Louise Stanger Interview Transcript
Louise Stanger is a licensed clinical social worker and professional interventionist. This interview was completed on September 13, 2018.
Jamal Khan: Please introduce the work you do and how it pertains to the Opioid Crisis.
Louise Stanger: Hello, my name is Dr. Louise Stanger. I’m a licensed clinical social worker, I have been both faculty and administrator at various universities, both public and private. I’ve been a licensed clinician since 1973, my interests have been in two arenas. The first is the addiction field which includes substance misuse, process disorders (4:02), chronic pain, which has a lot to do with the Opioid Crisis. The second is sudden death, which also has to do with the Opioid Crisis since 155 people die each day from an an opioid overdose with the global pandemic that we’re currently experiencing. Clinically, I do several different things. I work with families On issues such as mental health, substance abuse, process disorders, chronic pain and helping them find the treatment that they best need. I also am a trainer, educator, and keynote presenter. I present all over the country and am also an author and a blogger. I am excited to say that Routledge, which is known as a textbook house, is publishing “The Definitive Guide to Addiction Interventions: A Collective Strategy“, is coming out on September 26th. I do have a lot of Huffington... [5:14]. As a researcher or PI, I’ve had about $5 million dollars worth of NIH, NIAAA, or Department of Education grants dealing with alcohol prevention, or more global community intervention. And I’m a mom, I’m a grandmother, and I love adventure and SoulCycle. I usually traveled to Bhutan, which I think is very interesting when you look at global issues and I’m honored and delighted to be speaking with you today.
JK: In the course of your decades of clinical work, what was your single most memorable experience you had? Whether it was something you observed, or something that you heard someone say, what stuck with you?
LS: I think it's a chapter in my first book named “Falling Up”, which is a memoir. It is a philosophical stance or theoretical approach that states, “Nothing changes until something changes”. In the world of addiction, which is a disease, people experience substance abuse, they experience a process disorder—disordered eating, gambling, sex, and digital disorders), they experience chronic pain. People though, are much more than their disorder. I have come to believe, that however you define family—, albeit neighbor family, abilet business associates, nothing will really change with that person that experiences that disease, unless those people and places around them change.
JK: So like… a larger change in their environment?
We know that addiction is brain disease. It changes the way our brains sees us, it changes the way we think. So does chronic pain, etcetera. But the people around us, unwittingly, unconsciously help facilitate our diseases. Unless they begin to change, the person who is experiencing stands little chance. You ask me about a memorable experience and this year, I was prompted to write an article that was published in London about Grief and Family. What prompted this was that I had a family that did the best that they could do with their loved one, and their loved one had an overdose (one of many times). Once, he was was given Narcan and went back out again and finally, eventually, overdosed and had a heart attack and died. I realized that if there are a minimum of 155 loved ones dying per day—,if you take that times 10 or even 20, you realize there are so many people that are affected by the death of the Opioid Epidemic. And guess what? We don’t have any services for that, except for funeral directors or going to the morgue. And to me that was such a riveting point, where I realized that we must do a better job preventing death, but that we also need to help these faceless, nameless people get the help that they need?
JK: That's a great point. Many of the articles about the Opioid Crisis, focus on the statistics of overdose deaths and economic cost of the crisis. They oftentimes don’t include the larger consequences and repercussions, especially for family and close friends of the loved ones who have unfortunately, died from an overdose. How do you think we could help these other members of our population with this grief?
LS: I think that sudden death is, which is often the case for opioid overdoses, a special phenomenon that we need to train funeral directors. They are really key in this process. Police men, who come to the scene of the death, also need to be trained. We also need outreach workers that can work with these families. These families are not going to go down traditional routes such as hospice, which is long-term death. We need to be able to create a support group, or a chat room (in today’s day and age), which allows families who are grieving to have that kind of help. We need to train schools, our graduate schools of… [11:16] of information on natural disaster or sudden death. Really, the opioid epidemic appears to be a natural disaster.
JK: What do you think makes the Opioid Epidemic different from previous drug epidemics?
