One of my most memorable patients was a middle-aged man named Mike who came to treatment for his third drinking and driving offense. At the time, I was a young intern just learning how to connect with patients. He sat down in my office and before I could even begin my customary introduction to the clinic, he proceeded to tell me that I could not possibly have anything to offer him. During the last decade his wealthy parents had invested over 150K in the nations most prestigious alcohol treatment programs, and none of them had helped him. “Nothing against you,” he said dismissively, “but you’re an intern. Just tell me what I need to do to get out of here.”

I may have been an intern, but I was already deeply engrossed in understanding how science and research could inform my clinical work. My internship took place at a community-based treatment program which was part of a large university teaching hospital. On days where my patient load was light, I headed for the library and read the latest addiction journals. The year was 1997 and my curiosity led me to a facinating medication called naltrexone that had been used for a number of years to treat opiate addiction, but was now approved for the treatment of alcohol dependence. The only other drug available at the time was Antabuse (disulfiram) that caused sickness when alcohol was ingested. Most of the studies I read about naltrexone suggested that when combined with psychosocial therapies, outcomes were significantly improved.

As Mike sat there in front of me, half expecting that his deep resevoir of treatment experience would get him off the hook, I said flatly “how did naltrexone work for you?” At first he looked at me quizzically, but then quickly became more serious and said, “Oh yea, that stuff…I tried it but was still able to drink on it.” Calmly I replied, “I think you mean Antabuse. No, I am talking about naltrexone, the medication approved by the FDA a few years ago to treat alcoholism.” Now he really looked confused. “You’re shitting me aren’t you? If there was a new drug that would help me stop drinking don’t you think I would have heard about?” he said with frustration. I too was actually amazed that despite all the treatment episodes this guy had been through, and the fact that he had done time at some of the best in the country, that he would have heard about naltrexone. But he hadn’t. I went to my file cabinet and began pulling out journal articles to make my case. By the end of the session we had arranged an appointment for him to see our psychiatrist for a trial of naltrexone, and I was no longer just an intern in his eyes.

I would like to say that more than ten years later things have dramatically changed and addiction medications are well known and used appropriately in treatment programs across the country. But sadly, many who struggle with addiction still have no clue that a handful of powerful medicines have been approved by the FDA. My doctoral dissertation explored this topic in some detail, but if you want to skip to the chase I have also extracted the section that provides an overview of these medicines. Recently, Dr. Gupta from CNN interviewed a man who experienced success with naltrexone. The interview is short and worth watching. 

Although I strongly believe those who struggle with addiction should be made aware of addiction medications and decide for themselves whether to try them, let me be crystal clear that no medication will solve the problem of addiction. As I have discussed in other blog posts, addiction ultimately is about relationships. Medications can help manage cravings and decrease relapse so that therapy can more successfully focus on the developmental catch-up work necessary for long-term success.

This past Friday I took a rare day off from work and visited Our Lady of Guadalupe Trappist Abbey in Lafeyette, Oregon. This beautiful monestary was built in 1955 and is nestled among green fields in the heart of the wine country. Having never been to a Trappist monestary before, and having had a number of past clients with addictions participate in weekend meditation retreats at the Abbey, I was interested in seeing the place for myself. Within minutes of arriving, I noticed my body calming down, and felt a sense of peace just walking around.

After some time in the chapel observing the monks in silence, I visited the zen meditation room where a priest approached me. Unlike the others I had seen who clearly were engaged in their vow of silence, this one gave me a big grin and said “how are you?” Surprised that he spoke, I took the opportunity to ask questions about life at the monestary. He had lived there for over 50 years, had spent time with Mother Teresa in Isreal, and was full of colorful life stories. But what I remember most from our discussion was his answer to my question, “what has been the most profound thing you have learned from living the monastic life?”

He bowed his head and took my question to heart, and then after some time looked me in the eyes and said “Life is transitory, but we want things to be permanent.” He went on to explain that we spend a significant amount of time fighting the natural flow and rhyhm of life. The key to happiness, from his perspective, was accepting the impermance of our situation and going with the flow.

Addictive behavior hampers the flow of life. It is energy that gets misdirected into actions that have temporary pay-offs but long term consequences. It also is a way many escape the pain of change. Most of us like routines, habits, consistency. When life is changing, chaotic, or unpredictable, we experience stress. More stress, more addictive behavior. As a result, successfully dealing with addiction requires learning how to accept the impermance of life, go with the flow, and remain calm in the face of change – challenges for us all whether addiction is present or not. Daily meditation, solitude, time in nature, prayer, chanting, drum playing, mindfulness activities – all provide opportunities for evolving how we approach life and its transitory nature.

Although the common theme these days is to understand addiction as a brain disease with contributing “psychosocial” factors, I believe there is a more useful way to think about this problem that directly links with how we go about solving it. Addictions are about relationships with objects instead of people. Let me explain.

In all my years doing clinical work and research, I have yet to come across anyone who struggles with addiction that does not also struggle in their relationships with people. This is because addiction typically does not happen overnight, and involves multiple reinforcing experiences that basically tell the brain “keep it up.” Unfortunately, as a person invests more time and energy into their relationship with objects (alcohol, food, drugs, porn, video poker, the list goes on) less time is spent engaging with people in healthy human relationships. The result is that important developmental skills necessary to initiate, develop, and maintain intimate human relationships become significantly constricted. In sum, many adults who struggle with addiction are child-like in their ability to be in relationships with other people.

This suggests that our treatments and interventions very often miss the mark. We focus so much energy on stopping the problematic behavior that we miss the importance of helping those who struggle developmentally catch-up. We know well from work with autistic children, trauma victims, and others, that no matter how significant the developmental gaps, we can intervene effectively and help people create intimate, emotionally mature, and nurturing relationships that take the place of object-relationships. This work is not easy, and in future posts I will provide a lot more details about the specific developmental problems we see in those with addictions, and the treatment necessary for healing.