Читать книгу The Therapist's Guide to Addiction Medicine - Barry Solof - Страница 11
Оглавление“I’m Not an Addict; I Can Stop Anytime I Want!”
There are any number of reasons why people use and end up becoming addicted to alcohol and other drugs: to change the way they feel—for euphoria, sedation, and anesthesia; to self-medicate depression, anxiety, insomnia, boredom, and lack of pleasure. To treat addiction, you have to understand what it is, how people become addicted, and work to eliminate the underlying causes. If you don’t, you’re just addressing the symptoms and your treatment process won’t work. First of all, addiction doesn’t just happen—it takes time.
There appears to be a “continuum” of people who use alcohol and other drugs. Let’s start by stating that many people at the beginning of this imaginary continuum never get involved with substances. In fact, there really are many people who never use or even try alcohol or other drugs. It may be against their religion, like Seventh-Day Adventists, or for some other reason they are fearful, or simply uninterested. In other words, a lot of people never touch the stuff.
Having said that, let’s let the medical community weigh in with a definition. The American Society of Addiction Medicine defines addiction as “a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”
But please recognize that not everyone who uses alcohol and other drugs becomes addicted. Going back to the imaginary drug use continuum, we note there are many people who experiment with alcohol and other drugs but never become dependent or addicted to them. Who experiments with these substances? The answer is most people in our society. People experiment, even kids on a playground. You’ll sometimes observe them spinning in circles and going, Woo, I’m getting dizzy! This happens because people seem to have a desire to periodically alter their consciousness and it seems at the time like fun. I’m not saying that experimentation is always harmless because it isn’t. A kid can experiment with LSD and jump off a roof or experiment with cocaine and get arrested. But I am saying that many people do it and don’t run into any problems with it.
As we move on along the continuum we observe people who use drugs recreationally. Recreational drug use means you go to a party and you smoke a little pot or snort a little cocaine. Or you go to a baseball game and have a few beers. Now, again, I’m not saying that recreational drug use is harmless or for that matter, legal. Because you could use cocaine recreationally and have a heart attack or you could be observed smoking marijuana and wind up getting arrested. Or you could get stopped for DUI on the way back from the baseball game.
For these reasons and others, recreational drug use is a big problem in our society. Unfortunately, however, the media always manage to confuse addiction with drug use. Sometimes you’ll see an article in the paper reporting that the police busted a “rave” party, where kids were on ecstasy, and the media talk about what a big problem addiction is. The problem is that the two don’t have much to do with each other, at least not in that context. Kids do drugs, teenagers do drugs, adults do drugs. However, this phenomenon is not necessarily chemical dependency or addiction, but instead should be characterized as recreational drug use.
For that matter, when you see articles in the papers or the news media about some kid falling down and hitting his head or “overdosing” because he did ecstasy at a rave, how do you know it was really ecstasy that he was using? Remember, these drugs don’t come from a pharmacy. They come from street drug dealers who often cut them with all kinds of potentially toxic chemicals. You should be aware of an organization called Dance Safe (www.dancesafe.org). They’ll test the kids’ drugs before they enter the raves or parties. The kid gives them the drug for immediate onsite testing and they give it back to the kid with useful information like “I don’t know what you thought you bought, but this is really crystal meth,” or “You may have thought this was ecstasy, but it’s really DXM (dextromethorphan) and it’s cut with all kinds of bad stuff!”
Moving forward on our continuum, we see the next level of use: habit. Suppose a person has a glass of wine with dinner every night. Through repetitive experience, any action or reaction can become an acquired mode of behavior, also known as a habit. It is through ongoing repetitive experience, people become so accustomed to using alcohol and other drugs that this use becomes habituated.
By the way, according to the United States Public Health Service, one glass of wine or one drink a day for a female, and two for a male, is considered normative or noninjurious drinking. Risky or hazardous drinking is defined as more than seven drinks per week or greater than three drinks per occasion for women and greater than fourteen drinks per week or greater than four drinks per occasion for men. The reason there is a male/female difference, in addition to gender-based differences in body size/weight, has to do with alcohol metabolism. Because males have higher muscle to body fat ratio and most women have less of the alcohol-degrading enzymes alcohol dehydrogenase and aldehyde dehydrogenase, women can tolerate alcohol less well.
There are a number of studies that show that alcohol consumption in moderation is actually healthy. However, you can’t suggest that to your clients who are addicted because they have demonstrated through experience that they can’t just have one glass of wine with dinner. An often heard statement in AA is “one drink is too many, and a thousand’s not enough!”
After habit on our continuum is abuse, which means suffering adverse consequences related to the use of alcohol and/or other drugs. Actually, the term “abuse” has two meanings in the context of addiction medicine. In the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), substance abuse is defined by adverse consequences, such as relationship, job, or legal problems, but abuse also refers to the use of a drug by a person for a purpose for which it was not prescribed or intended—for example, when a kid goes to his or her parents’ medicine cabinet and steals Vicodin to “party” with it.
Adverse consequences of substance use can occur in different dimensions of a person’s life. Arrests for DUI or drug possession are examples of adverse legal consequences. Somebody who drinks so much that they sustain liver damage and continue drinking anyway is experiencing an adverse medical consequence. There are also adverse psychological and psychiatric consequences. Suppose someone uses cocaine or other stimulants like crystal meth, and he or she is depressed all the time but continues to use anyway. These substances wipe out the brain’s supply of dopamine (a neurotransmitter important to mood) so, of course the user is going to be depressed, an adverse psychiatric consequence. “Use despite adverse consequences” is a hallmark of abuse.
Addiction includes abuse, but it also includes other components. There are a number of different definitions of addiction, including the American Society of Addiction Medicine’s definition, but they all generally include abuse and some of these other elements. As of the time of this writing, the American Psychiatric Association is currently working on a new edition of the DSM (DSM-5), scheduled for publication in May of 2013. What seems to be evolving in the definition of addiction is a phenomenon of two overlapping neuroplastic (altering brain anatomy and chemistry) states produced by repeated drug use:
1 Physical dependence (which may be normal with certain prescription medications), plus
2 Compulsive out-of-control drug-seeking (which may be moderate or severe).
Drug dependence, which as we will see is different from addiction, means that neuroadaptation has occurred so that the brain doesn’t feel normal when not on it (whatever the “it” is). Ask someone who’s been on opiates for a long time how she feels when she stops taking them. She feels terrible, literally sick, because the long-term use of opiates changes the “thermostat” in the brain. With addiction there is physical dependency coupled with compulsive out-of-control drug-craving and drug-seeking. But remember, dependence isn’t necessarily addiction. You are not an addict if you are dependent on insulin, because if you are a diabetic you require insulin to function normally, and if you suddenly stop it, you will experience serious adverse consequences!