LS: That’s a great question, because when you look at the figures, we know that we have a losing trifecta to which I refer you to the ‘Huffington Post’ piece I wrote called ‘The Losing Trifecta’. It takes longer to die from alcoholism, but one out of three families in the U.S. is affected by alcoholism. But we see alcoholism as somewhat normative because it is legalized. We’re about to have… [12:14]. I’ll just go out on a limb, we are going to have a losing track with marijuana as well. People are going to argue that marijuana in and of itself does not cause death, but it can lead to psychosis and schizophrenia. There is the Governor's Drug Driving Report which is done by Pacific Institute of Research and Evaluation, that demonstrates that when you have drug driving i.e. marijuana driving, you tend to have more car accidents. In fact, some of the states that have legalized marijuana, have more car accidents. But what I think is so outstanding, is the sheer numbers of how Opioid Epidemic started in 2002. On October 31st, 2002, President Clinton set into motion that in all emergency rooms and doctor offices, that patients had to announce what your pain is on a scale of 1-10. However, pain is subjective. Your ‘10’ may be my ‘7’, my ‘10’ may be your ‘1’. At the same time, the Sackler family had been developing opioids and they were giving them out, but nobody understood how frequently and the quantity of dosages. The University of Arkansas did great research on how many opioids have to take to be at risk for dependency. If you have more than seven in ten days, you have a risk of 10% or 20% chance of becoming addicted given all other things. So we had a perfect storm, so to speak.
JK: In your perspective, what is the ideal doctor-patient relationship with regard to pain management?
LS: I think you need to define what pain, chronic pain, and acute pain are. There is a wonderful book called ‘Pain is Strange’, but in short, most tissues heal within 90 days. However, our brain tricks us into becoming attached to the pain, which is sending us signals. “Hyperalgesia”, is actually a condition that is caused as a result of using pain pills not as a result of what we precieive as the origin of pain. We know that chronic pain affects over 133 million Americans, or over one third of our population. The annual cost of chronic pain is $635 million. Chronic pain is more common among women than men and among older people. It is the #1 cause of long-term disability. It can come from anything, facial pain, neck pain, accidents, hips, low back, arthritis, sexual trauma, fibromyalgia etc. But what is chronic pain? It is pain that has lasted more than 12 weeks. For the most part, this pain has be treated in terms of body part. Today, scientists are rethinking what actual chronic pain it is defined as pain that has lasted over 12 weeks, but the cause of the pain may not be clear if someone is taking opioids. With chronic pain, medication is only partially effective because there are multiple approaches that are needed, and that the side effects of chronic pain treatment become harder to tolerate overtime and interfere with normal functioning. So what happens is: our brain, in the process treating pain with opioids, becomes addicted the opioids which is a condition called hyperalgesia. So if you are taking pain pills for 10,12,15 days, you now have a chance of being addicted to the opiods. You will know this, because all of a sudden you're in pain but you hand might stand on end, this called hyperalgesia. Over time, what happens is that your brain becomes attached to sending you pain signals that are not from the initial cause of the pain, but from an attachment/addiction to chronic pain. We call this an attachment disorder. This also what we talk about when we discuss attachment to drugs or alcohol. People become attached to the alcohol/drug for their craving, so that’s what happens with chronic pain. The other thing that happens with chronic pain is anxiety and depression, as well as a change in your relationships because you are spending more and more of your time saying what you can’t do, and what's bothering you. A lot of times when we see people with chronic pain, we see them as also having a substance abuse problem, with anxiety and depression,we may see them with some kind of process addiction, and some legal problems as a result.
JK: So it's almost like, chronic pain leads to all these problems over time that have other consequences.
LS: Yeah! What happens with families, is that they feel really awful. They feel really terrible. They identify that the person is sick, because they keep going to doctors. In fact, 92% of all MRIs don’t reveal anything, but the person may go from doctor-to-doctor to gain access to opioids or buying over-the-counter. I can give you case examples if you would like.
JK: I know that there are some concerns with prescribing opioid medications of the pendulum swinging too far the other way and could have an adverse effect on people who have debilitating pain. What is the best way to strike a balance between the two?
