Addiction Management Blog

How should we help people who struggle with addiction?

October 4th, 2012

I have posted this video before, but at some point deleted it because I was not completely happy with the overall quality. That said, it’s not bad, and the content is still very relevant to the site. I am posting it here because I have yet to get back to the camera and do an improved version, and I want to make sure the basic principles of treatment are available to all. One final comment. I have continued to refine how I think about and talk about treatment, and now refer to intervention in 5 actions. Although the video does not specifically use this framework, I do discuss each of the five actions. If you watch the video and then check out the 5 actions link you will be good to go. Enjoy!


 

Whose Will: A new book about addiction, courage, and hope

August 28th, 2012

I had the recent pleasure of speaking with Willie Harris, the author of Whose Will: Ordinary Person, Extraordinary Life, a riveting account of his personal struggle with addiction and path back to a spiritual and connected life.

Like most, the roots of Willie’s problems with alcohol and drugs began early in life, in a family awash in addiction, violence and trauma. His alcoholic father abused his mother, nearly killing her twice, and perpetuated his own traumas on Willie by passing down  the unfinished business of the previous generation. But even amidst the hell of family life, Willie told me, I personally had a spiritual connection that I cannot explain.  At ten years old, he would lay on the top bunk of his bed and talk to God. His mother thought something was wrong with him, and would often ask, who are you talking to?

But the connection did not insulate him from experiencing an early life of pain, misery and self-destruction. By 18, his world was spiraling out of control. The inability to appropriately process emotions, including rage, hurt and fear, set the stage for the perfect storm. Drinking, drugs and partying eventually landed him on the streets, where the brutal reality of his life eventually became the source of his awakening.

Although treatment played a role in turning Willie’s life around, it was the 12-step program that allowed him to take an honesty inventory of his life and begin to take responsibility for the role he played in his own undoing. The program also helped him understand the answer to the question  – why do I do these things to myself? He had a mental obsession with substances that was different than other people. He said, it overrides normal thinking. Once he understood he could not put substances into his body without serious repercussions, the path out of hell became much clearer.

He credits the 4th step of AA – Made a searching and fearless moral inventory of ourselves – as being a significant turning point in his life. By looking at me, I was able to forgive other people. I was able to go back and make amends, and every time I did I got better.

Today, Willie leads a simple, but spiritually grounded life. He is a successful businessman, happily married with two wonderful children, dedicated to his church, and to spreading the word that it is more than possible to overcome addiction. I was most impressed with his motivation and efforts to develop programs for teens, that can be taught in schools, to proactively help challenged kids better process and cope with painful emotions. I could not agree more that it is a tremendous need. It was an honor to speak with Willie and learn more about his story. I very much encourage you to get his book (www.whosewill.com) and be inspired.

Addiction treatment system 14 years later….still in need of an overhaul

July 9th, 2012

This past week The National Center on Addiction and Substance Abuse at Columbia University released a scathing report of our addiction treatment system: Addiction Medicine: Closing the Gap between Science and Practice. While the report says nothing new, it does a nice job of summarizing the fact that we have made little progress since the Institute of Medicine released Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment on January 1, 1998. Here we are, 14 years later, and well, where are we now?

The new report points out these grim statistics:

  • 15.9% (40.3 million) of US age 12 and older struggle with addiction to alcohol and drugs (the number is higher if we factor in behavioral addictions such as gambling, sex, food, and online activities)
  • 31.7% (80.4 million) of US age 12 and older, while not addicted to anything, engages in risky use of substances that threaten health and safety (again, this number is higher if behavioral addictions are included)
  • 89.1% of those who meet criteria for addiction involving alcohol and drugs (not including nicotine) receive no treatment
  • Of those who do get treatment, about 50% come from criminal justice (only 5.7% are referred from primary care medicine)
  • Over 50% of those who go to treatment drop out
  • Addiction and risky substance use costs our society an estimated 468 billion each year

Not good! I will admit I was a bit depressed reading through the report, but not surprised. Addiction is a problem still very much misunderstood. Take for example this huge 573 page report, that constrains the definition of addiction to substances. How can we possibly make progress evolving our treatment system if we continue to narrowly define addiction. It is not just to substances that people become enslaved, but to food, gambling, sex, and many online behaviors. We now have neuroimaging studies providing empirical support that the brain is an equal opportunity organ that does not care what stimulates it, so long as dopamine provides a nice reward that keeps us coming back for more. In a great book on overeating, cleverly titled, The End of Overeating, by David Kessler (which I plan to blog about soon), he makes the point that animals will work almost as hard for food as they will for cocaine. So, back to my point. How can we make progress in this field when we continue to slice up the addiction problem, and fail to understand that it is not about the objects per se, but the relationships that a person has with these objects – all of these objects?