To use an example that’s more to the point, you can be dependent on opiate pain pills because you have a legitimate pain problem and you can’t function without them due to the pain. Let’s say you have metastatic cancer and you need to be on morphine to control your cancer pain. If you stop that morphine, you’re going to go into withdrawal. So you have developed an opioid dependency, but you’re not necessarily an addict—especially if you don’t exhibit compulsive out-of-control drug craving and drug-seeking. Compulsive out-of-control drug craving and drug-seeking, coupled with dependence, is the hallmark of addiction.
We can use the process of making a pickle as an analogy for how this process works. You start with a cucumber, put it in vinegar or some kind of juice, and then let it sit there. After a certain period of time the cucumber turns into a pickle. However, you can’t make it return to a cucumber again, because the composition has been chemically changed. A chemical reaction has occurred and it’s no longer a cucumber; it’s now a different vegetable, a different substance—a pickle. Similarly, when someone has the disease of addiction, as much as he or she might wish to, returning to “controlled” drug use is not an option.
I’ve heard people say things like: “I abused alcohol when I was in college and now I’m fine; I am able to drink normally now.” I would argue that this person was never really an addict; that he went through a period of life during which he abused alcohol, maybe was going through a divorce, perhaps had a stressful job, and self-medicated, i.e., “drank too much.” But he never turned from a cucumber into a pickle and didn’t meet all of the criteria for addiction.
There have always been addicts. Depictions of intoxication and addiction occur throughout history, from the Greco-Roman period, through the Middle Ages, during the Industrial Revolution, and so forth. There have always been people who couldn’t control their use of mind- and/or mood-altering substances.
In 1914, the United States government passed the Harrison Narcotic Tax Act, which essentially criminalized opiate/narcotic drug use. The government position was that alcohol and other drug problems were not medical problems, but rather issues for the police and law enforcement. Then came the Drug Enforcement Administration and the ever-expanding criminalization of addiction—to the point where doctors were actually arrested for the “crime” of treating addicts. This was true right up until the late sixties when the American Medical Association finally got involved.
Some very brave people who started the Haight Ashbury Free Clinic were at the forefront of the sea change that took place when the “flower children” were going up to San Francisco, zoning out, taking LSD, and having bad trips. The police kept trying to bust the medical practitioners at the Haight Ashbury Free Clinic, saying, in effect, “This is not a job for doctors or nurses; it’s a job for the police to handle.” Finally a lot of bigwigs got involved and went to the American Medical Association, there was a big protest, and the pendulum has now swung in the opposite direction.
Now addiction is considered a medical problem, but there is still “personal choice/failure of character vs. disease” tension in America. I remember when a well-known conservative radio host used to say that we should arrest all the addicts and “send them up the river.” That was, until he became an addict himself. If you’re in recovery you may well relate to the examples that I give here. For those of you who don’t have any background in addiction, please be aware that when somebody goes down that dark road of addiction and experiences powerlessness and loss of control, it becomes a very humbling and oftentimes, a humiliating experience.
People used to say to me, “How can you know anything about addiction or how can you feel for this if you’ve never had this problem yourself?” And I always say, “Look, it’s a medical illness. I can be a good dermatologist and not have acne. I can be a good surgeon and not have gallbladder stones. So why can’t I be a good addiction physician, empathize with the patients and with what they’re going through, and not necessarily, as an important criteria, be somebody in recovery?”
Some people still say things like, “Addiction really isn’t a disease, because you guys don’t cure anybody!” Especially if the person is a healthcare professional, like a doctor or nurse, I reply to them with a question: “How many diabetics have you cured lately? How many patients with asthma have you cured recently? How many patients with high blood pressure have you cured recently?” The fact is that 90 percent of the work that doctors do involves the medical management of chronic illness. Diabetes is a chronic illness. High blood pressure is a chronic illness. Asthma is a chronic illness. For a lot of people, low back pain comes and goes and is a chronic illness. Headaches are a chronic illness. Arthritis is a chronic illness.
Most treatments in medicine today involve management of chronic illnesses. Sure, if somebody breaks his or her arm that’s an acute episode, and if somebody gets pneumonia he or she might require a hospital stay as well, so acute illnesses obviously occur. But the majority of what goes on in everyday medical practice is management of chronic illness.
I think diabetes is a wonderful model for addiction. Diabetes mellitus (sometimes called “sugar diabetes”) is a condition that occurs when the body can’t use glucose (a type of sugar) normally. Glucose is the main source of energy for the body’s cells. The levels of glucose in the blood are controlled by a hormone called insulin, which is made by the pancreas. Insulin helps glucose enter the cells as fuel, or food.
In diabetes, the pancreas does not make enough insulin (type 1 diabetes) or the body can’t respond normally to the insulin that is made (type 2 diabetes). This causes glucose levels in the blood to rise, leading to symptoms such as increased urination, extreme thirst, and unexplained weight loss. For people who don’t have enough insulin or can’t respond normally to insulin, the sugar in the blood stays very high because it can’t get into the cells to be metabolized (burned).
High blood sugar is toxic to many organs in the body. It’s toxic to the eyes and causes people to lose vision. It’s toxic to the blood vessels, people get heart disease, and can lose their feet to amputation because they don’t get proper blood circulation. They lose kidney function, they go into renal failure, and so on.
Type 2 diabetes is milder. People with this type may just have to take medication, increase their exercise, and adjust their diet. Type 1 is a more severe form of diabetes, which entails injecting insulin. But either way, if you have diabetes and take your insulin, take your medications, maintain your diet, do some modest to moderate exercise, and undergo what are termed “lifestyle changes,” you’ll probably go on to lead a normal, productive, and healthy life. If you don’t do those things and you remain in a state of denial and eat candy bars all day and rarely leave the couch, you’re at considerable risk of losing your vision, losing circulation to your feet, developing heart failure, and experiencing renal failure.
It’s the same with addiction. If you ignore your problem, maintain a state of denial, do not take your medications, and do not participate in treatment or support groups, you will progressively develop more and more serious adverse consequences, including a large number of medical complications, along with the potential for losing your life. On the other hand, if you acknowledge that you have a problem, take your prescribed medications, and make the necessary lifestyle changes, including support group participation, you stand a very good chance of living a normal, productive, and healthy life.
Here’s Dr. Solof’s “Two-step process,” framed for patients: Acknowledge you have a problem, and work with something outside yourself—professional resources, people, support programs, and a Higher Power, to help you do something about that problem. Of course it’s more complicated than that, but simply put, you have to stop using. You are no longer a person who can drink; you’re not a person who can use drugs. Sure, you’d like to go back to using alcohol or other drugs in some kind of controlled way, perhaps like some of your friends, but sorry, just like a diabetic would like to avoid the need for dietary restriction and insulin, this is no longer a viable option.