LS: First of all I think there needs to be centralized pharmacies. So, if I’m suddenly living in the desert and I go to CVS to get a prescription, but then I go to another doctor or online. How does anybody know how many opioids I have? The other thing is, I think we need to look at family history for predisposition to an ‘-ism’. Learn about what the chronic pain really is? Is it addiction to the chronic pain, or is it something that needs attention? For a year and a half, I had the privilege of consulting at a chronic pain facility and created a family program for that facility. I had the opportunity to work with numerous people who would come in, and their pain level would be off the charts. I can remember, there were multiple things that they did that really violated their standards. One example is a woman who had a lot of low-back pain and had become addicted to pain pills. So much so that she had been writing prescriptions on her husband’s prescription pad in triplicate, which caused the chance for him to lose his wife and for her to go to jail. The system was very kind and allowed her to go to treatment instead, where she spent six or eight months living how to live with the pain. It might not completely go away, but she could learn mindfulness and other tactics. There are about seven ways that can help with chronic pain, medication is the least effective of those treatments. Another gentleman I remember has been in 8 treatment centers before he got there. The doctor said he had back surgery, and that he was not available at the time. During this period, the patient’s mother was dying of cancer so there were a lot of opioids that he could take from her. We had a soldier, who had a beautiful three year old daughter, who was never available because he was always high. He had already had a history of substance misuse, and of multiple doctors, and of multiple problems with the back. Let me tell you, I watched him climb up high [24:58], so he could go to a twelve step meeting everyday to learn techniques such as mindfulness, meditation, breathing, yoga, chiropractic appointments, Cognitive Behavioral Therapy in order to be more present with his loved ones. I’ve seen people who you would have written off completely, and said there is no way they could get up and walk. There was a wonderful woman that I met who had two knee replacement, two shoulder surgeries, and another operation. When she came in she was not present at all. She was ugly, her hair was ragged, and she had her daughter’s wedding coming up. Her husband was a medical professional, and she had been the way for ten or twelve years. What she had learned to do was one of the things that was really attractive to her when she was younger. So, when you do a pain assessment, you find out what people like to do before. And for her, this was canoeing. Keeping people moving is probably the most important things to do with all the other modalities, and doing it to the fullest extent of their abilities. And lo and behold, four weeks later when she had come back, she had canoeing and walking around the property. This was a woman who could not get up and walk previously.
LS: Once they are medically detoxed, people will reveal a lower pain threshold. They may have to re-learn how to live life, and families may also have to as well because they have grown used to coddling them and giving them the bail out.
JK: I know that you have done a number of family interventions and there are many indications to the family that there is a problem, but the loved one may not necessarily be ready to acknowledge there is a problem. Or if they acknowledge it, they may not be ready to seek professional help. In situations like that, how do you approach the intervention that makes them willing to reach out and get help?
LS: I think that you need to do it compassionately and with care. You have to believe in the invitational approach, not the surprise. These are wounded people, and so are their loved ones. Some of their loved ones aren’t so willing to get help either, because one you change one part of the system, you change the status quo. I use a very particular methodology that I have developed, which you can extrapolate from the book that is coming up. I try to learn everything I can about what I call the ‘identified loved one’, which is not an original term. It’s really ‘heart, hurt, and help’. What I do is interview all the participants of the intervention team, and I ask to do so individually. I ask them, “What is special about this person?”, “What makes your heart sing?”, and I ask for specific examples. I also ask, “What is the tipping point?”, “What brought you to call me?”, because people don’t call me unless their hearts are hurting, they don’t call me unless they really don’t know what to do. They call me at the point when they’ve yelled, they’ve screamed, they’ve plotted, and they don’t know to do. Another question I ask is, “What have you experienced?”. I try to get them to understand that you can break into the confabulation (I use this term instead of denial), that everybody has, and invite them to change and consent to getting change. For people like myself, the word ‘no’ is really just a conversation starter. A colleague of mine shared with that Eskimos have a thousand words for snow, so when I hear a thousand different words for ‘no’, I go in with the mindset of ‘Yes’ and trying break into that interior with love and compassion. I just did an ‘Invitation to Change’ this past weekend, and this person does experience chronic pain. They were in tears after they heard their loved ones speak so lovingly about them. And they were ready to go. Is every intervention in the world easy? Absolutely not. But. there is a lot a footwork that goes into them. As a licensed clinician I can understand everyone else on the team, because sometimes the team may have a saboteur and we may have to invite them to leave. The other thing is matching people for the right treatment. Not all treatment centers are alike, and certainly are truthful in this day and age of behavioral health. We also have to consider how much money this family has, that they are able to give. Are they insurance dependent, do they have no money? So there are a lot of factors that go into not just intervention, but picking the right treatment center. And then, the most important ingredient, is what is to the extent that this center, or I continue working with the family so that they can get the help they need?
JK: It is interesting that you were venturing, that some of their closest people may also not want them to get treatment or that there might be a saboteur in the group.
