What if we told a different story about addiction?

How are healthcare practitioners engaging with the ‘opioid crisis’? How can we understand addictions differently, and therefore step up to this moment in ways that transform dominant narratives around addiction, reduce harm, save lives, and help build the world we believe in? Someone overdoses on opioids every 20 minutes in the US, and overdose is now the leading cause of death for people under the age of 50.  

At Casa de Salud, we are working to write a different story about addiction. Casa de Salud is a cozy, integrative medicine primary care clinic in the South Valley of Albuquerque NM. We see mostly uninsured Spanish speaking migrants, folks dealing with heroin and prescription opioid addictions, and trans folks seeking gender affirming care. We have a large syringe exchange alongside a harm reduction based recovery program. Our Strong Roots recovery program is a creative, visionary and deeply politicized recovery program integrating suboxone-based treatment with healing circles, primary care, traditional medicine and curandismo, peer support and popular education. We are weaving a new network of what harm reduction, recovery and healing can look like for folks dealing with opioid addiction in one of the hardest hit geographies in the country.

I have the profound honor to regularly meet with a group of folks in our Strong Roots recovery program, our curandera-nurse practitioner, our peer recovery coach and a health apprentice to develop workshops on ‘Criminalization the Drug War’, ‘Root Causes of Addiction’, and ‘Resilience and Social Change’. In addition to prescribing suboxone to folks in treatment, I get to work with them to develop the leadership and facilitation skills to lead the workshops with other people dealing with addictions. We are building a shared understanding of addiction as a community issue, a narrative that counters the pervasive shame and stigma society imposes on individuals. We are humanizing and politicizing its origins, and showing the inherent worth and dignity of people who use drugs, as well as their role in creating social transformation. My understanding of addiction has been deepening through these workshop series and through the wisdom, stories, and experiences of people directly affected by addictions as they unravel the structural inequities that set them up, the buried pains, and the desire to help each other out. As healthcare practitioners, I think it’s our responsibility to understand the broader context within which we practice medicine. And so, I think it is our duty to understand the structural and social determinants of health for folks who use drugs, and how we can engage with people who are in recovery in ways that reduce harm and promote healing. If we want to be effective at addressing opioid addiction and overdose, we have to understand the nature of the demand for drugs, rather than policing or trying to control the supply.

I was raised in the “Just Say No” to drugs era (though I didn’t adhere to it), and then was indoctrinated into the individualized medical model of addiction as a brain disorder in PA school. Reaching beyond these dominant narratives, I have come to understand that addition is rooted in structural inequities; in poverty, capitalism, colonialism, intergenerational trauma and the emotional pain that is engendered by these structures as they play out in communities,  families, and individuals. With others, I’m working to see and name how these structural inequities cause social distress, chronic stress, and trauma. Chronic stress and trauma often underlie the emotional pain that is at the root of addiction as people try to escape, mask or mitigate that pain. Dr. Gabor Mate explains addiction is neither a choice nor an inherited disease, but a human condition arising out of emotional pain and suffering.  Dr. Mate reminds us that there is nothing unique or special about opioid addiction, and that we are a society of addicts because we are a suffering people seeking escape from that pain through substances, sex, shopping, or technology.

The Adverse Childhood Experience (ACEs) study based on 17,000 patients confirms what people working in the field of trauma have known experientially—that early experiences of violence and trauma are harmful to health in a myriad of ways. The ACEs study demonstrates the direct correlation between severe childhood stress such as neglect, abuse, domestic violence, a mentally ill or substance using parent and various types of addiction. A child with four or more adverse experiences was found to be 5 times more likely to be addicted to alcohol, and 46 times more likely to inject drugs than children that didn’t have any adverse childhood events. The Racing ACEs publication expands on this work by explicitly naming racism- personal, structural and historical- as a root cause of modern trauma. We have ample research connecting trauma to addiction, we know that addiction changes the brain and impairs one’s ability to make rational choices, and yet our society and the medical field scrutinizes, pathologizes and blames folks dealing with substance use disorders unlike those living with asthma, rheumatoid arthritis or other chronic relapsing health conditions. Uniquely, the medical field interacts with substance use in ways that has implications for criminalization, as seen in the mythic “crack baby” frenzy (there is a whole other conversation here about the ways that the medical field scrutinizes and blames people for their chronic health issues such as diabetes or ‘obesity’  as they relate to fatphobia, classism, racism and sexism). As one of the participants in the workshop series who’s been incarcerated over twenty times exclaimed in a moment of revelation, “they should be helping us with treatment and instead they just lock us up or let us die”.

The impacts of opioid overdose and the state neglect that enable it are detrimental to all of our communities, albeit experienced differently based on one’s relationship to power. We have high rates of addiction across all sectors of people in this country- wealthy, poor, white, Indigenous, people of color, queer and trans folks, and straight people. (We are a suffering people). However, our society disproportionately criminalizes those who are already marginalized- especially poor people, people of color, migrants and LGBTQ folks at the intersections of those identities. The ‘opioid epidemic’ is increasingly seen as a public health crisis as more white folks are being impacted, yet the response to the ‘crack epidemic’ in the 80’s and 90’s had nothing to do with public health, and everything to do with the criminalization of people of color and dissidents through the drug war. In the 1970’s, Nixon called drugs “public enemy number one”, and declared a “War on Drugs” at a time when the rate of drug use was actually decreasing. A top aid for Nixon, John Ehrlichman, later admitted:

“You want to know what this was really all about. The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people. You understand what I’m saying. We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.”

The war on drugs created a media frenzy and punitive state response to drug use, boosting mass incarceration via mandatory minimums and the like instead of treatment programs. And here we are now, decades later with another substance use crisis, with no tools to respond appropriately because of racism and the pervasive culture of punishment.

Addiction is rooted in pain, and that pain is connected to larger histories and social contexts that we must grapple with in order to heal it. For many, the pain is emotional. For others, it is physical pain rooted in over-work and injuries, and the ways that stress and trauma manifest physically through the nervous system. Land dispossession and the trauma of colonialism and capitalism lead to broken interdependence from self, land and each other. Lorenzo Candaleria, a farmer, recovering heroin user and participant in the workshop series says it best,

“We lost the language because we lost the need to converse to mother earth. When you lose a language, you lose a culture, when you lose a culture, you lose identity…  a lot of addiction I see around me and the addiction I experienced was directly correlated to that loss of identity because we no longer have the need to refer to the sacred. So in losing the culture, we have no identity, without identity we have poverty, and that has led to despair, and it’s generational.”