Some studies show that “just stopping” actually works for some people. There is a small subset of people who do just stop on their own. It’s called “spontaneous remission.” In most cases, however, it takes a “wake-up call”; often some sort of “spiritual event” to get them to stop using drugs. And by spiritual, I don’t necessarily mean a religious experience.
It could be that a person suddenly wakes up from an overdose or a car accident resulting from being impaired, with paramedics standing over him, while he’s on the gurney, and he’s close to death. Or she wakes up in the emergency room. Or his wife leaves, or she gets fired from her job, or something similarly traumatic. Something has thoroughly shaken them up. And that something is frequently enough to motivate people to rethink the course of their lives and look at their use of alcohol and other drugs more openly than perhaps they have ever been able to before.
Once people stop using, the challenge is to stay stopped, and for most that involves engaging in the process of recovery. Many people need a support or mutual-aid program to accomplish this. The most popular support groups for addiction are found in the various twelve-step programs. Twelve-step programs—Narcotics Anonymous (NA), Alcoholics Anonymous (AA), and others—are the longest-standing mutual-aid/support resources for people struggling with addiction, and represent a spiritual (as opposed to religious) approach that has helped millions of people achieve and maintain recovery.
However a spiritual approach to recovery doesn’t resonate for some people. Some people prefer Secular Organization for Sobriety (SOS), other people go to Self-Management and Recovery Training (SMART), while others go to LifeRing or Rational Recovery. Some women derive benefit from another group called Women for Sobriety (WFS). A number of support groups are available that help many people.
An important point to remember, if you yourself are in recovery, is that your role as a counselor is to help your client recover from addiction. Occasionally, counselors in their own recovery experience some confusion between their role as professionals and their personal recovery. There is the potential for these roles to bleed into each other, but it is critical to maintain the boundaries between them. Counseling is always about the client and his or her individual needs. Remember that everyone is different. Perhaps for you, abstinence-based treatment and twelve-step-oriented recovery has been a great fit, but for your client it may be different.
You have to work with your client as an individual. Certain clients may be better off with Suboxone or methadone maintenance, or maybe they are extremely uncomfortable with the central role of a Higher Power in twelve-step programs, and an SOS support group would be a better fit for them. There are a lot of treatment programs that are twelve-step-oriented, but you can’t tell clients that “it’s either twelve-step participation or nothing,” because it’s not the only answer—and if you think it is, you’re in the wrong profession.
You’re going to read a lot more about this later in the book but for now, keep in mind that if you are going to be an effective counselor or therapist in this field, you need to be aware of all treatment and recovery-support options: those that are twelve-step-oriented as well other support groups, in addition to all the new medications for addiction that are coming out every day.
Twelve-step programs began with Alcoholics Anonymous in 1935 and expanded with Narcotics Anonymous in 1953. Since then there has been a proliferation of other twelve-step programs that relate to various manifestations of addiction and to other areas, including but certainly not limited to Cocaine Anonymous, Crystal Meth Anonymous, Nicotine Anonymous, Gamblers Anonymous, Neurotics Anonymous, etc. There are also multiple subgroups within some twelve-step programs. For example, in AA there is a group for lawyers, called the Other Bar; a group for airline pilots called Birds of a Feather; one for physicians called Caduceus; and one for police officers called Peace Officers Fellowship.
There are many different potential routes to abstinence. As I noted previously, there are some people who can stop by themselves without treatment and without ever going to a support program. Some people need treatment and participation in a support program. Others go to treatment but never participate in a support program, while others never go to treatment but participate in a support program long-term, and others may participate in a support program for a period of time, get the hang of it, not go back, and never use again. Some who leave support programs will return from time to time when they feel they again need the support/mutual aid, or after they relapse back into active addiction.
Some people go to AA or NA for the rest of their lives. Others go for years before deciding that they have their addiction under control so they stop, and many end up using again. It’s like chemotherapy for cancer. AA/NA is like their medication, their chemotherapy. If they don’t go, they often relapse, maybe not right away, but later if not sooner.
Even when addicts achieve stable abstinence and have time in recovery, they remain at risk. Research has shown that significant changes in brain functioning can persist long after drug use stops. In other words, the brain is not the same as it was, which is why addicts can go through a detox program, and then go on to complete treatment, remain abstinent as years go by, and then decide they can drink again. Within a very short period of time, they end up right back where they were when they stopped. This is evidence of disease progression. The brain is the same addictive brain—once “pickled” it is always “pickled,” and that pump is permanently primed. The first subsequent use of alcohol or other drugs can trigger a rapid return to active addiction.
The progressive loss of control that occurs in addiction is a very real, palpable phenomenon that does not differentiate based on financial status, job, race, religion, or gender. You can have a captain of industry, like someone who runs a Fortune 500 company, who went to Yale or Harvard, or is a senator, or a professional athlete who is brought to his or her knees by addiction. These are people who have been in control of everything around them for most of their lives. They may have millions of dollars and live in luxury homes in the most desirable, upscale communities, but then somebody introduces them to an addictive substance such as prescription opioids, cocaine, or crystal meth, or they get increasingly caught up in using whatever it is they can’t control. The more willpower they try to use, the harder they work to control it, the more they end up losing control.
They can’t control it because attempts to control behavior use the thinking part of the brain, the prefrontal cortex, as addicts try to think their way out of addiction. But thinking one’s way out of addiction is not possible because drugs of abuse target the midbrain (the so-called reptilian brain, below the cortex, which operates at a level beneath conscious thought). As a result, a different approach is required.
Sometimes patients will arrive and explain that they have their own ideas of what will work for them, and if it (whatever configuration of appropriate treatment, mutual aid/support group involvement or medication they may have in mind) does work for them, that’s fine. The problem I have is when patients come in and say, “I don’t want to go to AA/NA. I don’t want to go to the rehab program. I don’t have to see a therapist. Just detox me and let me go.” I say, “That probably isn’t going to work. You’re probably going to be right back here again in a month or two.” And their response is “Oh, no, I’m going to be fine.” And then they’re back again two or three months later, and this will go on and on.
Then there are the patients who are taking medications and they stop taking them because they think that the medication that they’re taking to help with their addiction is having an adverse side effect. One thing you learn in medicine, and it’s not just with addiction medications, it’s with any medication, is that with some people the medication is going to work effectively while others are going to get hives, a rash, or vomit. In short, they can’t tolerate the medication. Whether it’s an addiction-related medication, a blood pressure pill, or a diabetic medication, there is a lot of trial and error involved in what we refer to as empirical treatment. You have to try this and you have to try that in order to find out what works for each patient.
