“For every thousand hacking at the leaves of evil, there is one striking at the root.”  – Thoreau

In my life there have been many times when I felt isolated, lonely, disconnected, and alone. These times have never  been pleasant, and in the absence of nurturing relationships, close friends to call on a dime, or a tribe of my own, I coped by engaging in substitute relationships with work, money, entertainment, food, hobbies, and exercise (just to name a few). For years I felt shame about many of my behaviors, and my inability to connect in deep ways with others. Now I understand that so much of my adaptive behaviors were a response to underlying root problems, problems that needed resolving and hampered in significant ways my ability to intiate, develop, and maintain intimate and nurturing relationships with people. I also believe that now, more than ever, those who struggle with addiction share similar root causes that need to be addressed if successful longterm outcomes are to materialize.    

The roots of addiction go much deeper than the adaptive behaviors that so often are the focus of intervention efforts. This is because dealing with the symptoms (addictions) are easier than dealing with the root causes. I have long believed that addiction is a problem best managed over time like other chronic illnesses. But successful management necessitates addressing what drives the addictive behavior in the first place. It requires knowing how to turn down the flame, dig out the roots, and resolve problems that are solvable. These underlying roots come in many shapes and sizes, but there are two forms that I believe are the primary drivers of addiction today. This post will address the first form: adverse childhood experiences.

Adverse Childhood Experiences
In the mid 1980s, physicians from Kaiser Permanente’s Department of Preventative Medicine in San Diego made an interesting discovery. Those who were losing the most weight and succeeding in the weight loss program were the ones most likely to drop out and quit. Was it because they no longer needed the program? Nope. Further investigation revealed that the majority of dropouts did not maintain their weight loss and went back to struggling with problems of overeating and obesity. Why did they quit if they were succeeding in the program? A deeper look revealed that overeating and obesity were used as tools to cope with unresolved adverse childhood experiences (ACEs). In most cases, overeating was an unconscious behavior utilized as a protective solution to these unresolved childhood problems.

How was it unconsciously protective? In many cases, the ACEs involved sexual, physical or emotional abuse. Developing a relationship with food was safer than developing intimate or nurturing relationships with people who might abuse again. Being obese unconsciously deterred romantic interests and physically enhanced protection of the body. The finding that most of the participants in the weight loss program had prior ACEs led Kaiser to collaborate with the Centers for Disease Control (CDC) to explore the link between ACEs and general health outcomes.

The study involved over 17,000 middle-class Americans and has produced over 50 scholarly research journal articles. Among the most signficant findings in the study was that two-thirds of the participants reported at least one ACE, and more than one in five reported three or more ACEs. In addition, the higher a person’s ACE score, the more addictive behavior was utilized as a coping response. For example:

Here you can see that as the number of ACE scores increase, so too does the percent who meet criteria for alcoholism. This finding is detailed in an insightful paper titled The Origins of Addiction by the lead researcher of the study, Vincent Felitti. What the ACE study helps us to understand is that the roots of addiction are real, diverse, and if left unaddressed, will continue to fuel the behavior we are so badly trying to manage (or end).

Dr. Sandra Bloom is a psychiatrist largely responsible for the creation of the Sanctuary Model, which is both a framework for treating trauma, as well as an organizational change model that integrates evidence-based trauma interventions with the benefits of therapuetic communities. The brillance of this model is that it optimizes the safety and healing of all parties involved in social systems of care: patients and clinicians, prisoners and judges, victims and advocates, addicts and counselors. It is a model, in my opinion, that is applicable across all organizations no matter what their purpose, because it provides a roadmap for how humans should treat one another, no matter what position they may find themselves in.

Why do we need it? Because most social/healthcare service organizations are in crisis. U.S. healthcare problems were detailed in a number of publications by the Institute of Medicine, with outcomes indicating that the U.S. has the most expensive healthcare system in the world, yet ranks far down the list in terms of overall quality. But it is not just our healthcare system that is in dire need of overhauling. Our education, criminal justice, mental health, child welfare, and…yes, our addiction treatment system are all struggling to meet the needs of the populations they serve. The Santuary Model suggests that the problems are rooted in unhealthy systems, not individual people. If we understand the system, we then stand a chance of making changes within the system that ultimately translate into better outcomes for all involved.

