Last November, those of a certain age were sadly reminded of the death of President John F. Kennedy fifty years ago in 1963. While we’re now learning of his flaws, in the early 1960s many of us saw in Kennedy’s relative youth and energy the start of a new era. Shortly before his death, President Kennedy signed a bill authorizing funding for mental health programs. It was never fully funded. Some have said that President Kennedy’s assassination launched the notion of
“Question Authority” so popular in the years that followed and the beginnings of the lack of trust in our government.
Later in San Francisco in the ‘60s, we saw those concepts blossom. As the media spread the word of the marijuana/LSD/sex/rock ’n roll-infused Haight Ashbury neighborhood, the City decided that if it simply ignored the needs of the young people coming its way – they would turn around and leave. Recognizing a looming public health crisis, the lead author rallied colleagues at the University of California San Francisco, the San Francisco Medical Society and others to open the Haight Ashbury Free Medical Clinic in June of 1967 with the philosophy “Health care is a right, not a privilege.” We were immediately inundated with young people who needed treatment for an assortment of ills, including infections, fractures, lacerations, burns, scabies/crabs/lice infestations, dental issues, sexually transmitted diseases, and malnutrition, as well as pregnancies, and saw about 250 patients in the first 24 hours. To our surprise, we also became a haven for those facing the terrible dark side of the drugs they’d ingested – too much pot, too much acid, too much amphetamine, too much heroin. The narcs watched us from across the street, but decided we really weren’t selling or encouraging the use of drugs, and left us alone (we had a big sign at the top of the stairs to the Clinic – “No Dealing, No Holding, No Using”).
Rock ‘n’ roll kept the Clinic alive. Rock impresario Bill Graham organized benefit concerts to fund the Clinic, headlining such then-local acts as the Grateful Dead, Janis Joplin, and Creedence Clearwater Revival – and even rock royalty George Harrison of the Beatles. Our Rock Medicine program provided medical and crisis intervention services at small venues like the Fillmore Auditorium and large stadiums like the Oakland Coliseum, building on and refining the Clinic’s pioneering of the art of talkdown with LSD trippers.
In the early 1970s, somewhat astonishingly to the anti-Vietnam War generation, President Richard Nixon set up a White House office
for drug education and treatment, in part because so many soldiers were coming back from Southeast Asia addicted to heroin. The Clinic received a large grant for treatment and education, which allowed us to continue to develop our outpatient treatment of addicts, which at the time was illegal in California. Increasingly, the bulk of those funds have gone to the war on drugs, with education and treatment now allocated a relative pittance.
In the late 1970s, we borrowed a page from Alcoholics Anonymous, which at the time wasn’t too welcoming of drug addicts to its meetings, and started the first Narcotics Anonymous groups patterned on AA’s philosophy and structure at the Clinic’s Drug Detoxification, Treatment and Aftercare program. NA spread primarily on the West Coast and expanded across the country.
We have seen some progress. Drug addiction is losing some of its stigma and criminalization and becoming increasingly recognized as a brain disease. The American Society of Addiction Medicine (asam.org) has recently formulated a definition that states in part:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, cravings, diminished recognition
of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
In 2008, President George W. Bush signed the Wellstone-Domenici Mental Health Parity and Addiction Equity Act, requiring that mental illness be granted care on a par with physical illness. In 2010, President Barack Obama signed the Affordable Care Act, further establishing parity for mental health treatment, among a host of other regulations. How this legislation will play out remains to be seen, but various scenarios are possible and we may see a process of trial and error as new systems of care are developed for substance use disorders.