One of the problems practitioners encounter is that people now hear about many medications due to the hype of pharmaceutical company advertising and the promises made on TV commercials, and they think that’s the solution to their problem. Just take a pill and that will “solve my depression.” People often learn the hard way that there’s a lot more to getting through depression than just taking a pill. No two patients are the same; everybody’s an individual, so you have to do a comprehensive assessment to see what methodology can best be utilized with that client to help them with their recovery from depression.
While there are a lot of different drugs out there, you don’t have to be an expert on every single one of them because basically there are just five classes of mind-altering drugs. So whether you’re a counselor, a physician, nurse, or therapist, when you’re dealing with substance problems, you are always dealing with five classes of chemicals. The five classes of drugs all exhibit different effects. What they all have in common is that they stimulate the reward/pleasure center of the brain. They are
stimulants (cocaine, crystal meth, Ritalin, Adderall)
depressants/sedative-hypnotics (alcohol, antianxiety medications/tranquilizers such as Xanax, and barbiturates)
cannabinoids (marijuana)
psychedelics/hallucinogens (LSD, PCP, ecstasy), and
opiates/opioids (opiates such as opium, codeine, morphine, and heroin are derived from the opium poppy while opioids such as Demerol, Vicodin, Dilaudid, Percocet, Fentanyl, OxyContin, and Norco are synthetically produced).
People often ask me, “Isn’t marijuana a harmless drug?” My answer is that anytime you smoke something, it’s harmful. When you inhale smoke, whether it’s tobacco smoke or marijuana smoke, inhaling heated smoke is inherently unhealthy.
In addition, since, along with alcohol, marijuana is often a so-called gateway drug that people begin using in adolescence or even in latency age, we must ask ourselves how marijuana affects kids’ development. We know that the marijuana being used today is many times more potent than it was in the sixties and seventies.
We used to believe that the human brain was structurally complete at birth, that it had all of the neurons it would ever have, and that while these brain cells could die through damage or aging, more could never be added. We know now that the human brain is not fully formed until people are in their mid-twenties, and that it can continue to grow, evolve, and add neurons throughout one’s lifespan. The question is, exactly what is in the high-dose cannabinoids that contemporary, highly potent marijuana contains? We really don’t know what kind of negative impact these chemicals have on growing brains. We know that it leads to amotivational syndrome where users don’t feel like doing much of anything, whether going to school, doing schoolwork, doing chores, going to work, or taking care of other responsibilities. From a research perspective related to marijuana, one of the most important issues is to understand the vulnerability of young, developing brains to cannabis.
So despite the public’s perception that marijuana is relatively harmless, the numbers clearly tell us that it is an addictive drug. I tell people who don’t believe marijuana is addictive to go to a Marijuana Anonymous meeting, where they will see and hear people whose lives have been ruined by marijuana. There is no question that marijuana can be addictive. That argument is over. Add to this the marijuana withdrawal syndrome. It’s not so severe that we have to use medications for it, but its symptoms include irritability, anger, depression, difficulty sleeping, cravings, and decreased appetite. The withdrawal symptoms adversely impact attempts to quit and also motivate the use of marijuana or other drugs for relief of the discomfort of withdrawal.
This is especially relevant because more and more states have decriminalized marijuana and some have even moved toward legalizing it, often for medical purposes—both legitimate and concocted—including California where I practice. You just go to a “marijuana doctor” and walk in the door, where the only criterion for giving you a prescription is that you walked through the door. This is comparable to the old “snake oil salesmen” who used to travel from town to town and sell “miracle cures” for whatever ailed people. The Pure Food and Drug Act was launched in 1906 because these traveling salesmen would make absurd and false claims that their products could cure everything from hemorrhoids to dandruff and everything in-between.
Unfortunately, marijuana has become the latest version of snake oil in the sense that you can go into a medical marijuana clinic, claim virtually any compliant or ailment, and come out with a marijuana card—the equivalent of a prescription that gives you legalized access to pot. You have a headache, you get a marijuana card. You have stomach problems, you get a marijuana card. You have occasional back pain, you get a marijuana card. You have anxiety, you get a marijuana card. You’re a little depressed, you get a marijuana card. And a lot of people do this with a nod and a wink because we know that most of the people that go to “clinics” to get their marijuana don’t really have any medical problem at all.
That being said, I’m against the so-called “war on drugs,” and think it is actually a war on people. The “war on drugs” hasn’t made any real dent in the use of drugs in our society, and it’s often an extravagant waste of money. We should be putting this money into drug treatment and education programs. Personally, I’m in favor of decriminalization rather than legalization. It makes little sense to arrest, prosecute, and incarcerate people for possession of small amounts of marijuana (or other drugs people may possess for personal use), and subject them to expulsion from school, loss of financial aid, etc. Instead, we should be advocating education and treatment. We have zero tolerance in high schools where kids get thrown out of school because they were caught with one marijuana joint. This is not good for our kids. In fact, it’s not good for society.
Counselors or therapists in the field of addiction treatment need to know the medical aspects as well as the deleterious health impacts of marijuana. It can reasonably be viewed as similar to alcohol, where many people may have a glass of wine with dinner or a beer at a ball game and it’s no big deal. If somebody wants to smoke pot once in a blue moon, aside from the smoke-inhalation aspect of it, I don’t see it as analogous to smoking crack or crystal meth, or shooting heroin. No one smokes crack or crystal meth, or shoots heroin recreationally. But, marijuana also has a serious potential downside to it.
I had a patient who smoked pot because she was going through chemotherapy for cancer. It helped her appetite because cannabinoids increase appetite. However, there are other delivery systems available besides smoking it. If I were dying of lung cancer I don’t think I’d want to smoke anything. Marinol is basically tetrahydrocannabinol or THC, the main psychoactive ingredient in marijuana, in pill form and it can be taken by mouth. In addition to the tar and other impurities in the smoke, there are other psychoactive chemicals in marijuana smoke, so you’re not just getting THC.
So what is addiction treatment? Why can’t most drug addicts just quit on their own? How effective is addiction treatment, when is it necessary, and is addiction treatment worth the cost? Why isn’t more treatment available? What can we all do to help? There are about five federal government agencies now tripping over each other trying to get a clearer grip on these issues. We’ve got the National Institute on Drug Abuse (NIDA) and the National Institute of Alcoholism and Alcohol Abuse (NIAAA), both of which are part of the National Institutes of Health (NIH); we’ve got the Substance Abuse and Mental Health Administration (SAMHSA), which is part of the US Department of Health and Human Services (HHS); we’ve got the White House Office of National Drug Control Policy (ONDCP); we’ve got the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF); and the Drug Enforcement Administration (DEA).