Across the different social systems, the problems are similar: reduced funding, decreased training and education, more paperwork, more surveillance and  micromanagement, greater staff turnover, and lots of stress across all levels of organizations. These factors then translate into organizations that are chronically stressed, attempting to do more with less, always operating in a reactive/crisis mode, ultimately leading to folks being chronically hyperaroused. In this state, it is like Brian Farraher, CEO of Andrus Children’s Center has said, “Managing like your hair is on fire.”  Stress leads to a loss of basic safety and trust, a breakdown of emotional intelligence, behaviors that result in more conflict, and staff who feel disempowered. As relationships become strained, more autocratic approaches to leadership (counseling/healthcare/justice) emerge, and then folks just stop talking. In essence, organizations stop learning. The outcomes are costly for all involved.

The Santuary Model is the antidote. It acknowledges that stress, trauma…life problems, exist not only in the clients who show up for help (or are mandated for help), but also in the helpers. The served and the servers are mirrors of each other, and both require focus and attention on seven commitments:

Implementing the Sanctuary Model in organizations, and incorporating the commitments into all of our lives, means embracing our responsibility to the common good of all people, to our future, to our planet. The details of the commitments, and how best to implement them are documented on the Sanctuary Website and in Creating Sanctuary: Toward the Evolution of Sane Species.

If we ignore the warning signs so clearly right in front of us, “Human history becomes more and more a race between education and catastrophe.” HG Wells, Outline of History, 1920

This past week I had a few minutes to spare in Washington DC, so I dropped by the National Geographic Society headquarters and discovered a project that has significant relevance to successfully solving the problem of addiction. Writer and photographer Dan Buettner embarked on a journey around the globe in search of communities that optimized lifestyle for longevity and happiness, places he calls blue zones.  He boiled down his research for the book Blue Zones into principles for living a long and prosperous life. Here is a great summary of the book he did for TED:

For those who struggle with addiction, the keys outlined in the book (and the speech above) provide a road map for translating the MRC solution into reality. Let’s look at how they line up:

Manage
Successfully dealing with addiction requires identifying those things in your life that are chronic issues, and then developing strategies that appropriately keep these things in-check. When we expect to permanently solve a chronic problem we set ourselves up for failure because there is no cure or end to these issues, they require ongoing attention. Addiction, diet, chronic medical issues, time and exercise are all things we must learn to successfully manage. In Blue Zones, the keys that line up with manage include: 

• Learn to move naturally. Those who live to be 100 rarely engage in rigorous exercise. Instead, they incorporate  walking, gardening, yoga and other less body-stressful movements into their daily routine. Developing a healthy lifestyle free from addiction necessitates learning to move in the world in a new way, in a natural, physically and emotionally pain-free way.
• Slow down. Our culture perpetuates addictive behavior by encouraging lifestyles where multi-tasking, reliance on technology, and instant gratification become packaged in a speedaholic existence. Not so for those who live in blue zones. An important aspect of successful long-term management of addiction is learning to slow down, become conscious of how you spend your time, and align it with what is most important in your life.
• Eat and drink wisely. Food and drink are common objects of addiction, and although abstinence from alcohol is possible, we cannot stop our relationship with food. The same goes for those who struggle with sexual addiction. It is not possible to remain abstinent from sex, we are sexual beings by nature and healing requires finding healthy ways to express our sexuality. The key is moderation, balance, and of course, eating more fruits and vegetables. Red wine has also been shown to increase longevity, but if it creates more problems than benefits (e.g., abuse, relapse) it should not be on your list.

Resolve
There are some life problems that we should not manage, but solve, permanently. Homelessness, debt, acute pain, many developmental constrictions/deficits, legal problems, and suicide ideation. None of these things are healthy to manage over a long period of time, and our work should focus on resolution. Two significant problems most addicts need to resolve are lonliness and isolation. The key that lines-up with resolve is:

• Be Connected to Others. Those who live the longest put family and loved ones first. They belong to communities that nurture and protect each other. Many share their spiritual faith in community, and hang out with people that have healthy habits, both physical and emotional. I have written a lot about how the essence of solving the problem of addiction is disconnecting from object-relationships and learning to engage in healthy, intimate connections with people. But to do this very often requires resolving barriers to human relationships. These barriers include unresolved trauma that lead to isolation, developmental stuck points, and debilitating shame and grief. This work is not easy, but necessary for relationships to blossom.  