LS: Well it's not that they mean to, but unconsciously everyone has identified that this is the problem person. If you look at family history, you may find trauma in other people and you may also find that they also may be abusing a substance, even if it is not opioids. But if I’m considered the perfect person or perfect child and my brother is the one with the problem, if he/she gets well, what happens to my family position? And you have to really be able to understand that. And what happens to the mom, everyday she had a reason for living like making the food, putting the pills in the box, and all of a sudden she doesn’t have that role anymore. Even though she hated that role, so she said. So unconsciously, people identify around an identified loved one so that their behavior gets switched and they also have to change their way of looking at the world, their relationship to their loved one and the way they interact.
JK: So it's like, being an interventionist is a role that requires not just working with substance abuse disorder and mental health and so on, but it can expand to other psychological factors, other personal factors, and so on.
LS: That’s why I’m excited that Rutledge came to me and asked me to write a textbook. My hope and intent is that it gets adopted by graduate schools in Social Work, FT, and even law schools. I like that it is a living document with an E-Book, because there has been nothing written for academica before. Interventionalists come in shapes and sizes, and different backgrounds, but there is only a certification, not a license (needed to become an interventionist). I’m not saying that there are not really fabulous folks in the field,— I make mention of them in the book. But I really think that having a clinical background when you’re working with these complex families is a must. Its not as simple as getting someone from A to B.
JK: With these interventions, do you find that you have to do some work over time?
LS: I’m sort of persnickety, and I won’t work with a family unless they agree to solution-focused coaching as part of the agreement. I’m not interested anymore if we cannot follow-up over time because I know evidence-based change takes place after 60-90 days. So that means, everybody has to change. So if you are not willing to work over time, or that you think that you can spend time with someone for thirty days and it’s kind of a spin-drive, and everything’s going to be all better, and you don’t have any back work … [36:10]. I think we need solutions on the topical level, we need to set up centers with family programs, where people are set up to succeed.
JK: Do these interventions always happen in-person?
LS: Most of them are done in person. You know, people don’t understand how incredibly resourceful they are, and I have coached many families over the phone because they wanted to do it themselves. The thing with being social worker is that you’ve gotta start where your client is and join them. I think it's possible to coach certain ingredients. Recently, I did an intervention on a wonderful, wonderful family who had a 57 year old male and it was important for them culturally, to do it on their own. They followed directions and they was very successful! So it is quite possible, it just depends on who the person is and what the situation is. But I think professional coaching is really important in that venue. And if I’m not the right person, I know lots of people that could be the right person for that family.
JK: I can imagine that some of these families live in the suburbs, and a middle-class background. I know that in a lot of cases, there can be a sense of disbelief that it could happen to someone in their family, due to the stigma surrounding opioid addiction and how it is depicted in the media.
LS: That is one of the biggest misconceptions of the century, one in every three families are affected by addiction, by alcoholism, by drug addiction. In 1954, we did not American Society of Addiction Medicine, we didn’t have the American Association of Psychiatry, specializing in addition. In 1954, we just had attitude that ‘Alcoholism exists and it is a disease’, and we thought about it in the same way as heart disease and diabetes— that someone should be able to pull themselves up by their bootstraps. I don’t care where I go, sometimes I still experience that belief of ‘Why can’t they just do that?’. I think there was a wonderful article, I borrowed it from who was then, the drug czar. He wrote an article on words, words, words, and what are the right words to use to help decrease stigma. I think that it’s so important for everyone to know. It can happen to you, and anybody—color, race, economic status, has little to do with that.
JK: The analogies you make to diabetes and heart disease, that it is commonly accepted that these patients get the right treatment and that’s it.
LS: And do you know what the most resistant disease to treat in the United States is? If you had to pick between addiction, heart disease, or diabetes. Which one would you pick?
JK: Hmm, I’m not sure.
LS: It’s diabetes. In fact, there is a wonderful strategy called motivational interviewing developed my Dr. Miller and Dr. Rolnick, called motivational learning. It answers the questions of how do we join up and how do we roll when someone’s resisting? It was developed in hospitals with diabetics, it’s used effectively in people who have a substance abuse disorder and chronic pain as well. And so, what we need to do is realize that people are much more than their substance abuse. They’re a person, they might be a mother, they might be a sister, or brother, or husband. They could be a lawyer, a bus driver, a construction worker, they could be a student. They could be funny, they could be so talented. They could be a singer, they could be a dancer. People are much more than whatever that other label is. And people experience a substance misuse disorder, and people experience chronic pain, but they are so much more. So when I work with people I talk about people experiencing, I don’t call anyone an alcoholic or an addict. That’s a self label that you get in a 12 step group, which is wonderful, but it’s a self label.
