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 Stigma and The Fallacy of the Choice Argument

 Stigma and The Fallacy of the Choice Argument

If a doctor presented a lung cancer patient with the “equally effective” choices between cutting edge modern medicine and switching from cigarettes to cigars at home, there would literally be a malpractice lawsuit when the patient subsequently died in a smoking jacket. It’s such a ridiculous statement you must read it twice to see if it even makes sense. Change out cancer for substance use disorder and all of a sudden the recommendation sounds not only correct, but “empowering” for people with substance use disorders. We’ve gone down the wrong path with the new panacea treatment solution of substance use disorders in our society, but too many so-called “recovery advocates” are more invested in being right about their silver bullet than they are in slowing down the parade of bodies. It makes sense—people always prefer silver bullets to the idea of buckling down and putting in the work when they’re presented the options as equal, so letting go of the fantasy and returning to the solution is hard.

Even if you don’t want to look at the massive diversion of opioid based maintenance medications by actively using individuals who don’t actually want to stop taking heroin, and the ever-increasing market demand for fentanyl in the heroin supply that diversion keeps pushing up… you can’t deny the body count. Since our recognition of the opioid crisis and counterproductive implementation of lifetime opioid based maintenance protocols and diversion away from effective continuum of care, clinical solutions extending through all levels of care and even beyond behavioral healthcare (collegiate recovery programs in higher education or judges and lawyers assistance programs in the legal community for example), our annual death toll from opioids alone has quadrupled to over 60,000 per year.

Which brings us to stigma and the fallacy of the choice argument. No other lethal disease is treated as contemptuously as substance use disorder. Individuals suffering from leprosy are now viewed more favorably by communities than those with substance use disorder. Despite being recognized as a disease, this classification is being rapidly torn down by backroom profit driven maneuvering and the front and center irresponsible and incompetent bumbling of some so-called “recovery advocates.”

Every shred of evidence supports that individuals are orders of magnitude safer while receiving clinical care (which often includes medications I might add, as the two are frequently and inaccurately presented as mutually exclusive) than they are while receiving maintenance without clinical care. Yet somehow despite this, and the common sense to realize that you’re more likely to die in the unstructured environment you were just actively shooting heroin in than a structured one that supports your recovery process, a narrative has been established in which treatment is not only ineffective but somehow dangerous and archaic. The “gold standard” has become opioid based maintenance protocols with or without clinical services in this new alternate reality that is putting more of us with substance use disorders in the ground with misinformation than the state sponsored witch hunt in the Philippines is putting us in the ground with bullets and blades.

We don’t even test lethal overdose victims for the presence of buprenorphine or ask non-lethal overdose victims if they have been bridging in our hospitals despite the fact that every heroin dealer in America now also deals in black market diverted opioid based “maintenance drugs.” “Many pathways to recovery” has been hijacked and perverted into the new “pain is the fifth vital sign” campaign. The day the “best” option became lifetime maintenance protocols is the day we were told at the national level, that we can’t and don’t recover. The greatest bait and switch in the “recovery community” is that the proponents of the “choice argument” would see us corralled into one- and only one- life time matinence protocol to the exclusion of all other pathways and forms of “recovery.” That’s what stigma looks like. That’s what the face of mass murder through apathy and disdain, rather than direct action looks like. Of course, and I can’t believe I even have to write this, the choice to dictate our own treatment protocols armed with misinformation for the treatment of a diseased organ, which also happens to be in charge of making our choices, isn’t doing us any favors. If a person with another form of brain disease, cuts themselves with a razor blade we, as a society, make sure they have a safe place to stabilize and develop a discharge plan to set them up for the successful treatment of that brain disease. If a person with an opioid use disorder is legally dead and revived with Narcan, they may not even get a ride to the hospital and if they do its often to “treat them and street them” so they can get back to treating “real diseases and medical emergencies.”

Substance use disorder is a brain disease and the most effective treatment for our diseased brains is frequent, consistent and long-term exposure and interaction with healthy and even clinically trained other brains. When someone with a substance use disorder receives clinical services and subsequently has a lethal reoccurrence of use, the narrative has become that “treatment doesn’t work.” The truth is that more likely whatever facility they were receiving services at was under resourced or ineffective and didn’t provide services for long enough at each level of care. Someone skipping entire levels of care and going straight from medical detox to a recovery residence because their family can’t afford treatment isn’t a failure of the treatment industry, it’s a failure of society to properly support that individual and their family in their darkest hours. Whenever someone has a reoccurrence of use and the staff of a facility, an interventionist, an education consultant, or any other treatment industry professional fights to get that at-risk individual back into a higher level of care, the narrative has become “they’re just money hungry.” The truth is that we would never even have the thought let alone make such an outrageous accusation with any other disease. Nobody has ever said, “that hospital is greedy, they want to treat the cancer again that just came out of remission.” It’s stigma that keep such narratives alive. It’s stigma that forces families to make tough financial decisions because both our government and healthcare industry insufficiently supports those families (Economic solutions for this issue are proposed here and also here.

In the entire history of substance use disorder in our species, pressure and help have produced countless miracles. Pressure and help from wives and husbands, pastors and rabbis, moms and dads, sons and daughters, therapists, and school counselors. I know—because I’m the product of such pressure. Choices based on alternative facts and stigma have also given us something… They’ve given us overcrowded emergency rooms, overcrowded prisons, and overcrowded graveyards.


Andrew Burki outcome based reimbursement

Andrew Burki, MSW
CEO, Life of Purpose


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