Some of these agencies focus on research, including research on treatment approaches, some focus on providing information and policy, and some are concerned specifically with law enforcement. As far as policy and law enforcement, among my favorite things to pick on is the “war on drugs” because, as I’ve said, it is not a war on drugs; it’s a war on people. Throwing somebody in jail for simply using drugs does little to nothing to change individual behavior and serves no socially useful purpose. Even in some jails and prisons drug use is widespread, and the cost in dollars and human terms of incarcerating people for drug use is absolutely preposterous.
Addiction is a complex illness. It persists in the face of extremely negative consequences. If somebody burns his hand on a hot stove he generally learns from his experience and doesn’t go close to that stove again. Even my basset hound won’t go near the stove because a while back he burned his nose jumping up there. But an active addict will keep putting his hand in the flame or his nose on the stove. His thinking has become so distorted that he rationalizes “this time I won’t burn myself.”
Addiction is a brain disease that has direct impacts on thinking. The thought processes of someone who is addicted can be bizarre, as evidenced by his or her continuing to put his or her hands in a hot flame, thinking that “this time it’s going to be different.” If every time you drink you wind up in trouble, end up in jail, bleed from your stomach, and yet keep doing it again and again, that’s a special type of twisted thinking. Two impressive examples of the cognitive warping that takes place in active addiction that I’m familiar with involve a man with a gambling addiction who moved to Las Vegas to quit gambling, and a woman addicted to cocaine for more than ten years who switched to crystal meth to stop using cocaine.
But distortions in thinking related to addiction are not exclusive to addicts. Society still commonly sees addiction as a disorder of willpower and personal choice, so addicts tend to be viewed and judged differently than people who struggle with other chronic illnesses. Because addiction is a chronic disease, relapse is possible even after long periods of abstinence. Sometimes professionals, as well as lay people, challenge me on this point, saying that I don’t “cure” anybody because addicts in recovery often relapse and end up coming back to treatment.
But then, so do patients with congestive heart failure. Those patients are on heart medications and do well for a few months or a few years, but then have to come back to the hospital for a “tune-up” due to a relapse—a recurrence of their heart failure. Heart failure is an excellent example of how chronic illness works. Asthmatics frequently go through cycles of remissions and exacerbations (or relapses) of their symptoms, and have to come back periodically for breathing treatments, but we don’t pass negative judgment on them or consider giving up on them. Asthma is a chronic illness.
Most people, including many medical and behavioral health professionals, have an understanding that chronic conditions are managed rather than cured. But for some reason they think that if somebody with addiction relapses and needs to return to treatment again, it’s a treatment failure. It is not a failure. It is the natural course of the disease as it often manifests in those who suffer from it just like heart disease, diabetes, and asthma. Treating alcoholism and addiction involves management of a chronic disease.
Successful recovery from addiction means a stop to using drugs including alcohol and maintenance of a drug-free lifestyle, while regaining/achieving productive functioning with regard to family, relationships, work, and in society generally. Some people think that recovery is just about not using, and, of course, to a certain extent it is about not using, but I could handcuff patients to the wall and they won’t use, but that doesn’t mean they would be in recovery.
So recovery is more than just not using; it involves being a contributing member of one’s community, and making progress toward internal states of acceptance—not only of the need for ongoing abstinence, but also of people and situations that one has no control over—and peace of mind, otherwise known as serenity. This only comes with time and practice working a program of recovery by engaging in recovery-supportive activities.
In contrast, in very early recovery, many people are effectively “white-knuckling” it, holding on to their abstinence for dear life. It is in the days, weeks, and few months immediately after the cessation of using, whether the person went through professional treatment or not, that he or she is especially vulnerable to relapse.
It may come as a surprise to a lot of people, but addiction treatment is as effective as treatment for other chronic medical conditions. In other words, addiction treatment has basically the same outcomes—the same rates of success and relapse—as treatment for asthma, diabetes, congestive heart failure, high blood pressure, low-back pain, and other chronic medical conditions.
Effective treatment for addiction varies depending on severity, the types of drugs involved, and the characteristics of the patient. The best treatment programs provide a combination of therapies and other biopsychosocial services.
Since 1999, the National Institute on Drug Abuse, part of the National Institutes of Health, has maintained the following thirteen principles of effective treatment for drug addiction:
1 No single treatment is appropriate for all individuals.
2 Treatment needs to be readily available.
3 Effective treatment attends to multiple needs of the individual, not just his or her drug use.
4 An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person’s changing needs.
5 Remaining in treatment for an adequate period of time is critical for treatment effectiveness.
6 Individual or group counseling and other behavioral therapies are critical components of effective treatment for addiction.
7 Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.
8 Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way.
9 Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use.
10 Treatment does not need to be voluntary to be effective.
11 Possible drug use during treatment must be monitored continuously.
12 Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection.
13 Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.
There are many types of behaviorally oriented therapies, and for addiction therapists or students in addiction counseling programs, these are a primary focus of treatment. This is what we refer to as “talk therapy.” Talk therapy can take a variety of forms and orientations, including, but not limited to individual and group counseling, family therapy, educational lectures, cognitive-behavioral therapy (where the specific focus is on helping people to identify and change their thought processes and problematic behaviors), and psychotherapy.
A point of clarification: Most of the time, counseling and therapy essentially refer to the same thing. However, there are some distinctions between counseling and “psychotherapy,” with which it is helpful to be familiar. In the context of behavioral health (which includes addiction), “counseling” generally means a relatively brief treatment process that focuses on specific behavior. It often targets a particular symptom or problematic situation and offers suggestions and advice for dealing with it. Psychotherapy is typically (though not necessarily) a longer-term treatment that is oriented more toward gaining insight into mental and emotional challenges by focusing on the person’s thought processes and way of being in the world rather than on specific problems.
In clinical practice there is frequent overlap between counseling and psychotherapy. A therapist may provide counseling for specific situations and a counselor may function in a psychotherapeutic manner. As a generalization however, psychotherapy requires more skill than simple counseling, and is conducted by professionals trained to practice psychotherapy, such as psychiatrists, trained counselors, social workers, and psychologists. While a psychotherapist is qualified to provide counseling, a counselor may or may not possess the necessary training and skills to provide psychotherapy. These differences notwithstanding, for simplicity, I will use the terms “counseling” and “therapy” interchangeably.
Addiction treatment can involve the following levels of care: medical detoxification, inpatient rehabilitation, non-intensive outpatient treatment, intensive outpatient treatment, short-term residential treatment, and long-term residential treatment. All of these levels of care include various forms of talk therapy/counseling, addiction- and recovery-specific education, drug screening/testing to verify abstinence, and medication. Medications in addiction treatment can be those prescribed for detoxification and co-occurring psychiatric conditions, as well as agonist maintenance therapy and antagonist maintenance therapy.