As healthcare practitioners, how can we hold the big picture, the structural and social with the most delicate experience of individual human connection? How can we better challenge the stigma and judgement that arises in us and each other as we work with folks dealing with addictions, instead holding the complexity of trauma and suffering, and also of resilience and potential of the people we work with? As in organizing for social change, how we can honor that people who are closest to the problems are best positioned to create the solutions? How can we get out of the way and make room for folks who use drugs to determine the conditions of their continued drug use or their treatment, and to envision the policies to reduce harm and to end criminalization? There is so much that we can do together, and in collaboration and solidarity with folks directly affected by addictions.  The new recovery movement is one example of people in recovery sharing their stories as tools of empowerment and organizing, which includes storytelling as well as direct action. There are so many opportunities to organize for policy changes. We can get trained as suboxone / methadone (MAT)  prescribers. We can join harm reduction efforts to end discrimination against drug users, to prevent opioid overdoses through the distribution and access of naloxone (opioid antagonist medication used to reverse opioid overdoses), to pass good Samaritan laws so users are protected when they call in medical support for overdoses, to advocate for medical and mental health first responders to 911 calls instead of police, and expand access to syringe exchanges. We can join efforts to reallocate funds from prisons and policing into treatment programs. We can invest in treatment programs that are grounded in an understanding of trauma, healing, and the nervous system, and that use effective tools like  acudetox ear acupuncture, somatic therapies, and peer support. We can work to make these programs available for free for everyone, not just the elite who can pay forty to seventy thousand dollars a month for quality inpatient treatment. Let’s move towards wholeness, humanity and dignity, towards a new drug users union, an activist recovery movement, and healthcare practitioners participating in meaningful ways.

Queer Attachment: an anti-oppression toolkit for relational healing

A Zine by Leah jo and Fizz Perkal

We made this zine free and accessible in two versions: one to read online, and the other to print in zine format.

We invite you to read or print this zine for personal reading, or to share with others. We ask that if you do so, and are able, to consider making a donation to one of the following organizations, or another of your choosing. This zine was a labor of love, a gathering of teachings we have been lucky to receive from so many wise ones. In order to give back from what we have gleaned from the wisdom, leadership, teachings and inspiration of radical Black, Indigenous and POC leaders and organizers, healers and liberators, we hope that others will donate to some of the organizations that are making the way towards collective liberation for all of us. Donate here to support the Radical Dharma Movement Project. Donate here to Support Puente Arizona and their leadership for migrant justice, you can also specify “Healing in Resistance” to support their healing justice project.

Why we wrote this zine: 

We came to this project with a love of tools for self-growth that was born out of our own pain and pain we inflicted on others, as well as a desire to heal. So often this meant submerging ourselves in the deep and generally problematic waters of “self-help” books. While these writings led us to epiphanies and gave us a greater understanding of ourselves, engaging with them meant that we often had to filter out frameworks that didn’t fit us. Generally, the authors of self-help books are straight, white, cis folk who rarely acknowledge the larger structures within which our nervous systems and attachment systems exist. There aren’t many good how-to’s that substantially account for queer identity and provide an anti-oppression lens. So we decided to write something!

This writing weaves together what we have learned through more mainstream white attachment theorists, study of trauma and the nervous system, and radical queer Black, Indigenous, and people of color practitioners of this work. We are deeply grateful to the people we cite and reference directly, and also for the movements and visionaries who have shaped and inspired our analysis more broadly—especially the brilliant queer women and non-binary folks of color within the healing justice and transformative justice movements. 

We bow down to the writing, organizing, and intervening on generational trauma that, in the words of Cara Page, “transform the consequences of oppression on our bodies, hearts and minds.”[1]  We credit the disability justice movement for modeling how to center practices of community care, mutual aid, and interdependence. Whether explicitly named or implicitly present, these lessons are foundational in a politicized and comprehensive vision for relational healing. We are so grateful for all of the writings, conversations, and reflections that makes up this zine. This is a project of gathering wisdom that has been shared with us.  

We live in a web of systems of oppression and domination. Oppression is traumatic. Our bodies and nervous systems are not isolated individual entities untouched by the world. We are connected and related beings who are constantly impacted by each other and the larger systems that we exist in. We fundamentally believe that we are all harmed by systems of domination, albeit very differently depending on identity and experience within the historical and current contexts of settler colonialism, slavery and anti-Black racism, capitalism, ableism, and heteropatriarchy. 

We offer this writing to help connect the work of self-reflection and growth to political practices of accountable, deep, transformative anti-racist, anti-colonial, and feminist work. We’re coming from a place of believing that change must happen on many levels: personal, interpersonal, cultural, and structural. The same personal and interpersonal patterns we struggle with in our intimate relationships can play out in harmful ways in our organizations and movements, so we see this self and interpersonal work as intimately connected to social change work. 

Trauma is relational, so healing must be relational. Despite the conditions of trauma and oppression in our society, we are adaptive and resilient beings. This sentiment guides this writing as an aspiring road map to relational healing through the lens of nervous system regulation and (l)earned security.

Who is the We?

We are two white, queer, european settlers currently living on unceded Pueblo territory in New Mexico. Leah Jo is a community organizer, artist, and harm reductionist family medicine provider. Fizz is a non-binary community organizer, abolitionist, and full-spectrum doula. Leah Jo identifies more with anxious attachment, and Fizz with avoidant attachment tendencies.

We are not experts on attachment theory or the nervous system, nor therapists with extensive experience professionally supporting people in attachment related healing. We are two queers who have found these frameworks incredibly useful on our own healing journeys, and to supporting friends navigating relational challenges (romantic, platonic, and in organizing for social change). We also acknowledge that because of our privileged identities, we will inevitably miss things and make mistakes in this writing. We aim to be humble about our shortcomings; we are eager for feedback and dialogue!

