It’s true. How we remember the world determines how we live in it, how we move in it, and how we imagine the future. I think about myself. I think about recovery and addiction. People with substance use disorder are good at rumination. It’s like a talent. I feel the line between problem solving and growth is important in this book. There are some griefs we cannot move forward from, but acknowledging that is a form of going forward-- --Right, absolutely. So it’s not always clear cut. But can you talk about that line in this book, between rumination and problem solving, between growth and stagnation? So much of my use was a result of my inability or refusal to accept a number of things. The refusal to accept my own powerlessness. The refusal to accept that people I loved dearly were gone and gone in horrific ways. My recovery has been less about problematizing or problem-solving my own addiction or past, but finding ways to accept it, and that’s where magical realism came in with how I work with metaphor, for example. The pill. The body. The way it breaks down. How the moon wrestles with the sky, which is too big to hold. There’s something about making it larger than life that makes acceptance easier. For a lot of folks, it might be the opposite. For them to accept it, they have to understand it in a factual way. For me, I have to understand it in an emotional way and the easiest way for me to do that is to make it huge. So that line is less about rumination than exploring and mythologizing the need to find acceptance. It makes me think about the things we pathologize that aren’t a pathology. Okay, let’s talk about “Row” specifically. For me it got at this paradoxical feeling of becoming more distant from the memories of addiction that are so central to my core of self-definition--Yes. Right, right--But then also the feeling that it’s closer than ever, that precariousness. There is a tension between want dissipating and it still being there. Can you talk about how want appears in this poem?There’s the line: “In my favorite dream I row that boat forever; / the fire finds its way inside me. / I’ve been clean for ten years, sometimes / barely. I could throw it away if I wanted / and in my favorite dreams I do. I want. I give up...” No matter how far you get from it, you’re never that far. You’re never more than one drink or one smoke or one pill away from going back...so, you know. It’s interesting how easy it is to forget what was bad. Because that’s selective memory. There was this thing in my first four years of recovery where I would drive by someone’s house. They are out drinking a beer, and you’re like, “Oh man, it’s such a nice day. It would be nice to sit outside and drink a beer.” Well I forget what happened last time I sat outside and drank a beer. I had 30 more and headbutted a guy in the face and shattered his nose and woke up and my shoulder was out of its socket and my arm was swollen black. And I was covered in pie. I forget all that stuff. So how do you keep some of that close but also acknowledge that drugs and alcohol are a symptom of a larger issue? There’s a lot of unhealthy behaviors we can still engage in when we get sober. A big part of it is finding where these feelings are coming from. What kind of work do I have to do to accept where they are coming from, to work through this place? There’s talk that this is a golden age of poetry. I don’t know if I’m just starting to pay attention more, and yeah people have been writing about addiction and recovery forever, but I see all these amazing poets like yourself who are writing right now. We’d of course like to think it’s a golden age of poetry for everyone. Do you think it is for the population of folks in recovery from substance use disorder?There’s a lot more conversations around recovery than there was 20 or 30 years ago, and more conversations around addiction as a mental health crisis rather than a criminal justice issue. Part of that is because now we have white people dying during the opioid crisis. The face of addiction has become white and so now we talk about it more and in a different way. I know both white and black crack addicts, and I’ve seen people react to their stories differently. That was one of the difficult things for me when writing about addiction. When I would talk about being in recovery it was easy for people to hold me up as a hero. “You’re so brave. You’re so strong. You’re so courageous.” But like I was a total asshole while using! We need to talk about who is pathologized versus who is mythologized. That for me has always been a tension in recovery. But I do think culturally we are moving to a place where we are seeing addiction and recovery in a different way. We are also romanticizing it less, I hope anyway. One of the first books I read was by Jim Morrison, my first book of poetry--the second was Mary Oliver, which if you look at my work this all kinda fits [laughs]. Jim Morrison romanticized drug use and addiction, and he died at 27. We’re moving more toward a place of self-care and accountability nowadays. As within the political left, I don’t think that language exists in the same way across the country universally.What I don’t see, is the literary infrastructure geared towards folks in recovery from substance use disorder, the journals, fellowships, retreats, reading series, etc. Any thoughts on this?You’re right. I don’t see much of that either, and I really would like it. Especially fellowships and retreats. Poets especially can really party. It’s easier for me to be around it all now than when I was earlier in recovery, but even so. When I was a Scholar at the Breadloaf Writers Conference I was lucky enough that I ended up in a solo room, the rest of the male-identified scholars were all in one big house where they were reportedly up all night drinking most nights. I was seven years sober and would have made it out of that okay, albeit a bit annoyed, but when I was a year or two sober if I had received that scholarship that might have been a scenario that would have caused me to relapse. I spoke of my recovery in my application so part of me thinks the selection committee arranged for me to have my own room. Even then though, you’re stuck on a mountain for two weeks. If you feel like using there aren’t just a list of meetings you can attend. I’d love to see fellowships and retreats for writers in recovery. I think some really great partnerships between literary foundations and reputable drug and alcohol treatment facilities could be explored.You performed at UMass Boston when I was there. I remember halfway through your set you were like, Okay, more sad poems. [laughs] I was reading the poem “Joyous Work” in this book and I was like, “Wait, is this a happy Michael Lee poem!?” then I got to the ending and was like, “Nope.” I actually do see “Joyous Work” as the happy poem in the book, I joke that it must be because it has the word joy in it. It’s happy for me anyway. Every couple of years I go to Norway. I’ve got a couple of friends there who’ve owned a farm for ten generations. It’s in the poem when I talk about Mikkels Plass. Since I was a kid, physical work has always been special for me. My grandparents lived in a cottage in the woods with a giant garden and I learned how to grow food, to chop wood and keep the house warm. I learned how to fish and hunt and make dinner from the land at a young age. I feel very comfortable in that part of my life. So yeah, “Joyous Work” is about different ways of praying. The farmers were kind of flummoxed. I spent twelve hours in the silo. I remember my friend being like, “Alright, if that’s what makes you happy, we’ll keep dropping loads of hay down into the silo.” In terms of what’s next for me, I haven’t written many poems since my book. For now I’m focused on short stories about Norway and memory and definitely playing around with magical realism. Last question, are you touring right now?I probably stupidly went to Norway for all of October to work on the farm when I should have been doing readings. I did some shows in the fall and I’ll be doing more in the spring. Available for booking?I’m available for booking any month at this current juncture. You brought up your poem “Mikkels Place,” and I feel the ending is kind of bleak but at the same time nourishing, and it might be a great way to close out this interview. “There will, one day, be another war, and another, and the theory / of everything comes down to grass and is simply grass, which / grows long and green and endlessly. There are one hundred ways / to destroy it, and there are one hundred more ways it will find its way / back out of the dirt.”Yes, yes, I think this line is the heart at one of the things I’m trying to get at it in the poem. Look, it’s a heavy book. I’ve spent so much time living and writing it I don’t think I realized how heavy it is until I’m reading these reviews online where people are talking about how they cried their way through it. It is heavy, but I wanted to leave room for hope and healing, that we can make our way through this world, that despite all the destruction and violence there is also peace, and we have to find it in the small and odd places sometimes but it’s there. And it’s worth finding, and for me it’s worth being sober for and really feeling it all. I love that. I love being sober and being able to feel the world and be a part of it. It’s such a gift. It’s taken away from so many people, the world is, so we’d better hold onto it as tight as we can while we’ve got it. More poems from The Only Worlds We Know:“Finality” and “Look,” The Adroit Journal“Insomniac Maps the Night,” BOAAT“The Law of Halves as Applied to the Blade,” phoebe

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