Accurately defining the problem would be a start, because we could then start building systems of care that leverage interventions for a wide range of chronic conditions, including addiction. But even agreement on a broad definition will likely not be enough. We need big system changes to make big progress. The CASA report provides a list of recommendations for improvement, including:

  • Increasing screening and referral in primary care medicine
  • Improve training on addiction in medical schools
  • Establish national accreditation standards for all addiction treatment facilities and programs
  • Educate non-health professionals about addiction, screening, and referral (dentists, teachers, legal staff, welfare, etc.)
  • Require adherence to use of evidence-based treatments
  • Expand addiction treatment workforce
  • Implement more national public health campaigns

It is a list, but hardly a gutsy one or even close to what needs to be done if we are to make big progress. What would my list look like? Here are my top four suggestions:

  • National Institute on Addiction (NIA): While integrating NIDA and NIAAA into one organization next year is progress, I would like to see an institute called the National Institute on Addiction that puts the emphasis on understanding the relationships people have with all objects of addiction, not just alcohol and drugs. While I know these agencies have invested resources in gambling and food, the money is scant compared to what is spent on substances. One of the primary goals of this organization would be to get all stakeholders (researchers, treatment providers, public) on the same page about how we should define addiction.
  • Leverage the Internet: Over 80 percent of the US population has access to high-speed internet, which means that we have the potential to reach the 90 percent who don’t get care. I am not saying this is easy, but there is a saying in marketing that you go where the customers are – and they are online.
  • Stop criminalizing addiction and treat those who do end up behind bars: The vast majority of folks behind bars suffer from addiction and most don’t get treatment. This needs to change. Because most will get out, why not use their time while in prison to treat their addiction, educate them, and provide them something to live for when they get out? I know, this costs too much money. See my last point.
  • Invest in families/prevention: Addiction is primarily a problem born out of adolescence. Most who develop addictions begin their journey before the age of 15. We need to devote significant resources to helping families flourish. We need programs that help people developmentally obtain the capacities they need for optimal mental health, for intimacy, parenting, and getting along with each other.

What would be on your list?

Siddhartha’s path out of addiction

June 30th, 2012

I’m not sure how I missed reading Hermann Hesse’s Siddhartha (Hilda Rosner translation) in high school, but I did. It’s one of those enchanting books I wish I would have read earlier! If you are unfamiliar with the story, I encourage you to read it and soak in its many wonderful messages about life. I have no intention of recapping the story here, but instead want to use parts of the story to illustrate one path out of addiction.

Siddhartha is a man on a mission, on a journey to the center of Self, to a place where Self is merged into unity, or the All. On his way to enlightenment he has many interesting adventures, including a period of time where he hangs out with the beautiful Mistress, Kamala. “She played with him, conquered him, rejoiced at her mastery, until he was overcome and lay exhausted at her side.” She enticed him into the world of the ordinary, a life of attachment. “The world had caught him; pleasure, covetousness, idleness, and finally also that vice that he had always despised and scorned as the most foolish – acquisitiveness. Property, possessions and riches had also finally trapped him. They were no longer a game and a toy; they had become a chain and a burden.

I find it interesting that as Siddhartha descends deeper into his attachments, Hesse beautifully describes addiction. “He played the game as a result of a heartfelt need. He derived a passionate pleasure through gambling away and squandering of wretched money….He won thousands, he threw thousands away, lost money, lost jewels, lost a country house, won again, lost again. He loved the anxiety, that terrible and oppressive anxiety which he experienced during the game of dice, during the suspense of high stakes. He loved this feeling and continually sought to renew it, to increase it, to stimulate it, for in the feeling alone did he experience some kind of happiness, some kind of excitement, some heightened living in the midst of his satiated, tepid, insipid existence.

And like so many who suffer from addiction and relapse to numb the pain and despair of an insipid existence, Siddhartha too experiences the consequences of his actions. “And whenever he awakened from this hateful spell, when he saw his face reflected in the mirror on the wall of his bedroom, grown older and uglier, whenever shame and nausea overtook him, he fled again, fled to a new game of chance, fled in confusion to passion, to wine, and from there back again to the urge for acquiring and hoarding wealth. He wore himself out in this senseless cycle, became old and sick.