Trauma and the nervous system

There is a strong relationship between the development of our attachment styles, the social systems we are raised in, and the development of our nervous system. We’re going to talk about the nervous system, and how it relates to trauma and to our survival and coping mechanisms.

What is trauma?

We hear the word trauma a lot these days. With trauma, we are talking about the way the body responds to and holds onto stressful and harmful experiences. Whether a one-time incident or a sequence of wounds, trauma is a form of disconnection, an experience of overwhelm so big it is stored in the body to be processed later. As there is often not an opportunity to deal with it later, this becomes survival patterning in the body. This can look like anxiety, nightmares, panic attacks, disproportionate/strong emotional reactions either to small daily incidents, (a loud noise, getting cut off in traffic, a comment) or to something for no visible reason. 

Trauma is experienced both individually and collectively. Oppression is traumatic, and oppressive systems prevent many of us from being able to process or resolve trauma. In the case of the US, these systems of oppression—historically rooted in genocide and land theft of Indigenous peoples and the system of chattel slavery—have been present for 500 years. This means 500 years of unresolved collective trauma. Today, people are living under the direct threat of policing, immigrant detention, the decimation of Indigenous sacred sites for extraction, and the chronic stress of surviving under capitalism. In these conditions, there often isn’t the physical safety and space to collectively process or resolve trauma.

What is the Nervous System?

When we talk about how trauma shows up in the body, we are talking about how it impacts the nervous system. The nervous system is an intricate network of nerves and chemical communicators that run through and connect our brain, organs, and really, our entire being. Our nervous system is organized into some big-word categories, but here we’re going to talk about it in terms of “survival” and “sustainable” physiology (a word used to describe the function of the body). Our survival physiologies are the states of our nervous system that help us fight, flee, or freeze. These are old and adaptive states that serve a function when engaged appropriately, but because of generations of trauma and systems of oppression, many of us are chronically stuck in our survival physiologies.

Download the zine to read more!

What is Attachment?

Attachment styles are unconscious coping mechanisms, or relational adaptations, that we develop at a young age based on our early caregivers. Our attachment styles go on to impact how we behave in our intimate relationships and relate to attachment figures in our adult lives. The terms and definitions we synthesize here are simplified, though we acknowledge that to attempt to simplify something as complex as the human experience within attachment relationship is slippery. We encourage folks to read and learn more if interested, and there are many books, podcasts, and writings available. Further, we acknowledge that attachment theory is a U.S. and euro-settler centric framework, which comes with all sorts of shortcomings (including a disproportionate amount of studies being based on straight white people). 

Our intent here is to share some simplified definitions, and help others access what we feel is another useful framework to better understand ourselves in connection to others. We investigate some of the ways that our attachment styles are informed not only by early nuclear family-based relationships, but also by intergenerational trauma, and the isolation, disconnection and chronic stress of capitalism, patriarchy and white supremacy that create an almost systemic attachment wounding in our society. Lastly, we aim for this framework to help folks build towards (l)earned security inside of ourselves, our relationships, and our organizations. By (l)earned security, we are referring to the ability to resist anxious or avoidant patterns that we’ve inherited and instead to cultivate secure, safe, and connected tendencies in our relationships. We use this spelling because we see this as both something that we work for (earned) and that we teach ourselves and each other (learned).

Tools Section

In this section, we will explore some of our favorite tools and frameworks for (l)earned security and nervous system regulation. We are using the term (l)earned security as an umbrella for various strategies and approaches to relational healing, or the healing that we do in relationships. Nervous system regulation includes different tools and approaches to help regulate our own biology and emotional states. Put another way, (l)earned security is about co-regulation, and nervous system regulation is about self-regulation.

In Nurturing Resilience, the authors talk about regulation as our bodies’ ability to manage our emotional state and to calm ourselves when we experience heightened emotions such as fear, anger, and frustration. They explain that regulation is a learned process that we integrate by observing others and through attachment with our early caregivers. Nervous system regulation relies on co-regulation and self-regulation skills. Co-regulation is the way in which our nervous system is settled through the support and soothing we get in attuned relationships with others. We can learn co-regulation early on with attuned caregivers if they soothe us when we are upset, and let us explore in developmentally appropriate ways.

Mainstream attachment theory exclusively focuses on the ways that attachment wounding arises in monogamous romantic relationships. The container of intimate romantic relationships is particularly ripe for early attachment wounds to be triggered as we unconsciously seek out and reproduce familiar unhealthy caregiver dynamics in order to attempt to heal and transform them. We want to acknowledge that attachment wounding can also be triggered in platonic and community level relationships, but not usually to the same degree of intensity.

Attachment healing work in romantic partnerships can be tremendously powerful and transformative. However, too often this work happens in isolation and separate from community support. We feel that the most powerful potential for interpersonal transformation within romantic partnerships is when they are held in community. When we build resilient communities with many layers of secure relationships, we create more space for mirroring, accountability and deep love within romantic partnerships. We hope these tools will be helpful in both attachment healing within romantic relationships, and on a community level. 

As Naomi Ortiz says in Sustaining Spirit: Self Care for Social Justice, “The reflection for growth and transformation, the work we have to do inside of ourselves, is not quick or efficient. The greatest transformations happen when we make time to reflect on what is possible.”[5] We don’t want to downplay how challenging, long term and deep this work of (l)earned security and nervous system regulation can be—and yet, we fundamentally believe that humans are resilient and have the capacity to be on the non-linear, messy, beautiful journey towards relational healing. One of the outcomes of this work is that we get to live our best lives.

We begin by sharing some frameworks that radically reimagine how attachment theory can be applied to social change work. Next, we explore (l)earned security, and some more tools to build secure relationships. We then finish with a few tools for self-regulation and nervous system healing.

Download the zine to read more!

To the organizers of the AAFP Adult Medicine Course…

To the organizers of the AAFP Adult Medicine Course,

I just attended the Adult Medicine Course in Phoenix Arizona, and wanted to take a moment to share some reflections and feedback with the organizers of this event. There was a lot of important, succinct, and relevant material that was presented in the four-day conference, and I am grateful for some of the clinical highlights I was able to take away from it.