Create
Many who struggle with addiction spend all their time on the pathological side of the equation. Treatments, interventions, fixes, cures, treatments….all intended to reduce or stop addictive behavior. This stuff is important, but at the same time it needs to be integrated with actions that optimize life.  Sometimes taking a break from intervening on addictive behavior and directing energy to what we want out of life can actually produce the outcomes we seek. Those who live in blue zones:

• Have a clear purpose. They call it “ikigai” – the reason for which you wake-up in the morning. If your ikigai is that you don’t want to drink, smoke,  or act-out today, well…this is not a very compelling reason to get out of bed, it just gets you to focus on what you don’t want! The key is redirecting your life energy towards creating what you do want.

For additional information on blue zones, checkout the author’s website: bluezones and the book.

There are many things I struggle to manage in my life, including time, food (or more correctly my weight), exercise and making sure my dog gets her heart medicine every eight hours. I have other vices as well, but what links all of these things together is that they are ongoing issues that come and go in my life. At times I eat healthy, exercise regularly, and use my time well. Yet at other times I find myself scarfing down junk food, skipping workouts all together, and feeling like a mouse on a never-ending treadmill.

Addictive behavior is similar in that it also comes and goes to varying degrees over time, it is not a constant. Although some can find permanent solutions to end particular behaviors (“I just stopped smoking and never went back to it”), for most people, even if one behavior goes away, another usually takes its place perpetuating the problem of addiction just in a different form. Because objects of addiction can also come and go, it is easy to see why dealing with addiction can become so hard – different addictions, different times, different problems, but most often sharing many underlying traits. As a result, I believe that the most humane way of dealing with addiction is by utilizing a management approach that aims to decrease harm for all behaviors over time, and improve ones quality of life. Too often I see people going in and out of treatment, attempting desperately to put a lid over the behavior and banish it forever, only to get depressed and frustrated when it returns in its original form, or surfaces in another addiction. So how do we manage behavior? Whether it’s addiction or giving my dog her pills, I have found four key things that make a difference:

Awareness: You cannot manage anything if you are not aware of it and how it plays out in your life. Awareness is not so easy these days because we are bombarded from every side with people vying for our attention. But you must increase your awareness of the behavior you wish to change if you have any chance of success. How do we do this? (1) utilize reminder messages on your computer, phone, on sticky notes, put them on electronic calendars that email you reminders, set alarms to go off at critical times, (2) talk with someone about the behavior on a regular basis and process your progress – could be a therapist, friend, pastor, mentor, coach, spouse – who does not really matter so much as just having an ongoing connection and doing it, (3) utilize a form of meditative practice to help clear away psychic junk and make more room to help you stay aware of what is truly important to you, and (4) set-up your environment in such a way as to increase awareness: find new routes to work that avoid high-triggery places, get rid of the extra refrigerator in the garage where you store beer, add things that you want to focus on instead of the addiction like an easel for painting, a musical instrument, or perhaps a pet if you don’t have one.

KISS: Yes, the tried and true Keep It Simple Stupid (OK, maybe the stupid needs to go) applies to managing behavior change. The more complicated you make it, the less likely you will succeed. Simple means we don’t try to change too many things at once, and we do our best to find the simplest and easiest way to accomplish our goal. Earlier this year I significantly changed my diet and felt great. More energy, better sleep, all the things promised from this new way of eating materialized. Yet a few weeks later I was back to my normal, disappointed that I could not maintain what I started. But I shouldn’t have been. I changed too much too fast. We humans live so much by habit, and the many routines our brains lock into very often determine our behavior even when we desperately want to behave differently. In a recent post I mentioned how the environment also sets us up, particularly for making it difficult to eat healthy. We have to be begin by making small incremental changes that support new brain connections, new habits. Change is a process with many different drivers, the key is finding the one that works best, and just staying on the road.

Statistics. For many statistics is a foreign language, existing in a country you never want to visit. But in truth, we live statistics every day of our life. We read sports statistics, check weather reports, listen to stock updates, and hear percentages thrown around in the news. Statistics is the science of making effective use of data, and in the case of managing behavior, there are many things that can be helpful to track over time: days abstinent, relapses, weight, money lost, time spent on particular activities, etc. We track things because of our limited ability to keep a lot of this in our head, to remember the specifics. Keeping a record of progress provides a clear indication of how well we are staying on the road. It provides us feedback that is critical to successful change. Our tracking methods can be as simple as keeping a tally on a notepad, or creating more elaborate outcomes on spreadsheets. I have seen a number of those struggling with addiction get very caught up in statistics, particular days abstinent, where relapses become devastating events instead of opportunities for growth and learning. Statistics should always be used to help us grow, learn, and better manage our behavior over time.

