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.

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.