However, I was disappointed with some core structural issues of the conference, and wanted to take the time to bring up my concerns, as well as provide some suggestions for things to consider in the future.

I think we are in a moment in society and in medicine, where there is an invitation and social responsibility to acknowledge the impact of structural oppression and inequity on health. We are in a time of greater wealth inequality than ever before, a time of climate change induced crises and migration patterns that are affecting health globally, a moment when movements for racial justice are drawing attention to the ongoing epidemic of daily police murders of people of color. We are living under a presidency that is assaulting our healthcare system, decimating the reproductive rights and access to reproductive choices of most women, and where millions of elderly, poor, and otherwise vulnerable Americans are facing the loss of health insurance.

I believe we are in a moment where it is no longer acceptable for large, well respected, healthcare leaders such as the AAFP to not only ignore these issues, but in fact reproduce the same oppressive dynamics that we are seeing under our current administration, and in the worst of our society at large.

In the entire four-day AAFP Adult Med conference, there were exclusively white, male, physician presenters. This is concerning for a number of reasons. There are growing numbers of female and people of color physicians and allied health professionals, and it is only appropriate to have presenters at a conference reflect the demographic of the field. Further, due to the socialization process within a society that systematically prioritizes men over women, white people over people of color, and educated and/or wealthy people- like physicians- over working class people, there are countless blinders and biases that white male physicians have been socialized to carry-albeit often unconsciously. This lack of awareness and lived experience from a diversity of identities creates gaps in knowledge of the presenters, and robs participants of a comprehensive educational experience.

I wanted to share just a few of the numerous examples of how the presenters reinforced oppressive dynamics and stereotypes throughout the conference.

  • One presenter made a joke about “you know…the obese woman stealing Halloween candy from her neighbor and then demanding thyroid replacement”. This exemplifies the unacceptable sexism and body shaming in western medicine, which reinforce negative stereotypes about women, and especially obese women. There were a number of body shaming remarks throughout the conference that exemplify the fatphobia physicians consistently enact on patients in ways that are both dehumanizing and oppressive.
  • In the hepatitis C case presentation, I noticed that the majority of the case studies were of African American patients. The over-representation of African American people in the hep C case studies reinforces negative stereotypes of African Americans through subtly implying that there are disproportionate Black IV drug users, as well as eliciting other narratives of anti-Black racism such as African Americans being “dirty” or “infected”, which have been inherited from generations of slavery, Jim Crow segregation and persistent manifestations of racism today.
  • One presenter continually referenced and projected his own Christian values. He made several comments such as referring offhandedly to “Jewish culture” when talking about religion, and telling the audience that, “everyone should just be monogamous because it’s safer and better”. This kind of Christian dogma from a presenter in a position of power is inappropriate at a medical conference that likely has participants from a variety of religious and spiritual backgrounds. Further, it is an unacceptable model for patient care in a time where non-Christian religions and especially Muslim people are being targeted and threatened at increasing rates.

From the AAFP website:

The American Academy of Family Physicians (AAFP) has a long history of supporting health equity and reducing health disparities in patient care. In fact, one of the key strategic objectives of the Academy is to “take a leadership role in addressing diversity and social determinants of health as they impact individuals, families, and communities across the lifespan and to strive for health equity.”

This ethic and commitment I see articulated on the Center for Diversity and Health Equity AAFP page was sorely lacking from the AAFP Adult Medicine Conference. Beyond the specific examples I provided, there was a consistent lack of analysis around this core understanding of social determinants of health and how they impact our patients. This was demonstrated repeatedly, as presenters would provide racial demographic information such as the risk differential between African American and white patients in regard to ASCVD risk without any context or acknowledgement of why African American males’ 10 year ASCVD risk is 6.1% as compared to 2.1% in a white female with the same risk factors. Without the appropriate framing of how social determinants of health impact health risk and outcomes, this information is implicitly interpreted as inherent or genetically driven, which is not only inaccurate but a missed opportunity to invite providers to better understand and address the social determinants of health and the health disparities that result in these risk differentials with our patients.

I am not suggesting that you make a superficial effort to “diversify” the presenter team by inviting in a token female or person of color presenter. Rather, I am inviting you all as leaders in family medicine education nationally to consider intentionally reflecting, evaluating and addressing these dynamics to improve the quality of your work and conferences in the future. People of color, women, LGBTQ and other marginalized people have a lot to offer the field of family medicine education. This might require asking the difficult questions such as; Why did we organize a conference with all white male presenters? What barriers exist that would keep qualified women, people of color or LGBTQ presenters from playing more leadership roles? What steps would we as an organization need to take to truly move towards our stated goal of addressing diversity and social determinants of health and strive for health equity? What kind of resources, time, money and support would be necessary to authentically work towards organizational transformation that addresses white male patriarchal standards and uplifts the voices and leadership of people of color, women and LGBTQ people?

As an organization that makes tremendous contributions to medical education and care Nationally, I hope that you are able to invest the appropriate time and resources to ask the difficult questions.


Leah Jo Carnine

Organizing against Trumpcare…

The summer monsoons have started, and after a month of temps hovering in the 110 range, I am again in love with Southern Arizona. I’m filled with appreciation for the resilience of the desert, amidst forest fires spreading rampant through the state. I’m trying to hold onto the monsoons when the world feels like the forest fires these days, on so many levels.

The Trumpcare bill in its’ various iterations is something I’ve been following closely in despair and fear. Reading the estimated impacts of the Trumpcare bill moving it’s way through the senate right now wakes me up in a panic, or hits me randomly throughout the day, moving me to tears. I think it’s something about being a human that cares about humans on the most basic level, and also something about being a healthcare provider and working with people who would be dead, or institutionalized, or in impossible medical debt without the programs that are under attack in this impending bill that’s hitting me super hard.

Most of my patients (and many friends in Arizona, for that matter) benefit from Medicaid expansion and/or Medicare. These programs fund most everything helpful I’ve ever been able to do for my patients. The defunding and dismantling of these programs is devastating beyond my imagination, and of course and as always, will disproportionately harm women, poor folks, people of color, disabled people and queer and trans folks.

