How should peer recovery coaches think about client cannabis use?

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This article has been on my mind since it came out earlier this year. I didn’t write anything at the time, but my mind kept coming back to it, in part because it’s representative of a lot of contemporary academic activity.

The article focuses on the attitudes of peer recovery coaches toward cannabis use by their clients. In the implications section, the authors state the following:

Research on provider-based stigma toward SUDs suggests interventions that facilitate interaction with people in recovery are associated with long-term stigma reductions (Bielenberg et al., 2021). Training for PRCs may therefore include testimonials from recovering individuals who use cannabis. Training in motivational interviewing principles is another popular strategy for addressing provider-based stigma toward SUDs (Bielenberg et al., 2021) and may provide PRCs with a useful tool, particularly when self-disclosure may be harmful. Finally, supervisors will play an important role in helping PRCs to process and manage biases favoring abstinence-based recovery. Staff supervising PRCs can incorporate debiasing and bias management techniques, such as appointing someone to play “devil’s advocate” in group supervision, or “slowing” strategies to promote analytical reasoning (Bowes et al., 2020).

Pasman, E., Clift, J., Broman, M., Madden, E. F., Agius, E., & Resko, S. M. (2023). “It Depends on What You Consider Recovery”: Perceptions of Client Cannabis Use Among Peer Recovery Coaches. Journal of Drug Issues, 0(0).

What bothered me was the author’s stance toward peer recovery coach ambivalence about client cannabis use.

The authors seem to frame the peer’s ambivalence as stigma, ignorance, bias, and lack of clinical sophistication or skills.

However, I hear a lot of sophistication in the comments of the peers:

  • They distinguish substance use vs misuse; addiction vs other SUDs; and harm reduction goals vs recovery goals.
  • They also repeatedly affirm the patient’s right to choose their own pathway with statements like “that’s not for me to say”; “it’s their choice”; “who am I to say what works for them and which is better”; “I can’t tell somebody ‘Hey, you shouldn’t do that. I wouldn’t do that’”; “It’s not for me to verbalize whether or not I support or don’t support their path.”
  • They communicate awareness that their personal experience isn’t universal with statements like “I myself personally”; “for me, it didn’t work.”; “Personally, that wouldn’t be something that I would choose”; “that’s somebody else’s recovery journey.”
  • They recognize that some clients may be able to use cannabis without problems – “maybe they can still have a manageable life while using marijuana. It’s so personal to the person.”; “I’ve seen people use it for pain management and sleep purposes and function normally.”
  • They convey a lot of self-awareness – “I really do my best despite my own biases to support whatever that choice is for them.”
  • They convey a commitment to the relationship, regardless of the approach chosen by the client.
  • One of them talks about cannabis as an “exit drug” for some people.
  • They convey considerable cognitive empathy and cognitive flexibility.

One might argue that a cautious, wait-and-see approach might be the most sensible approach. After all, there’s a long history of learning from the failures of drinking privileges in therapeutic communities and the failure to recognize addiction as a problem rather than specific substances.

A pastoral response, rather than doctrinal

Another way to frame their approach might be pastoral.

I had a chance to speak with Phil Valentine about the philosophy behind CCAR’s well-known assertion that “you’re in recovery if you say you are.”

One of the things we discussed was whether that was a pastoral or doctrinal stance. Here’s what I mean by that. When Pope Francis started communicating a very different tone toward LGBT people, I asked a Catholic friend if the church was changing its teachings about homosexuality. He responded that none of this represented a change in doctrine and that it was a pastoral response to the spiritual needs of LGBT people and their families.

I asked Phil if CCAR’s stance (you’re in recovery if you say you are) might be thought of as more of a pastoral response than a doctrinal response. He responded that this was probably a helpful way to think about it.

To me, the peer recovery coaches in the study seemed to be working through the right pastoral response when they’re faced with something that doesn’t fit with doctrine (continued substance use while in treatment, ongoing substance use as an endpoint, or ongoing substance use being included in the category of “recovery”). They convey a pastoral commitment to engagement, self-determination, and supporting whatever works for the individual, even if there’s a mismatch with their doctrine.

Maybe peers are demonstrating a multiple pathways approach to establishing and maintaining helping relationships? They’re demonstrating that they don’t have to choose between doctrine and the relationship, and that their own lived experience and the client’s experience don’t have to be fully aligned to work together.

Does research indicate peers should endorse goals for moderate AOD use?

Of course, this frame calls for an examination of the peers’ doctrine. Here’s what the paper says:

Research shows substance use treatment benefits individuals with both abstinence and non-abstinence goals, and clients have better outcomes when they select their own goals (Paquette et al., 2022). Thus, helping PRCs to empower people with SUDs to choose their own recovery pathway, including one that involves cannabis use, may improve treatment engagement, retention, and outcomes (Paquette et al., 2022).

Pasman, E., Clift, J., Broman, M., Madden, E. F., Agius, E., & Resko, S. M. (2023). “It Depends on What You Consider Recovery”: Perceptions of Client Cannabis Use Among Peer Recovery Coaches. Journal of Drug Issues, 0(0).

The authors point to better outcomes when clients are empowered to choose non-abstinence goals and use Paquette et al., 2022 to support the claim. What does this source say?