An agonist is a molecule that combines with a receptor on a cell to trigger a physiological reaction. I liken the process to turning on an appliance through electricity. When you plug a blender into an electrical outlet, the plug is the agonist and the outlet is the receptor. The brain contains receptors. When certain drugs and medications fill those receptors, they trigger specific reactions. Agonist therapy includes medications like methadone and Suboxone (though technically, Suboxone is a partial opioid agonist—more about that later) that are designed to substitute for opiates/opioids, whether illicit or legally prescribed, on which people have become dependent (this will be discussed at length in Chapter Five). This notwithstanding, these medications have their own addictive potential and their use should be carefully structured and supervised.
There is also antagonist treatment. An antagonist is the opposite of an agonist. It is a medication that acts against and blocks the mind- and mood-altering effects of specific substances. Agonists and antagonists are key players in the chemistry of the nervous system. An example of a medication antagonist is naltrexone. This is used to block the effects of opiates and alcohol. I will also discuss these medications at length in Chapter Five.
In addiction treatment we see a lot of people who have psychiatric issues along with their addiction. There is a lot of depression and no small amount of bipolar symptomology among people with addiction. Addiction treatment providers also see a lot of anxiety disorders. Sometimes alcohol and other drugs are the primary cause of these psychiatric symptoms. In many others, the addiction contributes to and exacerbates co-occurring mental health problems that began prior to the initiation of substance use. Moreover, the existence of psychiatric issues also commonly complicates and exacerbates one’s active addiction.
When the field of addiction treatment was young, “sequential treatment” was typical. Unfortunately, what used to happen was that psychiatrists, psychologists, and therapists often refused to work with patients who were actively using alcohol or other drugs. At the same time, a lot of people in addiction treatment were uncomfortable working with addicts who also had psychiatric issues. As a result, nobody wanted to work with these patients with co-occurring addiction and psychiatric issues and they often fell between the cracks of the treatment and service delivery system. We have since learned that integrated and concurrent treatment in which patients’ addiction, mental health, and medical needs are addressed simultaneously is the most effective approach.
Behavioral therapies offer strategies for dealing with cravings, teach patients ways to enhance their coping capacity and prevent relapse, and help them deal with relapse should it occur. Addicts often suffer severe cravings. And unless they receive some form of treatment to help them learn how to manage cravings and withstand them, many addicts feel as though they have no option but to use. In treatment they learn and can practice other options. The desire to use is normal and may pop up from time to time, but there are a range of behavioral strategies that addicts in recovery can draw on instead of using.
Perhaps the most fundamental of these is instilling and reinforcing in patients the knowledge that cravings will pass because they come in bursts and spurts. Even though, for the person experiencing an intense desire to use, cravings can feel like they will last forever, they are always temporary. It is critical to teach this information because addicted people are not aware of it. The solution to cravings is to develop ways to ride them out. This often involves distraction, such as listening to music, going for a walk, going to a movie, or calling friends. This is one of the many areas where participation in mutual-aid/support programs, twelve-step programs in particular, can be extremely valuable. When people in twelve-step recovery are struggling, they can call their sponsor. They can go to a meeting; they can talk with members of their support group who have been through very similar experiences.
Why can’t addicts quit on their own? In the beginning, many addicts believe they can and from time to time they try to stop. For most addicts, discontinuing using means going through detoxification, the process of substances leaving the body and brain. Depending upon the substance and how long and how much someone used, the withdrawal symptoms people experience during detox can be agonizingly painful to potentially lethal. For example, opiate withdrawal from opiates/opioids like heroin, Vicodin, and OxyContin causes a withdrawal syndrome that is horribly painful, but it’s not dangerous (opioid overdose is dangerous but opioid withdrawal usually is not). However, withdrawal from sedative-hypnotics such as Xanax and Valium, and from alcohol, is extremely dangerous because people can die from DTs (delirium tremens) and seizures.
It’s important to not confuse how addicting specific substances are with the severity of the withdrawal syndrome associated with them. These are entirely different areas. For example, stimulants like cocaine and crystal meth are very addictive, but their withdrawal syndrome is minimal compared to opiates, sedative-hypnotics, and alcohol. To give you an idea of why, think of the neurons in your brain as little springs—alcohol and the sedatives keep the springs down, because they’re depressants. If you let a spring up really quickly, it bounces all over the room, but if you let it up slowly, you can control it. When people suddenly stop drinking, their neurons are firing like crazy (the springs are bouncing uncontrollably), and that can result in physiological instability, up to and including seizures.
But even when addicts are able to stop using—whether they detox on their own or through a medically supervised detoxification regime where medications are administered to make them safe and somewhat less uncomfortable—without treatment and/or working a program of recovery, the vast majority fail to achieve long-term abstinence. Detox is merely ridding the body of the physical presence of substances. It is not addiction treatment, though many addicts go through detox as a prerequisite to treatment. A lot of people go through detox and then refuse to attend treatment.
Medical detoxification is only the first step. A lot of addicted people come in, especially to a medical facility, and say, “I’m here to get detoxed,” or “I want to get detoxed.” Once they’ve been detoxed I say, “I now want to set you up to go see a counselor or therapist to go over addiction treatment.” Their response will sometimes be, “No, I’m not interested in that; I only came to be detoxed.” Addicts come in all stripes. We have patients at our clinic who come in for detox and we never see them again. And there are those who come back six months or a year later for detox again. They won’t meet with a counselor, won’t get any kind of treatment, and don’t establish any real abstinence, nevermind recovery. And we don’t see them again until the next time they need detox.
I always tell people that even when addicts can stop using, the problem is they don’t stay stopped. They stop for a day or two, or a week; they stop for two weeks, or even a month. And then they go right back to using again.
What defines success in addiction treatment? For people who complete a treatment program, one basic definition of successful treatment is no substance use and no criminality for a minimum of two years. Positive outcomes are correlated with adequate lengths of treatment. Success depends in part on whether patients remain in treatment long enough to experience and integrate its full benefits. As a generalization, the longer people remain in treatment, the better their chances of remaining abstinent and achieving recovery. And whether a person stays in treatment depends on multiple factors related to both the individual and the program.
Important individual factors include personal motivation to change, family dynamics, social supports, medical insurance, and other financial resources, as well as outside pressure to stay in treatment. Such factors include the criminal justice system and the Child Protective Services system, where the options are often either addiction treatment or incarceration, or potential loss of the custody of one’s children. Other external motivating factors are the person’s partner/spouse/family and his or her employer. All of these variables can play a role in whether the person enters and remains in treatment long enough to complete it or not.
These individual variables assume many different configurations, consistent with the diversity of addiction treatment patients. This diversity ranges from (for example) the previously high-functioning Beverly Hills attorney who is abusing alcohol to the schizophrenic high school dropout who is shooting heroin and living under the freeway overpass.
