“You Have to Want It”: A Pervasive Mental Model of Addiction Recovery and Its Implications for Sustaining Change

Background: Addiction to illicit drugs is a complex phenomenon characterized by cyclical patterns of relapse, remission, and, for some, a full recovery. People who use drugs (PWUD) and their loved ones form ‘mental models’ of recovery that develop over time through experience and observation. The role of these mental models and how they interact to undermine or support recovery is poorly understood. Therefore, this study asks: 1) What do people who use drugs and their loved ones believe it takes to successfully recover from addiction? and 2) Given these beliefs about recovery and the available evidence on remission, relapse, and recovery, what places to intervene and leverage points would support recovery and prevent relapse? Methods: Data were collected from in-depth qualitative interviews with 14 people who use drugs (PWUD) and 10 loved ones of PWUD (“loved ones”) in a rural county in Missouri to elicit their mental models of addiction recovery. A grounded theory was developed and translated into mathematical equations to build a system dynamics model. System dynamics is a method to understand systems in terms of their interacting reinforcing and balancing feedback loops. The model was calibrated to replicate a prototypical pattern of addiction relapse, remission, and recovery. The grounded theory and model experiments were used to identify leverage points for sustaining positive change (i.e., recovery). Results: Participants believed that “you have to want it” to recover from addiction, where “wanting it” means improved social role functioning, seeking support, and abstinence. Insufficient proof of “wanting it” leads some loved ones to withdraw their support, which reinforces the addiction cycle. Model simulations show that expectations for social role functioning are a key driver of addiction and recovery. Changing the model structure so that support is not contingent on proof of “wanting it” has negligible immediate impact on drug use but creates the strongest eventual recovery. Support that is no longer contingent increases expectations for social role functioning, the benefits of which accumulate over time. When these benefits combine with strong balancing feedback loops, the recovery is stronger. Discussion: Increasing expectations for social role functioning is a key leverage point for recovery from addiction (i.e., for sustaining change). Support can be a critical factor that increases expectations. However, “wanting it” is, in effect, to no longer be addicted, meaning that many PWUD do not get support when they need it most because they have not yet proven to others that they can respond rationally to negative consequences. Thus, expectations must also be increased through means other than support from loved ones, including connecting with others who have similar lived experiences, and sustainable, meaningful changes in social role functioning. This requires social welfare, health, and criminal justice policies and programs that reverse, not merely slow down or even strengthen, the reinforcing loops that drive addiction

Cross-Cutting Narratives of Opioid Use Disorder Among Pregnant Women and Mothers: Implications for Humanistic Care

Opioid-related fatalities in the U.S. have increased drastically. Pregnant women and mothers with opioid use disorders (OUD) are a rapidly growing and vulnerable population. Using a critical narrative approach, this dissertation examines how the syndemic of trauma, substance use, and mental health conditions influences opioid use and treatment trajectories among pregnant women and mothers across the lifecourse. The goal of this dissertation was to examine three discursive resources that shape the social construction of perinatal and maternal opioid use across all strata of social life: macro-level (news media), meso-level (scientific), and micro-level (individual) narratives. Informed by 18-months of ethnographic observation, in-depth interviews, and mixed methods analysis of scientific research and news media coverage of perinatal and maternal OUD, this research brings together the voices of women in recovery, clinicians, social workers, policymakers, and the public. Building from what Sanders (2014) refers to as the “gendered double standard” faced by women with substance use disorders, in this dissertation I characterize the intersecting identities of female, pregnant/mother, and substance user as a gendered triple standard. Throughout this work I argue that being held to this gendered triple standard intensifies the stigma faced by pregnant women and mothers with OUD as they navigate the medical, legal, and social service institutions. Key findings from this research include: (1) a predominating focus on “fetal victimhood” (Knight, 2015), which overlooks the needs of pregnant women and mothers with OUD that run concurrent to ensuring a healthy pregnancy and birth; (2) approaches to addressing the opioid “crisis” that elide key at-risk populations (e.g. People of Color, active substance users, and polysubstance users); (3) “folk” pharmacokinetic knowledge and practices utilized by pregnant women and mothers that function as both facilitators and barriers to treatment engagement; and (4) the traumas associated with institutional policies and procedures specific to the management of opioid use (e.g., practices associated with civil commitment to treatment, loss of custody, and intergenerational family separation via the criminal justice and/or foster care systems). Informed by key findings, this dissertation concludes with five specific recommendations for research and practice