Social Support: You’re aware of what you want to manage, you put a program in place that is simple, easy to stick with, and does not change too much too fast, and you begin to track your progress. The final key and perhaps the most important is understanding that managing any behavior change we make is embedded within the social systems in which we exist: family, school, work, clubs, self-help groups, church, sports, neighborhoods. We are social creatures by nature and influenced greatly be those around us. Successful change requires taking stock of our social connections, both those that support our change and are positive, and those that clearly contribute to perpetuating problems we wish to stop. I have said many times that addictions are ultimately about relationships, and the goal is to replace unhealthy relationships with objects with healthy relationships with people. This is an ongoing process of learning how our past relationships influence our present ones, and how we can heal past wounds and emotionally mature in a way that allows to both receive and give love.

As we begin a new year (and a new decade), many of us will set goals to better manage behaviors in our life. Whether the desire is to reduce drinking, drug use, or have a more fulfilling relationship with food or sex, we stand a much better chance of succeeding when we utilize the above four keys. Happy New Year!

I believe basic truths in life get repackaged in unique or creative ways throughout time, resurfacing in books, self-help strategies, stories, movies, or movements. When these things come on to our radar seemingly for the first time, we either embrace them and they become big hits, or we reject or dismiss the ideas because the timing is off - our society is not yet ready.

How to deal with addiction is one of these “basic truths.” Although mankind has behaved in excessive ways for centuries, only in the past couple-hundred years has society evolved the idea of excessive behavior being called “addiction” and requiring intervention. And, only in the past 5 to 10 years has society been ready to accept the basic truth that addictions are problems that we manage over long periods of time, similar to other chronic conditions. In 1955 the book Management of Addictions was published, offering a collection of treatment approaches for alcohol and drug abuse problems. Although the interventions outlined in the book provide significant evidence for how far we have come in our treatments, what I find most interesting is that over 50 years ago a collection of healthcare professionals embraced the idea of “management” in dealing with addiction.

Yet today, we give lip service to addiction being a chronic condition and still largely treat it as an acute problem, where average treatment stays can be measured in days or months. At an addiction treatment conference not long ago, I was frustrated by the complete lack of discussion about how to transform our current acute-based system into one that truly embraced addiction as a chronic condition. It was the elephant in the living room, yet folks went on and on about this ear and that toe…little incremental band-aid solutions to treatment - completely ignoring the opportunity to truly talk about how we might improve care for millions through systems-level change.

I don’t blame them. We have invested a lot in our current system, and many have built careers around the status quo. But the time is right to envision a new treatment enterprise that truly embraces addiction as a chronic condition and wisely utilizes resources to optimize long-term patient outcomes. Idealistic? Maybe so, but the status quo presently sees less than 10 percent of those in need of help, staff turnover in treatment programs is higher than in the fast food industry, and of those fortunate enough to have access to treatment, most do so multiple times. We can and we must do better.

What does it mean to manage addiction? We know manage is a verb that implies action. So, what actions are necessary to get us where we need to be, both with our treatment system and in helping individuals who struggle? Here are a few things to get us started:

• We know multiple treatment episodes are costly because often patients require intensive services (detox, residential, transitional housing, etc.) upon each admission. We should find creative ways to incentivize or reward treatment providers who can keep patients in treatment for years, decreasing costly hospital admissions and residential stays.
• We need to leverage technology and the fact that over 70 percent of folks in the U.S. have high-speed Internet, and many of those who don’t, can still access it now in many public places. Recent evidence suggests that computer-based treatments may be as effective as individual or group counseling. Are human counselors soon to be replaced by robots? Likely not, but there is little doubt that in the years to come computer/Internet-based interventions will play a critical role in healthcare delivery.
• Addiction treatment providers (and patients) should beg, steal (ok, maybe not steal), borrow, utilize, and adapt management interventions from diverse disciplines. Significant research has been devoted to the topic of how best to manage chronic conditions, such as the chronic care model. Let’s not reinvent the wheel, but seek out what others have done, and bring practical, useful, easy-to-implement behavioral management tools to those who need them now.