More primary care clinicians will be trained to screen for and identify substance misuse and/or addiction, resulting in an increased demand for treatment. Existing treatment facilities will expand and consolidate with others to develop cost efficiencies. Addiction treatment centers will incorporate medical facilities into their programs to better address the physical issues their patients bring with them. We’re seeing the start of many new facilities using evidence-based medicine in their treatment, funded by investors expecting solid returns. These are not “Malibu-style” luxury detox centers, but more mid-priced ventures, and they’re establishing relationships with insurers, expecting that the new parity regulations will once again require insurers to cover substance abuse treatment on a parallel with their coverage of physical ailments. We will likely see more of a range of facilities, ranging from front-line inpatient detox through residential treatment through “halfway house” to sober living residences, where individuals share a living situation and provide informal mutual support, while holding jobs to pay the rent and other expenses (the organization or entity operating the house usually has a paid part-time staff member to ensure rent collection and payment of utilities, taxes, insurance, etc.).
It’s unknown at present how the core peer staff of many existing treatment programs will be recognized as caregiver/clinicians by
this new influx of funds. Will the first-hand experience of having gone through the addiction and sobering process receive the same acknowledgement of value it does now? Will insurers demand additional credentials and licensing? While the overall concept of parity will bring much-needed mental health services to many, the questions of actual implementation are many.
The criminal justice system will (hopefully) increasingly realize that every dollar spent on treatment saves about seven dollars in social costs such as jails, prisons, parole and probation officers, attorneys, et al.
As addiction is increasingly recognized as a brain disease and mental health issue, its treatment is becoming increasingly medicalized. While methadone counters the effects of heroin, newer medications such as buprenorphine (with or without naloxone), depot injectable naltrexone, and others can moderate the uptake of opioids by the brain. Other medications are being developed for other classes of illicit drugs.
While medications, treatment facilities, counselor credentials, and peer groups provide necessary support for regaining freedom from misused drug and/or alcohol, one of the most important steps in recovery is to maintain a healthy brain. The simple acronym HALT reduces this to the basics: Avoid HUNGER. Avoid ANGER. Avoid LONELINESS. Avoid getting TIRED. These stressors break down our defenses and make us more likely to look to alcohol and other drugs to relieve the tension and make us feel better. As we’ve all learned, “feeling better” is only transitory and only serves to remind the brain that it once needed those mind-altering substances, leading to craving and the undoing of one’s hard-earned sobriety.
There’s a lot to be said for natural highs – and we’re not talking about banana peels and poppy seeds. Exercise releases endorphins, which activate the pleasure and reward centers of the brain in ways similar to opiates. A healthy diet that minimizes sugars, fats and meat, while emphasizing fruit, vegetables and grains, feeds the brain as well as the body. Developing closer relationships with spouses, children, families and friends provides a support system to counter the temptation to return to the “old ways.”
Get enough sleep. Think positive. None of these is rocket science, but when you remember that addiction is influenced in large part by genetics, you realize that you have to stack the deck as much in your favor as possible.
One of my colleagues has suggested that use of particular drugs runs in approximately six-year cycles and we’re currently approaching the waning of the prescription drug epidemic. Currently, we seem to be facing increased Ecstasy and bath salts use. In the 1980s, we introduced the concept of clinicians who were Dated, Disabled, Dishonest and/or Duped in their drug prescribing. The Haight Ashbury Free Clinic developed training and education programs for impaired physicians, nurses and other clinicians that were adopted by what is now the California Society of Addiction Medicine and “exported” across the U.S.
One of the most interesting addiction-related advances in our increasingly technological age is the development of apps for supporting recovery. Downloadable to a smartphone, these constant companions can remind you of the benefits of staying clean and sober. Some provide interactive access to a counselor, while others offer affirmations, daily check-ins, virtual meetings, and other options.
Of course, the importance of one’s sponsor, family and friends in living a sober life can never be overemphasized. These are the folks who’ll be with you, no matter what. Treat them right.
David E. Smith is board-certified in addiction medicine and a certified Medical Review Officer. He founded the Haight Ashbury Free Medical Clinic in 1967 and has taught that addiction is a brain disease for over 45 years. Leigh Dickerson Davidson volunteered with Rock Medicine and other Haight Ashbury Free Clinics programs for many years and published books on women’s health and related issues for over 25 years.