Pharmakon in the Firelands: Connecting Historical Discourses and Small-Town Social Contexts with Substance Use Experience

The ongoing increase in opioid and polysubstance-related overdoses and mortality in United States coincides with a shift in the ways substance use is understood. Once almost exclusively treated as a criminal problem, substance use, and overdose is increasingly viewed in terms of public health and from an urban to rural issue. The discourse surrounding the use of psychoactive substances largely omits the voices of the very people who use them. Likewise, the social context of small towns, at once not quite rural nor entirely urban, is generally given little consideration. To address these gaps in the research, I conduct two historical discourse analyses; the first analyzing advertisements and the second studying news articles published in the Northern Ohio region known as The Firelands. I conduct and analyze unstructured interviews with current and former opioid and polysubstance users, their family, and friends. I employ ethnographic data collection to advance and enrich the sociological understanding of the lived experiences and knowledge of the people who use psychoactive substances. The results of the discourse analysis are used to contextualize the knowledge of small-town opioid users and their lived experiences. Collectively, these insights contribute to the sociological study of deviance, a deeper understanding of drug use within the context of space and place, and the sociology of health and medicine

Drug Use on the Coast: Examining the Opioid Epidemic in Maine Lobster Fishing Communities

Since the beginning of the twenty-first century the rate of opioid overdoses in the United States has increased dramatically (CDC 2017a) and daily is responsible for over 100 deaths (CDC 2017e). The opioid epidemic is pervasive and affects people of all backgrounds, but rural America has been hit particularly hard with rural drug overdose death rates exceeding urban rates (CDC 2017a). Maine, the state with the highest percentage of people living in rural areas in the country, (Wickenheiser 2012) saw 354 deaths due to opioid overdoses alone in 2017 (Russell 2018). Situated within this context a newspaper series found that the opioid epidemic is especially prevalent in Maine’s lobster fishing communities (Overton 2017). While this observation is consistent with nationwide trends of rural drug use and literature on Deaths of Despair, there is little formal knowledge about why the lobstering community is particularly affected by opioid use (Case and Deaton 2015). To provide a more systematic understanding of this phenomenon, this study aims to: 1) examine the drivers behind opioid use in the lobster fishing industry and 2) identify opioid prevention and recovery techniques that are most effective for the lobster fishing community. These questions were explored using a qualitative study design. Semi-formal interviews were conducted in three Maine lobster fishing communities with lobster fishers and community members (N=20). Results found that the drivers for opioid use were largely consistent and industry specific and included: ability to purchase drugs, boredom, work injury and work environment. There was inconsistency in the prevention and treatment options available in the communities investigated, though there was uniformity among barriers mentioned

"That Look That Makes You Not Really Want to Be There": Health Care Experiences of People Who Use Illicit Opioids in Small Urban and Rural Communities - A Critical Social Theory Analysis

The phenomenon of interest is the health care experiences of people who use illicit opioids in small Ontario urban and rural communities. Using the qualitative constructivist paradigm the perspectives of participants who used opioids and of nurse participants were interpreted using Frieres critical social theory framework to explore sociopolitical, economic and ideological influences. Findings describe a divide between people who use illicit opioids and the nurses who care for them: Its Like A Switch Gets Flipped (describing an abrupt change in attitude by nurses once illicit substance use is identified), Reciprocal Mistrust, Caring for Women is Different and In a Small Town the Stigma Lasts Forever. Discussion places these findings in the context of health care systems as agents of social control, the influence of neoliberalism, and the impact of the global War on Drugs. Findings lead to recommendations for contextualized nursing practice, education and research and for policy change