JK: I can imagine that these words and these terms, and the connotations and effects that they can have. They can be magnified if someone wanted to get treatment or not, depending on how it makes them feel. In any other respect, is there anything else that you came across in the course of your clinical work that changed your perspective on the opioid crisis?
LS: It's such a big problem, and I think we need micro and macro solutions. I think I have more questions than answers. I hate the way we, in the United States, go “Oh hi, guess what we have an epidemic!”, and then we rally, but then we really don’t do anything. I think we need to get stuff actually done. There is a great need for affordable treatment, not just treatment for people with means. I think we need to do a lot of community education, which doesn’t mean we allocate it to our schools. I think we need to have an open discussion about it and allow people to have their voice. I also think we need to have some mass funding in terms of what works. I think insurance is not always our friend, because they’re dictating treatment in order to make money, not because some kind of treatment works. And I also have a call out for the behavioral health field. There has been an increase in treatment centers, but not all treatment centers are alike, not all treatment centers are honest. I mean if you call me another time, we can talk about the ethics in the behavior health field. I mean this is a billion dollar business, but they are in the business of saving peoples’ lives with qualified staff, with the right kind of treatment, to make this something that can work—not just take someone’s money.
JK: Right, and if someone gives you a magic wand that allowed you to change any policy or any rule in this space to help more effectively alleviate the crisis, which policy would you change?
LS: I wanna be visible, vocal, and visionary, and not the big, big question. I love that question, Jamal. That leaves me almost speechless. Access and availability policies for everything. I mean I want to change access and availability of not just opioids, I wanna change it for marijuana. I know the FDA came out today on vaping. All these things can lead us down that road to higher risk things. I think there needs to be a discussion in every medical school, in every nursing school, in every school of social work about how do talk to patients about opioids. What is it that we really get to do? And, do we have enough time to actually spend with patients besides the two minutes we do it. And now, I understand that the Sackler family, or the same producers are coming out with a new pill to end the other pill, so now that will be the new pill. I think that is not the answer, I think that people need to be treated. I would like everyone to have a policy on how we really treat chronic pain.
JK: Speaking of the Sackler family, what role and responsibility do you think pharmaceutical companies like Purdue, have in the effort to alleviate the crisis?
LS:I think that everyone has an obligation to alleviate this crisis. The fact that the Sackler family made billions off of this without marketing. I mean I remember when I was a physician I got free trips, I got free everything and was able to get everything that I wanted. I think they have an obligation, as I think every pharmaceutical company is to be careful. I think we need stop advertising on television, to be quite honest with you. Have you ever looked at the TV set? I mean, you can get cured from everything, but do you ever listen to the side effects? I mean, we have billboards that say ‘this can save you’, there needs to be some kind of advertising regulation. Who was it, Macklemore, that had the famous song about drug dealers? I think that they didn’t know what they were doing in the beginning, so they did the best they could do. But know we know differently, so we need don’t need Big Pharma, we don’t need individual physicians. We have a big black market now because when we run out of pills, heroin, fentanyl. It’s on the streets, thats a killing field all together. We also need to go to distribution, like where are you getting this stuff from? So, it's almost sort of astronomical. But your question was, should the pharmaceutical industry get involved in the crisis, and I think yes, they should, but so should a lot of other people. I also wonder why they can’t be taxed like the cigarette industry is taxed, and the money can go to treatment. I don’t know Jamal, you’re the expert in policy. What do you think?
JK: I know that there’s been some litigation that has been taking place, and if that can move forward and the states can get some funds, that can be a source to be used to help individuals who have opioid abuse disorder to get treatment. Provided, that the money they recover is actually used for that purpose, and not used for other policy purposes by different states. I know that with cigarette companies something like that happened, where they got a big settlement, but not all of it was used for people who were dealing with the health consequences of cigarettes. Some of it was used for other things, to fill a gap in the state budget and other things. So hopefully, if the settlement does happen here, it will be used to help people who have been adversely affected by the opioid crisis. Were there any additional thoughts or ideas that you would like to share?
LS: I just wanted to say thank you for being open, visible, vocal, and visionary in tackling this problem. I was honored to contribute!