I work with dozens of patients living with disabilities in their homes, within family and community, with Medicaid paying for the assistive devices, and home or family care to make it possible. Since the early version of Trumpcare, and the powerful disability rights & justice organizing against it, I have learned more about the history of disabled activists organizing for years to make it possible for disabled people to live at home, in community, instead of institutions. And I’ve learned about the real threat this legislation poses to undo those hard won battles.

I keep thinking about this undocumented/uninsured 15 year old boy I saw at the free clinic who had concerning cardiac symptoms, and an abnormal EKG suggestive of congenital heart disease, and how the state would have just let him die (turns out, we got him into a specialist and his heart is alright), or my friend’s mom in a state that opted out of Medicaid expansion who I am in almost daily contact with trying to help her navigate the system to rule out possible scary and life threatening illnesses without insurance coverage (nearly impossible). I think of the millions of undocumented folks that are already navigating this layer of exclusion and attrition policy, the death and pain and sickness and medical debt from ER visits that are yet another weight on a community that is already carrying so much.

Every day that I see patients, I click these diagnosis codes, which are generally diagnoses that are considered ‘pre-existing conditions’. This proposed bill eliminates mandatory coverage for many of these ‘pre-existing’ conditions, and doesn’t cap the amount that folks with ‘pre-existing conditions’ can be charged for insurance, and repeals protections for life time limits on healthcare costs that insurance will cover. In a comment on my facebook post, Aurora Levins Morales wrote about how oppression creates ‘pre-existing conditions’. And I keep thinking about how true and ironic that is. How state violence, capitalism, poverty and the chronic stress of living under white supremacy really actually create the social and economic context for pre-existing conditions to exist. And like everything this Government has and is doing, this bill targets most impacted and most vulnerable communities, via singling out folks with pre-existing conditions essentially created by state and structural violence. It feels like ‘A Handmaid’s Tale’ dystopian future mixed with Christian colonial logics, and real time anti-Black and white supremacist death policy.

We know how bad it is, and a lot of people are working really hard to stop this bill from getting through the US Senate. And while there are some real critiques of there being lots of white leadership and lots of new organizations leading the way, there is also some most impacted leadership, like seriously fierce disabled activists that have been participating in civil disobedience and putting their bodies on line.  There are groups like Public Health Awakened which are consistently centering a racial justice analysis, and tying the ACA repeal to the attack on migrant communities, and providing public health tools for racial and migrant justice, and Black women dreaming of Healthy Black Futures

I’ve been in my own journey of trying to figure out how to organize against the Trumpcare bill, doing my own weird professional healthcare advocacy with LTE’s and video collabs with a big hospital in town. I’ve been grateful to work at a Community Health Center that’s doing it’s own kind of advocacy, and linking up with some community groups to do visits to Senator Flake’s office with Medicare recipients, disabled folks and healthcare providers, making those calls to the Senator’s office, yelling on the street corner in the blazing sun. And while it feels like yelling at a wall, because it feels more like petitioning a power that doesn’t give AF about people, than building power in most impacted communities to win, it’s felt important to do something. And now, as this next round of the bill gears up for a senate vote as soon as next week, I’m excited to see a big mobilization in D.C. to shut down the senate, and my heart just wants to be there.

Beyond this next week, I want to be full on deep in this fight, and I want to do a different kind of organizing around healthcare. I want to work on our analysis to center most impacted communities, to tie the Trumpcare bill to the same logic that allows police officers to murder Black people with impunity. I want our talking points and actions to fight for Black lives and Black health. I want to work on getting these new-er white-er groups to show up in full force to support the struggles led by migrant folks and Native folks and Black folks and queer and trans people and poor people and sex workers and drug users- because these struggles are very much about staying alive, living with dignity, and of course health. I want to talk to poor or working class or middle class white folks impacted by this healthcare bill that might have voted for Trump about how this attack on basically everyone’s healthcare who is not rich, is working out. Not in a ‘serves them right’ shame-y sort of way but in a hey, maybe we can move together on this, and maybe that can be a step towards moving on to dealing with white supremacy way. I want to honor the wisdom of my comrade Diana Perez Ramirez, community organizer and public health genius in her invitation to use health as a lens for organizing, because it touches everything. I want to get inspired with people about autonomous health zones, and growing skills and knowledge together around health and body and food and herbs in a way that honors lineages of that knowledge that has been stolen from Native folks and communities of color, and gets them back into the right hands. I want to build healthcare infrastructure as a tool of organizing and connection, like the health fairs we did with migrant justice orgs in Phoenix, or healing days for most impacted leaders & organizers to get massages and acupuncture and stress relief tea, to just get taken care of for a day to regenerate. I want to follow the vision and strategies put forward from the healing justice track at the AMC, and the amazing mostly POC, mostly queer folks doing healing justice work.  I want to fight for a visionary universal healthcare plan that covers undocumented people, and reimburses healing modalities that actually work, like acupuncture and midwifery.

Right now, I am just trying to counter rage and despair with small actions, presence and grains of hope.

On navigating power dynamics and challenging white supremacy in medicine

I recently finished reading the brilliant ‘Structural Racism and Supporting Black Lives- The Role of Health Professionals’ published in this months New England Journal of Medicine, and am feeling gratitude for the mostly people of color doctors and public health folks putting out words like these, and leading efforts like #WhiteCoats4BlackLives. This article hits on some deep and core threads of white supremacy, impacts of systemic racism on health, and medicine’s collective failure at integrating any kind of analysis or praxis for addressing root causes of health disparities, or challenging systemic premature death experienced by communities of color. It lays out several recommendations for clinicians (and researchers) who want to do a better job, including; learning about and understanding the roots of structural racism in the U.S., understanding how racism has shaped our narrative about disparities, and naming and defining racism in health care and research.

As an organizer, I want to think through and talk about what we do as healthcare providers to work to challenge and dismantle white supremacy as part of larger social movements, how we organize and agitate and educate in medical schools and clinical institutions to implement this brilliant platform. But today, as a relatively new healthcare provider, I want to chew on what it looks like to do strive to do this work in my day-to-day as a clinician working with patients.