The Beverly Hills attorney is the head of his law firm, is married and has two kids, went to Harvard, and makes a million dollars a year in his law practice. One day, he comes home and an intervention is waiting for him. His wife, his law partner, and his kids are all sitting there with a trained interventionist, and they all say in various ways, “Listen, we love you, but we don’t love your drinking.” You know how the rest of it goes: “If you keep drinking we’re going to leave, we’re going to turn you over to the state bar, you’re going to lose your law license, we’re going to remove you from the law firm, and all these bad things are going to happen unless you go into a treatment program.”
Then there’s a heroin addict with an eighth-grade education who has schizophrenia, who contracted HIV from intravenous drug use, has no job skills, and is hearing voices. How do you compare these two situations? Obviously, there are many significant differences between these two people.
There are also treatment program factors related to retention. It is essential for counselors to establish positive therapeutic relationships with clients as early in treatment as possible, and ensure that a treatment plan is developed and followed in collaboration with each client. Clients also need information and psychoeducation regarding what to expect both structurally and experientially during treatment. Medical, psychiatric, and case management services should be available concurrent with psychosocial addiction treatment, and transitions to step-down continuing care or aftercare need to be agreed upon well in advance and be as seamless as circumstances allow.
Something that comes as a surprise to a lot of people is that individuals who enter treatment under legal pressure have outcomes that are just as successful as those who enter treatment voluntarily. That seems counterintuitive, doesn’t it? We tend to think that somebody “forced” into treatment because the court has given him or her the choice of treatment or jail would rebel against the process. Of course some people do rebel against the structure and process of addiction treatment—but that happens regardless of whether their motivation is primarily internal or external.
Interestingly, once many people who are mandated to enter treatment are exposed to recovery, positive things happen, and a lot of people begin to turn their lives around. I tell patients that “I don’t care all that much about the reason why you’re here. I don’t care if you’re here because your wife or your husband or your parents sent you, or if it’s the court or Child Protective Services that made you come, as long as you’re here. If you want to do it for your wife or whomever, do it for her, just as long as you’re here, and then we’ll see what happens after that.”
Here’s a critical point for aspiring addiction treatment professionals to consider: not everybody wants to stop using. That’s something you need to learn right now so your expectations can be set realistically, and you don’t burn out from the frustration and disappointment of not succeeding with all of them. Often, it’s much more than denial that we have to deal with. While many people don’t stop because they are in denial and contend that they “don’t have a problem,” there are people who simply don’t want to stop using alcohol and other drugs and are not yet ready to stop, despite the adverse consequences they have experienced to that point.
In order for addiction treatment to be effective, addicts usually have to get to the point where the pain of using and everything that goes along with it significantly outweighs the pleasure and/or relief that using brings. We used to talk about the need for people struggling with addiction to “hit bottom,” but at a minimum, addicts need to get to a place where they are confronted unavoidably with the reality that the negative consequences of using far exceed the perceived benefits. Ambivalence is common, even if technically, a person is not being “forced” into treatment.
A skilled counselor can tip the scales of this ambivalence by helping the patient to specifically identify the “good” things that he or she gets from using, as well as what using has cost, continues to cost, and is likely to cost him or her in the future. As this list is formulated and processed, it usually becomes clear that the costs of using are greater than its benefits, that the advantages can no longer compete with the disadvantages. This helps people come to the realization that they really don’t wish to continue living the way they have been, and they become willing to enter treatment.
Over the last decade or so, drug courts have evolved as an innovation wherein both drug abuse/addiction and criminal acts can be addressed in an integrated way. The most effective models incorporate criminal justice considerations with drug treatment that includes screening, placement, counseling, testing, monitoring, and supervision, and often include attendance at twelve-step meetings. Treatment should also include assessment and counseling for high-risk infections such as hepatitis C and HIV. Intravenous drug users, in particular, are going to be at considerable risk for these viruses. I’ve rarely met an IV addict who didn’t have hepatitis C. Many of the patients you will work with in addiction treatment are going to have HIV, they’re going to have hepatitis C, they’re going to be pregnant (with complications), and they’re going to have a range of medical problems from their using. We’ll cover these commonly seen medical comorbidities later.
Sometimes it isn’t possible to motivate clients externally to seek treatment. I recall one patient many years ago who had AIDS and was addicted to crystal meth. The only reason he periodically came to the hospital was because he was running out of money and running out of drugs. He had abscesses all over his body from injecting drugs and by the time I saw him, he had wasted away to about ninety pounds. He needed antibiotics and medical stabilization, as well as to get some food and hydration in him. Rather than let him die, we’d admit him to the hospital for a few days. One day I said to him, “Why don’t you give this up?” He said, “Doc, I don’t have much to live for. I’m going to die in a year or two anyway, if I live that long. At this point, the only enjoyment I get in life is shooting up crystal meth.” I didn’t have an answer that would satisfy him. I told him that his life would get better if he didn’t use, even if he only had a year or two. I never saw him again and I guess he died. In this field you see people who, for whatever reason, don’t want to stop using.
I had another case where a woman brought her husband in for treatment. They had been married for a long time and their marriage had reached that critical moment where she said, “Look, either you follow the doctor’s advice and get into treatment, or I’m leaving you. I don’t care how many years we’ve been married, I’ve had enough. It’s either me or the booze.” He said goodbye to his wife, right there on the spot in my office.
It’s not possible to force help on someone who absolutely doesn’t want to be helped. There are times when, faced with that choice of treatment or incarceration, people will actually choose to go to jail. For some people, especially if they have a history of incarceration, the idea of going to jail is more comfortable and (believe it or not) less scary than entering treatment.
You can put somebody in a psychiatric hospital against his or her will on what we call a seventy-two-hour hold, sometimes called a psychiatric hold, but that’s only if the person is acutely suicidal, an imminent danger to other people, or gravely mentally disabled. In this situation, there is a judicial hearing within seventy-two hours. But no one can be hospitalized against his or her will simply for using drugs, even if continuing to use puts his or her life at risk. Sometimes this is very difficult to explain to family members.
One of the ways to tell that someone is unmotivated to enter treatment or to complete it and achieve recovery (regardless of what he or she may say) is when the family, the doctors, and the therapists seem to be working harder on behalf of the patient than the patient is. Everyone else is pulling their hair out while the patient is drunk and stoned and often doesn’t care one bit. This is an example of codependency. Officially, codependency is defined as “a psychological condition or a relationship in which a person is controlled or manipulated by another who is affected with a pathological condition (as an addiction to alcohol or heroin).”2
More broadly, codependency is a psychological condition wherein a person’s view of him- or herself and self-esteem is dependent upon the welfare of others, most often the primary partner and/or family. Someone who is codependent defines him- or herself only in relationship to others, rather than as an independent individual. Codependents are much more concerned with the needs of others than their own needs. As as result, people who are codependent are overly responsible and controlling. They take responsibility for the feelings of others and can only be happy when those they are in codependent relationships with are happy.