It’s your turn. What can we do to start transforming our current acute-based addiction treatment system into one that is similar to how primary care treats other chronic medical conditions? What self-management or disease-management tools do you believe are the most helpful? How might we package these tools to make them more accessible to the 90 percent who presently are on their own to deal with addiction?

One of my first and most memorable patients was a Native American man who I was treating for alcohol dependence (among many other complicating factors). On multiple occassions, he had been admitted to the hospital for detox with blood alcohol levels that would kill most humans. He could drink a lot, but the problem was he also had a traumatic brain injury that required medication, so with every relapse came the potential for death and need for hospitalization. After months of weekly individuals sessions, and despite frequent relapses, we had an incredibly strong therapuetic relationship – so strong that one day he came in to session and said…

Your approach isn’t working. I know you mean well, but the western way is hard for me to understand. Here is my bible…and he handed me a copy of Seven Arrows by Hyemeychsts Storm. It was one of those valuable early lessons  where I realized that there is no one right path in healing from addiction. Only the path that is right for you. But the story continues…

Months later after reworking our treatment plan around the medicine wheel, he is still relapsing, ending-up in the hosptial for detox, and I am left wondering where I went wrong. Fortunately, my Clinical Supervisor at the time was an insightful, experienced therapist who suggested I review all hospital detox admission records since he first entered treatment to gain some perspective on what was actually happening. Since every relapse had been followed by a hospital admission, I was able to easily complile a graph of relapses over time, and when I did, something amazing materialized.

He was getting better. It was right there in the data. After plotting the relapses on a graph I was able to see that the time between them was increasing – actually doubling with every relapse. What on the surface seemed like failure to me, was in fact – after reviewing the data – success. And why should have I expected progress to be any faster? This guy had years and years of drinking history behind him. Change is a process, and with addiction, takes incredible patience. We also know that addiction is a chronic, relapsing medical condition where relapse is part of the process. When I presented the graph to him at our next session he was equally pleased, and even more motivated to continue the progress.

Six years into our work he had well over two years of sobriety. His relapses continued to decrease in frequency maintaining the pattern he began when he entered treatment. The moral of the story: 1) follow a recovery path that is right for you, 2) track relapses and other significant events because data can provide insight where memory fails, 3) change is slow - patience is key, and 4) relapse, even after significant abstinence time, should be an opportunity for learning and not a time for shame and blame. We all make agreements with ourselves to do things (diet, exercise, New Years resolutions), and we all fail at times. Relapse is not an addiction phenomenon, it is a human phenomenon.

In the late 1990s I begin attending workshops on trauma therapy because I realized many of those who struggle with addiction also wrestled with untreated underlying trauma – sexual, physical, and emotional. It was at one of the workshops that I first heard the name Stanley Greenspan. Today he is known as one of the foremost experts on autism having published over 35 books and many scientific publications since graduating from medical school in 1966. But for me, he has become an instrumental figure in understanding the foundation of long-term successful addiction management - which in a nutshell is healthy relationships.

In an earlier post I described how addictions are about relationships, and that long-term success in dealing with addiction necessitates replacing unhealthy relationships with objects with healthy relationships with people. The key to doing this is realizing that to initiate, develop, and maintain healthy relationships requires developmental skills that become constricted, or in some cases, never develop due to trauma or time spent in addictions. These skills are critical to relating to others in many contexts: intimate relationships, child rearing, work environments, marriage. Yet most treatment programs and self-help groups are unaware of the critical need to assess and treat emotional developmental problems. When they go unaddressed, many continue to relapse and struggle in life without the benefit of knowing what is missing in recovery.

Based on his extensive clinical and research experience, Stanley Greenspan created a developmental framework that I believe is among the very best at helping us understand the essence of what it takes to succeed in relationships, but even more, how to optimize our mental health. The framework, in brief, suggests that emotional development occurs in six sequential steps. This overview paper focuses on infants and toddlers, but in the book The Growth of the Mind, Greenspan details how many adults become stuck at early developmental levels and require developmentally based therapy to catch-up. Unfortunately, many treatment programs and therapists will intervene in ways that never advance emotional development, resulting in a lot of hacking at the leaves instead of getting to the root. In all fairness, I spent plenty of time hacking at the leaves with patients because assessing emotional development and knowing how to do developmentally based therapy is not so easy. In fact, it requires a therapist to be attuned to their own emotional development and have some fairly advanced therapuetic skills. But therapy is not the only way to increase developmental capacities. By doing things out of your comfort zone, joining diverse types of groups, engaging with people in many contexts, and journaling about your emotional world can help. In future posts I will be more explicit about specific things that lead to developmental growth.