White supremacy is one system we continually interface with in medicine, as part of the intersecting web of oppressions including colonialism, ableism, classism, fatphobia, patriarchy and so on. There are so many layers of power we are constantly navigating (intentionally or subconsciously), depending on our personal location within this web, of course. And then there is this whole other layer of power dynamics in health care that exists between patient and healthcare provider, with a whole history of expertism and professionalization of medical knowledge out of the hands of everyday people, and medical injustices like medical experimentations and forced sterilizations. I think the practice of naming our location is a powerful step towards challenging racism and other systems of oppression. Especially for those of us experiencing layers of privilege as many healthcare professionals, this practice of seeing what we have been socialized not to see is necessary to dismantling systems of oppression. So, I want to start by locating myself as a white, settler, queer woman, able-bodied, class privileged, professional-classed medical professional.

When I first started at my job, I had just finished a visit with a man in his mid 40’s on dialysis, with bilateral amputations from diabetic complications and rheumatoid arthritis so severe he couldn’t inject his insulin. I had some tears in the bathroom from witnessing some of the late affects of colonialism on this persons’ body – including the severity of diabetic complications in Native folks linked to generations of forced displacement, land theft and separation from traditional farming practices, among other things. One of my colleagues caught up with me and gave me this misguided advice that I think is at the crux of how we consistently fail at this part, when she said, “Just remember, they did this to themselves”. This person is not a bigot, and she’s actually a tremendous healthcare provider that gives excellent individual care and is loved by her patients. I share this to show how much we as healthcare providers often fail at holding the larger picture of how systemic oppression (and all of the manifestations of it, including internalized oppression) affects people’s health. There is so much blaming patients that happens in medicine, so much rhetoric around “lifestyle choices” as if the way people eat or whether or not they exercise is a simple choice. In so much medical training, we are taught that health disparities exist for genetic reasons or lifestyle choices, without any acknowledgement of systemic injustice. So our day to day work seeing patients provides many opportunities to challenge our selves and each other on tendencies to blame and shame patients, to write off chronic illness as inevitable results of people’s bad lifestyle choices; to push to deepen analysis and hold these broader contexts of systemic injustices while striving to not victimize or pity the folks we work with.

For those of us working with marginalized folks, the call to learn about and understand the roots of structural racism (and other forms of oppression) is this real and tangible thing that we have the opportunity to do constantly in this work. How can we, for example, hold this broader context- of legacies of slavery and genocide, of medical experimentation, of eugenics and forced sterilizations, of lands stolen in exchange for Indian Health Services, of police murders and drug wars- in a clinical visit. To hold the violence and heaviness, and also the resilience of the folks we work with. One part of holding this bigger picture, I think, is to understand some of the mechanisms by which systems of oppression impact health. There is a tremendous amount of new research documenting what impacted communities have always known – that racism is bad for health – from racial profiling and chronic stress to the pathways of neighborhood segregation, discrimination, implicit bias, environmental racism and internalized oppression on health disparities, to how police killings are a public health epidemic. There’s also all the research coming out about the impacts of childhood trauma on health, and while to be more comprehensive and accurate, the Adverse Childhood Events checklist might also include experiences like policing and racial profiling in the neighborhood one grew up in, if we acknowledge that oppression is trauma, we can make the connections there.

I remember reading Dr. Gabor Mate’s book “When the Body Says No”, and piecing together how being on the short end of power can contribute to the development of certain chronic health conditions like autoimmune disease (i.e. lupus, rheumatoid arthritis). He explains how the immune system’s essential task is to distinguish self from non-self and protect self from things that can harm the body (viruses, bacteria, etc.). He goes on to explain, “Repressed anger will lead to disordered immunity. The inability to process and express feelings effectively, and the tendency to serve the needs of others before even considering one’s own, are common patterns in people who develop chronic illness”. For me, working with Native folks (who have the highest incidence of autoimmune conditions in the country according to the CDC), this framework resonated (women also have exceedingly higher rates of autoimmune disease than men, go figure). We can imagine how colonialism and the systemic disempowerment of Indigenous people could contribute to the immune system being misdirected and attacking self. This is just an example, but what I’m getting at is that using an anti-oppression framework can allow us to understand how oppression and power imbalance might be contributing to any number of health experiences our patients are coming to us with. And that providing good healthcare should include this parallel work around building an analysis around racism, anti-oppression and health.

Amidst my sporadic musings on how to integrate this analysis into patient care, I had the opportunity to interview Dr. Mate a while ago, and I asked him a question along the lines of “Within the limitations of a primary care medical visit, how can I talk to patients about the connections between colonialism and trauma and health in a way that is not disempowering?”. He responded by asking me questions until I could see that as a (white, settler) caregiver, bringing up colonialism could feel like an agenda. He encouraged me to think of ways of asking questions that help people identify the stresses in their lives, and see that dis-ease does not exist separately from their lives. He told me it sounds like I am speaking more than I listen, and I need to listen more. He talked about attunement, and agreed that the constant self work we can do, the nervous system regulation work we can do, allows us to be present and attuned, which is one of the greatest gifts we can provide. So in thinking about how we show up in an exam room, I think a lot about the conversation we had.

I continue sorting through these questions of how to show up with people one on one in an exam room, in a busy day, amidst all of the pressures of primary care work, and all of the stressors in people’s lives and the social determinants of health that are so much bigger than what I can address in a visit. When I’m at work, I’m often running from room to room, my nervous system dysregulated and frazzled, and it’s hard to be how I want to be with people. So I do my best, and try to be gentle with myself when I slip up, and try to slow down so I can learn how to be a different way, and then get swept up in the chaos of it all over again. I’m chewing on practices that I/we can cultivate to subvert power and meet people meaningfully in a clinic visit. And while so much of the context and analysis building around oppression, trauma and health feels like the necessary foundation from which to cultivate these practices, the moment to moment of it feels a lot like trying to be a decent human being. I think there’s something in the intersections, like praxis (theory and action), that I’m striving for. Like the analysis of a broader context of oppression allows for a container to better understand/imagine how people are where they are- with illness, addiction, pain, etc. And holding that bigger understanding I think allows us to shift from judgment, from some subtle “you did this to yourself” thinking, to empathy. And I think people feel the difference. So maybe with that, and with some practices is where the praxis is.