Reference Notes for Palliative Care Consultation

The interprofessional health care specialty of palliative care employs holistic evaluation and person-centered communication in the care of people with life-threatening illness. Palliative care clinicians are consulted for one or more of the following reasons: Symptom assessment and management Assistance with making difficult decisions about continued use or withdrawal of life-sustaining interventions Communication for planning the most appropriate care setting to meet person/family goals for end-of-life care Assessment of suitability and eligibility for hospice care This resource is a compilation of previously published documents and tools useful to palliative care clinicians in preparing for and conduction these consultations. In addition, it can be a reference for students and clinical trainees doing course work, analyzing case studies, or simulating clinical communication scenarios. The materials are indexed for easy retrieval, referenced to acknowledge sources and allow further exploration, and organized into the following categories: Palliative Care Definitions/Domains/Dimensions Communication Symptom Assessment Functional Status Evaluation Prognostication End-of-Life Assessment and Management Symptom Management Hospice Eligibility Criteria Withholding and Withdrawing Life-Sustaining Interventions Pediatric End-of-Life Issueshttps://scholarworks.gvsu.edu/books/1017/thumbnail.jp

2019 Conference Abstracts: Annual Undergraduate Research Conference at the Interface of Biology and Mathematics

Schedule and abstract book for the Eleventh Annual Undergraduate Research Conference at the Interface of Biology and Mathematics Date: November 16-17, 2019Location: UT Conference Center, KnoxvilleKeynote Speaker: Sadie Ryan, Medical Geography, Univ. of Florida; Director, Quantitative Disease Ecology & Conservation Lab (QDEC Lab)Featured Speaker: Christopher Strickland, Mathematics, Univ. of Tennessee, Knoxvill

Current Rural Drug Use in the US Midwest

The nature and challenge of illicit drug use in the United States continues to change rapidly, evolving in reaction to myriad social, economic, and local forces. While the use of illicit drugs affects every region of the country, most of our current information about drug use comes from large urban areas. Data on rural drug use and its harms justify greater attention. Record overdose rates, unexpected outbreaks of HIV, and a dearth of treatment facilities point to a rapidly worsening health situation. While health sciences have made considerable progress in understanding the etiology of drug use and uncovering the link between drug use and its myriad associated harms, this promising scientific news has not always translated to better health outcomes. The scope of the problem in the Central Plains of the US is growing, and can be estimated from available sources. Clear remedies for this rising level of abuse are available, but few have been implemented. Suggestions for short-term policy remedies are discussed

Current Rural Drug Use in the US Midwest

The nature and challenge of illicit drug use in the United States continues to change rapidly, evolving in reaction to myriad social, economic, and local forces. While the use of illicit drugs affects every region of the country, most of our current information about drug use comes from large urban areas. Data on rural drug use and its harms justify greater attention. Record overdose rates, unexpected outbreaks of HIV, and a dearth of treatment facilities point to a rapidly worsening health situation. While health sciences have made considerable progress in understanding the etiology of drug use and uncovering the link between drug use and its myriad associated harms, this promising scientific news has not always translated to better health outcomes. The scope of the problem in the Central Plains of the US is growing, and can be estimated from available sources. Clear remedies for this rising level of abuse are available, but few have been implemented. Suggestions for short-term policy remedies are discussed

Young Women and the Initiation Trajectory of Prescription Opioid Misuse

The most recent opioid epidemic in United States history emerged in the late 1980s and continues its destructive impact to this day. It has evolved into a devastating public health crisis with a broad range of medical, social, and economic consequences. This dissertation focuses on the “first wave” of this opioid epidemic characterized largely by the misuse of prescription opioids. The research questions here were focused on developing a greater understanding of the social processes involved in young women’s initiation of prescription opioid misuse (POM) during this first wave. The research methodology consisted of a cross-sectional, exploratory study using qualitative data collection and analytic methods in the grounded theory tradition. An ecosystems perspective was used in the categorization of findings at the individual, interpersonal, and community levels, and a description of the POM initiation trajectory experienced by participants is described. A grounded theory that emerged from these findings is presented, as are key themes that include the importance of an initiation trajectory as a concept replacing the term initiation; the impact of female gender on this particular initiation trajectory; the lack of evidence-based information about addiction across the prevention, treatment, and recovery landscape; key differences between POM and other substance misuse trajectories; the contribution of stigma as a barrier to accessing support for substance misuse; and an examination of the connections between boredom, lack of meaning and substance misuse outcomes. Study findings point to a set of recommendations for interventions at the individual, interpersonal, and community levels that can inform practice, policy, and research moving forward