The current review highlights a notable gap in research empirically evaluating the effectiveness of nonabstinence approaches for DUD treatment. While multiple harm reduction-focused treatments for AUD have strong empirical support, there is very little research testing models of nonabstinence treatment for drug use. Despite compatibility with harm reduction in established SUD treatment models such as MI and RP, there is a dearth of evidence testing these as standalone treatments for helping patients achieve nonabstinence goals; this is especially true regarding DUD (vs. AUD). In sum, the current body of literature reflects multiple well-studied nonabstinence approaches for treating AUD and exceedingly little research testing nonabstinence treatments for drug use problems, representing a notable gap in the literature

Paquette, C. E., Daughters, S. B., & Witkiewitz, K. (2022). Expanding the continuum of substance use disorder treatment: Nonabstinence approaches. Clinical Psychology Review, 91, 102110.

So, “the current body of literature reflects multiple well-studied nonabstinence approaches for treating AUD and exceedingly little research testing nonabstinence treatments for drug use problems”, yet these peer recovery coaches should be embracing and empowering nonabstinence goals? This suggests an approach that maintains engagement and takes a cautious wait-and-see stance might be the most appropriate way to go.

Paquette et al. describe nonabstinence approaches for alcohol use disorders as well-studied. What does that literature say? One of their sources is a 25-year review from moderation research pioneers, Linda and Mark Sobell. They reported that subjects with severe alcohol problems predominately recovered via abstinence while subjects with lower severity problems predominately recovered through reduced drinking.

This aligns with one of the themes identified by the peers — if this person has addiction (high severity, high chronicity drug problem characterized by impaired control) their cannabis use might be a problem, but if they have a lower severity drug problem they might be more likely to successfully moderate.

This highlights a long-standing problem in the assessment of drug problems that was made worse by the DSM 5, though we might be able to improve assessment with attention to the “big 5” diagnostic criteria.

The authors recommend training in motivational interviewing for coaches, but motivational interviewing does NOT abandon directing. For example, practitioners are not expected to be neutral about tobacco use (even if a significant number of tobacco users will never develop tobacco-related illness) but they are expected to honor client autonomy.

Why do we have peer recovery coaches?

All of this also invites questions about the role of peer recovery coaches. The current emphasis on peers as part of treatment teams/systems was a response to systems of care that had become increasingly detached from communities of recovery and had (knowingly or unknowingly) abandoned recovery as an endpoint. Many programs, researchers, and systems of care conflated treatment and recovery. For example, overemphasizing engagement as an outcome. Bill White also described the conflation of recovery and remission:

Recovery from opioid addiction is also more than remission, with remission defined as the sustained cessation or deceleration of opioid and other drug use/problems to a subclinical level—no longer meeting diagnostic criteria for opioid dependence or another substance use disorder. Remission is about the subtraction of pathology; recovery is ultimately about the achievement of global (physical, emotional, relational, spiritual) health, social functioning, and quality of life in the community.

White, W. & Torres, L. (2010). Recovery-oriented methadone maintenance. Chicago, IL: Great Lakes Addiction Technology Transfer Center.

The peer role was intended to disrupt these systems, reintroduce the lived experience of recovery, and reconnect addiction care to communities of recovery. It seems that many researchers, policymakers, and treatment providers are now ambivalent about the lived experience of peers and the communities of recovery they are connected to. This ambivalence sometimes generates efforts to reshape or confine their lived experience to match the vision of the researcher, policymakers, advocates, or providers.

This can result in the selective use of lived experience–calling upon the lived experience as a person who uses drugs or is addicted rather than the lived experience of recovery. Pressures to assimilate peers into clinical cultures are a common problem, making attention to role drift very important. Reasonable people may disagree, but teaching clinical models risks organizational role drift.

Right endpoint, right patient

Addiction treatment providers historically claimed ownership of all substance use problems and did a poor job differentiating and tailoring interventions for lower severity types versus high severity, high chronicity, and high complexity types.

We’ve long known that something like 60% of young adults with alcohol problems will mature out and moderate or quit as they reach milestones like graduating from college, starting a career, or starting a family. Unfortunately, many of these people were plugged into a one-size-fits-all model of care.

The call to recognize that some patients don’t need to abstain is NOT a problem. The call to recognize that we need models of care for patients who are not ready to abstain is NOT a problem. To suggest that we should support those populations with treatment plans that include moderate use is NOT a problem.

When I did more clinical work, I would often explain to clients that 60% of young adults with alcohol problems will mature out, but 40% will not. We’d talk through the risk factors for being in that 40% (family history, early onset of use and problems, duration of problems, high tolerance, a signature experience, polysubstance use, AOD-saturated social networks, high-risk drugs/methods, etc.). If they had multiple risk factors I’d explain that I can’t know the future, but the odds were against them being able to moderate and my recommendation was abstinence. However, it’s their life and that was a decision they needed to make for themselves. If they wanted to pursue moderation, we could see how it goes and, if it didn’t go well, we could revisit that decision.

We can share information and make recommendations to patients and continue to earnestly work with them if they choose another plan.

However, to suggest that we should unquestioningly adopt an endpoint of moderate use for people with addiction (high severity, high chronicity problems whose hallmark is impaired control) IS a problem that will result in suffering and death for people with addiction and their loved ones. Further, to establish an expectation that peer recovery supports be trained out of recognizing the risks of continued AOD use in addiction is to negate the lived experience of many of them and expect them to be something very different than the role originally envisioned for them.

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