Here are some ideas, mostly things I want to do more of:

  • Asking more questions than talking
  • Never standing/hovering above someone
  • Taking a breath between exam rooms to energetically clean my filter
  • Ask for consent before a physical exam/touch
  • Give back options/power wherever possible “sit wherever is most comfortable to you”, “would you prefer my medical assistant to be present for the pap or that it’s just the two of us?”
  • Admitting not knowing
  • Not shaming people’s decisions/food choices/addictions/bodies/etc.
  • Trusting people’s intuition and expertise about their bodies
  • Not making assumptions
  • Talking to everyone about sex and practices in a normalizing way
  • Asking good questions, the kinds that help people make connections about stress, life, struggle to dis-ease/illness/pain, and about possible solutions
  • With addictions, or coping mechanisms, or other things that might harm people in some way, striving a balance between honoring those things and where they come from without shaming, and being supportive if/when someone wants to make changes (& practicing harm reduction)

I want to collectively be part of showing up for big justice-oriented transformations in our world and in healthcare. I want healthcare folks to increasingly be inspired by and participate in solidarity with the Movement for Black Lives, #NoDAPL, support Oak Flat and other Indigenous struggles, #Not1More and migrant justice efforts, combatting Islamaphobia and welcoming refugees because all of it is about public health, and I really believe that social movements are some form of preventative medicine. I want to be in daily struggle with myself to stay woke to the horrors of systemic racism and oppression, and bring more and more folks with me. I want medical (and PA and nursing schools) to teach about racism, capitalism and patriarchy as the threats to public health they are, and at the least integrate an awareness of social determinants of health into all levels of healthcare education. I want to see medical/PA/nursing schools subsidize people from impacted communities to become providers, so providers can serve the communities they come from. I want all the things, and in the meantime, I’m just going to try to stay open, stay in conversation, and try to work on these daily practices to do my job a little better.









on having a DEA#, chronic pain and addiction in primary care

I’ve been working as a PA doing primary care for just about 2 years now, and am still sorting through lots of big questions about my role in healthcare, medicine, power, how to support self-determination and wellness in this busted healthcare system, and so many things. I spend a lot of time working with people who are living with chronic pain, and have been thinking about how that links up with trauma, and where pain does and does not overlap with addiction.

I received very little training about chronic pain or the roots of chronic pain in my medical training. My training in addiction was equally limited, albeit more pathologizing, and I believe almost entirely inaccurate. Then I got my first job out of PA school on the Pascua Yaqui reservation, working with folks who have been impacted by colonialism and inter-generational trauma for hundreds of years. Here, I delved into a steep learning curve around many things, two significant ones being chronic pain and addiction. My analysis around colonialism and trauma gave me some preliminary context for the profound amount of suffering the patients I work with are dealing with on a daily basis due to the complications of diabetes, chronic pain, and addiction. The writings of Dr. Gabor Mate helped me develop an understanding that addiction is rooted in childhood trauma. He explains, and extensive scientific studies now shown a link between significant family trauma-such as family violence, addiction, incarceration, and sexual or emotional abuse- and addiction. Further, studies show that beyond individual experiences, entire communities with intergenerational and extreme trauma have higher rates of addiction, and that these are causally linked. For Native communities, this trauma is the result of colonial violence including sexual abuse in boarding schools, genocidal land theft and forced relocation. Dr. Mate helps link the systems of capitalism and colonialism as major contributors to traumatic events that can predispose people to addiction.

The research is out there on how child adversity/childhood trauma and higher ACE’s (adverse childhood events) scores are related to significantly higher rates of cancer, depression, autoimmune disease, heart disease, and addiction. The research demonstrates that chronic, toxic stress, and the environment one is raised in effect the expression of genes (epigenetics), brain connectivity and shape, resulting in these shifts in health. Dr. Gabor’s analysis, and my own experience providing healthcare with Native folks puts this in a broader context of how systemic oppression and the manifestations of wealth inequity, lack of power, police violence and incarceration are in themselves trauma, and inform trauma on the individual, familial, and community levels.

We are in a National moment with the chronic pain and “opioid epidemic” debate in healthcare. Everyday the news has headlines like, “The Opioid Crisis: Anatomy of a Doctor Driven Epidemic” and “Prescription addiction: Doctors must lead us out”, The rise of opioid prescribing is largely due to big pharma lobbying to increase medical prescriptions in the ‘90s, and 2000s. Among other things, this included the push for “pain as the 5th vital sign” wherein healthcare providers were encouraged to ask all patients about pain, and “treat” it by prescribing opioids widely and liberally. Now we are in a sharp turnaround in medicine, where government, state, healthcare agencies and media are in a frenzy about the “opioid epidemic”, and there is incredible pressure for ER docs, primary care providers, and even pain specialists to dramatically and rapidly decrease opioid prescriptions, and get as many people off of chronic opioid prescriptions as possible.

This frenzy is coming in the midst of some real public health concerns—including opioid overdose or poisoning, which is leading to an average of 44 deaths daily in the U.S. As it turns out, even back in the 90’s, people were overdosing or developing opioid poisoning. But it was just a much smaller number of people, so it went below the radar. The “opioid epidemic” topic intersects with an upsurge in heroin use, which may have some to do with people getting taken off their opioids for chronic pain, but seems to have a lot to do with the broader social and economic context we’re in. We are seeing staggering wealth inequity and poverty, a partial collapse of the white middle class, a rise (or perceived rise) in unemployment all of which are hitting lots of folks, and suffering, pain and isolation are major risk factors for addiction. Thing is, these are all getting smooshed together in a confusing mess of media and mixed messages, and being a healthcare provider in the midst of it has left me craving some politically grounded, harm reduction based insight and guidance for how to engage.

Some things I’ve gathered. Oppression is in itself trauma. Systemic oppression and childhood trauma and adversity impact many facets of health- including both addiction and chronic pain. Opioid dependence for people living with chronic pain, and people living with an opioid addiction have some areas of overlap but are by and large not the same.