To get a flavor of the genius of Dr. Greenspan, here is a very short clip from the documentary film “Autistic-Like: Graham’s Story.” Although he is talking about the early development of his DIR model of intervention for autism, such insights are very appliable to those who struggle with addiction. Because “emotions serve as the orchestra leader for getting the mind and brain working together” it is absolutely critical to long-term successful addiction management that significant energy is invested in understanding, managing, expressing, and acting on the vast array of emotions we experience every day.

Addiciton is among our most significant public health problems, which is why I am so excited that the Obama/Biden Administration has named A. Thomas McLellan to the post of Deputy Director of the Office of National Drug Control Policy. Tom brings tremendous talent and experience as an addiction researcher to the position, and from my experience and discussions with him, will not shy away from speaking his mind and doing what is right for those who struggle with addiction.

His appointment comes at a time when the National Center on Addiction and Substance Abuse at Columbia University recently released their second report on the cost of addiction in our society: Shoveling up II: The impact of substance abuse on federal, state, and local budgets (can download entire report for free!).  In short, “The CASA report found that of $373.9 billion in federal and state spending, 95.6 percent ($357.4 billion) went to shovel up the consequences and human wreckage of substance abuse and addiction; only 1.9 percent went to prevention and treatment, 0.4 percent to research, 1.4 percent to taxation and regulation, and 0.7 percent to interdiction. Let’s hope Tom can change this.

I am often asked what I think about the war on drugs, and my answer is:

The modern war on drugs really began when the Office of National Drug Control Policy (ONDCP) was created in 1988 to deal with the epidemic of cocaine abuse throughout the 1980s. Since its inception, ONDCP has spent billions to battle illegal drug abuse in the United States, primarily pushing three goals: 1) stop use before it starts through prevention efforts, 2) heal drug abusers by getting treatment resources where they are needed, and 3) disrupt the markets for illegal drugs by attacking the economic basis of the drug trade.

In a critical analysis of the effectiveness of ONDCP, Dr. Matthew Robinson and Dr. Renee Scherlen, both Associate Professors from Appalachian State University, conclude that the drug war has been a massive failure. After reviewing six editions of the annual National Drug Control Strategy between 2000 and 2005, they provide significant empirical evidence that ONDCP has not represented the facts about the drug war accurately, often skew statistics to put a rosy face on less than productive results, and in the end, should be abolished.

What then should our policy be? 1) stop saying “war on drugs” as this punitive ideological language does not represent a well thought-out and humane approach to addiction in our society, 2) beef-up our prevention efforts in families and communities using empirically validated risk/protective factor approaches that address a wide range of adolescent problem behaviors, 3) increase funding for treatment, 4) drop the “abstinence” approach to drug abuse as the only viable intervention option and incorporate scientifically validated harm reduction approaches (e.g., needle exchange programs), and 5) decriminalize marijuana for personal use (see Reefer Madness).

This topic reminds me of one of the best movies ever on this topic – Traffic. This clip where the head of ONDCP catches his own daughter doing drugs, makes the point so clearly that a war on drugs is a war against our own loved ones (note audio disabled).

Estimates of the co-occurrence of trauma and addiction are quite high, and depending on how trauma is defined, one could argue that most who struggle with addiction have experienced some type of trauma in their life. In my clinical work, most patients had histories of traumatic events that shaped their life in significant ways, even if their present symptoms did not meet criteria for PTSD. The problem with trauma is that it is the gift that keeps on giving – but often in very subtle ways.

What I mean by this, is that when a person has experienced trauma, not only do physical changes in the brain take place that increase sensitivities to stress, but psychologically a person becomes vulnearable to future traumatic experiences – often experiences similar to the original trauma. This is because trauma is like unfinished business, it desires resolution or completion – or a way to make sense of what happened. What this looks like in everyday life is that a person will continue to repeat similar experiences: a sexually abused child will hook up with adult partners that continue the abuse, a physically abused child may find themselves in situations where they are physically abused as adults - and so on. Although each situation may appear different, the underlying theme is that unresolved trauma plays a role in perpetuating a painful life. Because reexperiencing trauma in different forms is painful, addiction becomes a powerful antidote. Thus the reason why one cannot expect good outcomes from addiction treatment if underlying trauma issues are not addressed.

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.