Codependent caretaking of the addict by family, friends, or others enables him or her to avoid taking responsibility for his or her behavior and actually helps keep that person in active addiction. Codependents often have the best possible intent: With their pleading, they convince the addict to begrudgingly enter treatment; they may call all over town to find a treatment program, transport the addict there, make arrangements to pay for treatment, and after two days, the addict wants to leave treatment because “he had a fight with his roommate” or “didn’t like the way that counselor talked to him” or “doesn’t like the food.” So he calls his mother or whoever is likely to be the easiest to manipulate, who then agrees to allow him to come home and picks him up, thus saving him from the “horrors” of treatment and potential recovery.
Amazingly, it’s not that unusual for addicts, whether adolescents or adults, to get money for their drugs from their parents. Often the parents have not been told what their child needs the money for. But at a certain point, it’s evident and people are just kidding themselves. Allowing children to continue to live at home rent-free while they use whatever money they can get for drugs is another common way that parents practice codependency. Somewhere along the line, the parent comes to you, the addiction treatment professional, and says, “I want you to fix him, to cure him.” This is not to assign blame, but to clarify that active addiction generally has the unwitting assistance of people close to the addict. Their reactions to the addiction and its related problems enable it to continue.
How do twelve-step programs fit with addiction treatment? Many people who could benefit from addiction treatment have neither health insurance that covers it nor the resources to pay for what are often expensive services. Most addiction treatment programs require patients to have health insurance with the appropriate coverage or the ability to self-pay for treatment. Although many communities have some publicly funded or subsidized addiction treatment that is accessible to people without financial resources or health insurance, these programs are often limited in size and types of services they offer (for example, they may provide detox only), have narrow eligibility criteria, and may have long waiting lists for admission. It is an extremely positive development that the new federal healthcare law, the Affordable Care Act, mandates some coverage for addiction treatment, but how long it will take to become widely operational and how much positive difference it will make in terms of facilitating access to addiction treatment remains to be seen.
AA, NA, and the other twelve-step addiction recovery programs are free. As I noted earlier, as necessary as professional treatment is for many people, many others achieve and maintain recovery through twelve-step programs alone. Sometimes patients will ask me, “I go to twelve-step meetings, so why do I have to come to your treatment program? Or, alternatively they may ask, “I’m attending your treatment program, so why do I have to go to twelve-step meetings?” I try to explain to them that twelve-step programs provide invaluable opportunities for mutual identification and support.
They are self-help fellowships run by the members themselves, wherein members share their “experience, strength, and hope” with one another.
Frequently, the most effective approach is a combination of professional treatment and twelve-step program participation. I tell my patients (quite truthfully) that it’s really therapeutic for them to associate with people who have the same disease they do and have been through similar kinds of experiences. As such, people in twelve-step programs can understand, relate to, and support one another in ways that few others can. But it’s not professional treatment; it’s not professional counseling, and people involved in twelve-step programs alone are not learning about addiction as a brain disease, and do not have access to medications that might help them maintain abstinence or assist them with psychiatric or medical problems. Without professional treatment, needs that can be critical to the recovery process frequently remain unaddressed. Twelve-step program involvement and professional addiction treatment complement each other and work hand in hand.
How can family and friends make a difference? Family and friends can play a critical role in the recovery process by participating in professional treatment in the form of family therapy with the addicted person and/or attending one of the twelve-step programs for the family members and significant others of those struggling with addiction, such as Al-Anon or Nar-Anon. One of the valuable things that significant others of addicted persons learn in these programs is that they do not have any control over the behavior of other people; they have no control over whether the addicted person uses alcohol or other drugs. They learn what they can and cannot realistically do to help the addicted person and themselves in dealing with this problem. These groups provide information, mutual aid, support, and important opportunities to connect with people who share very similar experiences.
Addiction is a state in which an organism engages in compulsive drug-taking. The behavior of drug use is neurochemically self-reinforcing, which leads to a loss of control in limiting intake. The hallmark of addiction is this compulsive out-of-control drug-seeking, combined with obsessive thinking, drug craving, and physical dependence. Remember, people can be dependent on a substance/medication and not be addicted to it. Dependence is a state in which an organism functions normally only in the presence of a drug and manifests as a physical disturbance (withdrawal) when the drug is removed. Someone who has cancer can be dependent on opioids for pain management, but he or she may not demonstrate the obsessive-thinking, drug-craving, and compulsive drug-seeking and drug-taking that define addiction.
Is addiction treatment worth the cost? The short answer is yes, and that’s one of the reasons this book exists. It is also why the government allocates resources to conduct research on the disease of addiction and how it can be most effectively treated. Addiction treatment is cost-effective in reducing alcohol and other drug use and its associated health and social costs.
According to the National Institute on Drug Abuse, every dollar invested in addiction treatment programs yields a return of between four and seven dollars in reduced drug-related crime, criminal justice costs, and theft. When savings related to healthcare are factored in, total savings can exceed costs by a ratio of twelve to one. Major savings to the individual and to society also come from improvements in workplace productivity.3
It’s much cheaper to help people stop smoking now than it is to treat their lung cancer later. In the same way, it’s much cheaper to help people stop using alcohol and other drugs than it is to pay for them to be hospitalized for an overdose, after a car accident from driving while impaired, or for a liver transplant.
The bottom line is that addiction treatment works. If the same principles are applied to the disease of addiction that are used to treat any other progressive chronic illness, we find that addicted persons respond to their prescribed treatment just as those who struggle with any other chronic illness do.
Recap: The most important points to remember are
Alcohol and other drug use is not the same thing as addiction.
Addiction is a chronic brain disease that is amenable to treatment.
Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are valuable mutual-aid/support programs, but they are not the only support groups available for people with addiction, and they do not constitute treatment.
If you apply the same principles to the disease of addiction that you would use to treat any chronic illness, you will find the disease of addiction will respond to treatment just as any other chronic disease would.
Addiction treatment works.
CHAPTER ONE NOTES
2 By permission. From Merriam-Webster’s Collegiate® Dictionary, 11th Edition, ©2013 Merriam-Webster. Inc. (www.Merriam-Webster.com).
3 National Institute on Drug Abuse, “Understanding Drug Abuse and Addiction: What Science Says” (2007), http://www.drugabuse.gov/publications/teaching-packets/understanding-drug-abuse-addiction/section-iv/6-cost-effectiveness-drug-treatment (accessed January 2, 2013).