I was able to participate in an online learning network called Project ECHO Pain that gave me some tools and framework for understanding chronic pain and better engaging patients who are living with chronic pain. We talk about three main types of chronic non-cancer pain (chronic pain from cancer is a whole different topic): nocioceptive (broken bones, stubbed toes, etc.), neuropathic pain (diabetic neuropathy), and what one of my teachers calls psychological pain—which I prefer to call chronic nervous system pain. All of this is experienced as pain in the body. There can be overlap between the different types of pain, but by and large they are unique etiologies. In medicine we often haven’t been trained to distinguish between the types of pain people are experiencing (or the root causes). And we have largely been prescribing opioids for any kind of pain, without performing appropriate evaluation to identify the actual cause.

There are a bunch of people living with chronic nervous system pain rooted in childhood adversity and trauma. For many, this pain is being managed by opioids, perhaps inappropriately. This does not mean that all people with chronic pain on opioids are addicts, although some of them might also be struggling with addiction. Many of these folks are dependent on opioids for relieving chronic pain that is psychological or nervous system pain, and therefore opioids are not ideal. When people are living with chronic nervous system pain, there is often a high level of nervous system dysregulation and stress, so opioid medications like oxycodone that soothe anxiety may make people experiencing this kind of psychological and nervous system pain feel better, but that doesn’t mean that it is the best treatment.

For me, the role of being a gatekeeper to opioids for a lot of folks who want them- whether for an opioid addiction or to soothe the psychological and nervous system pain of intergenerational trauma and colonialism- is a tension I struggle with daily.

Working with Native folks as a white settler healthcare provider in a legacy of colonization that created the very conditions for addiction, at a clinic where well meaning or indifferent healthcare providers have prescribed opioids indiscriminately for years, is not a simple thing. Mix in racial bias in prescribing opioids, by which I mean the research showing how people of color receive less opioids for acute pain and the internalized racial bias I am surely holding while prescribing opioids. And grappling with the daily experience of sitting face to face with a human being who is suffering, who is in significant and often debilitating pain. Sitting with someone who might be asking for a prescription of oxycodone, and whether or not opioids might be the best treatment route for that pain, looking at that person in pain and having the power to write that prescription or not is a complicated and often painful role to be in.

I know in primary care, especially for those of us working with marginalized folks, we are crunched with time, have too few resources and are engaging with problems that are much larger than any solution we can offer. But the reality is, we are the ones who need to be present and available to delve deeply and responsibly into chronic pain and addiction with our patients. It’s here I’ve been looking for resources, and while I haven’t figured out all the answers, here are some things I have found useful.

I’m in a learning process of how to engage in authentic conversation, loving investigation and accurate evaluation of chronic pain that is transforming my clinical practice. One of my teachers from Pain ECHO, Dr. Bennet Davis wrote an article, “the 9 Best Practices for evaluating and treating pain in primary care”, in which he breaks down a process for learning and getting to know your patient, including the psycho-social factors that impact their health and wellbeing, centering the patient in all decisions, orienting goals for pain treatment to how well someone is able to function in the ways they define as a priority. I started doing a more thorough intake for patients with chronic pain concerns, including the ACEs (Adverse Childhood Events) survey, a sleep evaluation, a brief pain inventory, and an opioid risk calculator. These forms give me tremendous information about the person I’m working with, their trauma history and risk for chronic nervous system pain, and how they are living, working, sleeping, existing in relation to their pain. I’m slowly learning how to ask questions to support people in making the links between their own difficult childhoods and their pain, and their ideas about how to heal. The next step is trying to get an integrative team on board, which means working with multiple providers to holistically address root causes of their chronic pain- including therapy, physical therapy, acupuncture, and whatever other resources are available (this could be another post: working with what’s reimbursed/affordable with patients when so many of the things that work and support healing are so expensive and inaccessible). I’m trying to learn how to really listen, how to be in tune with someone to know when it’s time to ask a question, or suggest a change or just sit in one brief moment of empathetic silence.

When addiction comes up, we need to have some more tools to offer—some framing around the learning-developmental, or the biopsychosocial model of addiction– which roots addiction in the environmental factors of one’s early life, as opposed to the medical ‘disease model’ of addiction (which pathologizes addicts as having brain chemistry disorder in a vacuum), or the ‘choice’ model (society’s approach to addiction where people are making a choice and have lack of willpower). We can counter the “tough love”/punishment approach to engaging with addicts rampant in our society and criminal justice system by being compassionate, available, empathetic, non-punitive and trauma informed in our approach. We can work to practice harm reduction and have relevant resources for addicts, including needle exchanges, free hep C testing, condoms and whatever else can help patients stay safer when using is a start. When patients want to talk treatment, offering up 12 step programs as one tool amidst many, including motivational enhancement therapy (an approach to therapy focusing on improving an individual’s motivation to change), acupuncture, medication therapy and/or methadone/suboxone maintenance therapy.

Because our nervous systems speak to each other, as an empath, I can mirror and take on pain in ways that are not helpful to myself or the people I’m working with. I am learning that how I am in my own nervous system is part of what I offer as a health care provider and as someone committed to social justice. My attempt to work on my own nervous system regulation for my own well being as well as for the care I can provide to my patients is requiring a tremendous amount of my own self-work, including somatic experiencing therapy (a body oriented approach to healing trauma and stress), slowing down, meditation and tonglen practice (Tibetan Buddhist practice of breathing in personal and collective suffering) and more.

There is so much suffering and pain in this world, and to have a DEA# and the ability to prescribe opioids amidst such a complicated mess of factors is a responsibility I couldn’t have imagined before stepping into it. So here we are, trying to make sense of chronic pain in a system that values profit over people, in a country unwilling to reckon with the legacies of injustice and the implications on our collective being. As healthcare providers we have this impossible role; we are asked to medicate and manage the manifestations of trauma and oppression on the body, without acknowledging root causes. Working with chronic pain is often something I want to turn away from, which is why the practice of turning towards it, engaging and going deeper feels necessary. While this work is so difficult, and I feel I have so few medical solutions offer, it’s also an opportunity to treat people who’ve been judged and shamed for their pain or addiction with dignity and respect, which is actually something well worth offering.