For those who struggle with addiction, and their family and friends forced to endure a life on the edge, there is an insightful lesson in the story of Siddhartha.

I have had to experience so much stupidity, so many vices, so much error, so much nausea, disillusionment and sorrow, just in order to become a child again and begin anew. But it was right that it should be so; my eyes and heart acclaim it. I had to experience despair, I had to sink to the greatest mental depths, to thoughts of suicide, in order to experience grace, to hear Om again, to sleep deeply again and to awaken refreshed again. I had to become a fool again in order to find Atman in myself. I had to sin in order to live again.

For someone who reaches enlightenment, it’s strange imagining Siddhartha sitting by a river thinking about suicide. But he does. And in the pain of the moment, “he understood it and realized that the inward voice had been right, that no teacher could have brought him salvation. That was why he had to go into the world, to lose himself in power, women and money; that was why he had to be a merchant, a dice player, a drinker and a man of property, until the priest and Samana in him were dead. That was why he had to undergo those horrible years, suffer nausea, learn the lesson of the madness of an empty, futile life till the end, till he reached bitter despair, so that Siddhartha the pleasure-monger and Siddhartha the man of property could die. He had died and a new Siddhartha had awakened from his sleep. He also would grow old and die. Siddhartha was transitory, all forms were transitory, but today he was young, he was a child – the new Siddhartha – and he was happy.”

So often when addiction is the problem we believe heading off to treatment is the answer. No doubt treatment can be helpful and at times life-saving. But this story is a powerful lesson in how change, even the most challenging of changes, are possible when we access what is already inside us. Atman. The All. “To much knowledge had hindered him; too many holy verses, too many sacrificial rites, too much mortification of the flesh, too  much doing and striving.” Too much treatment, too many self-help meetings, too much reliance on evidence-based practices and medications. Too much action. Sometimes, the path of no-action, the path of contemplation – of sitting, listening, and just being is the path out of addiction.

 

Addiction is about three relationships

June 29th, 2012

There has been a push to understand and define addiction in our society as a brain disease, primarily because of the strong evidence from neuroimaging studies that have identified clear changes in the brain for those who struggle with addiction. At the same time, others have provided evidence that addiction is an adaptive response to underlying, unresolved, adverse childhood experiences (i.e., the ACE Study). We know the truth is that both are right. Roughly 80 percent of those who go down the path of addiction begin  prior to the age of 15. So early life experiences are critical to understanding this problem. Although the ACE study provides significant insight into the roots of addiction, we must also factor in to the equation a wide range of risk and protective factors, as well as genetic vulnerability. While I support incorporating all of these perspectives into our understanding of addiction, I believe how we understand this challenging problem should link directly with how we treat it. For me, this has led to a reconceptualization of how I understand and define this problem, one that I want to share with you.

Addiction is about three relationships with Self, Others, and the All. Let me explain.

The relationship with Self is best characterized by shame. Early adverse childhood experiences (and other risk factors) set-up a belief system that something is wrong with Self, and addictive behavior over time becomes a powerful way to manage the trance of feeling unworthy. To add fuel to the fire, when attempts to stop addictive behavior fail (due to changes in the brain), shame and feelings of unworthiness deepen even more, creating a destructive cycle that results in great pain for the Self and those around the person struggling. The relationship with Others is best characterized by isolation. I have written about this particular relationship in past posts. Isolation occurs because the developmental capacities necessary to initiate, form, and maintain healthy relationships with others become constricted over time, due to spending considerable time with objects of addiction (e.g., alcohol, drugs, porn, food) instead of people. In essence, adults who struggle with addiction are childlike in their ability to be in relationship with others. This makes it hard to hold jobs, parent kids, remain in committed, intimate relationships, and build community. It also helps explain why about 80 percent of those behind bars struggle with addiction, as well as many who return home from war and feel isolated and disconnected from those who have not had similar war experiences. The third relationship is that with the All (e.g., God, Atman, the One, Yahweh, Brahman, Allah), or what 12-step programs call higher power. It is a relationship I have devoted little time to on this blog, but one that I intend to give far more attention to in the future. It is best characterized by Truth and Love. The truth comes from experiencing all that addiction is – both its pleasures and pains. It is no coincidence that at the moment of orgasm, the instant the body feels the sensations from a drug, or the second one realizes they have had a Big Win on the craps table, the words “Oh God” come forth. Going deep into addiction is a search for the All, for truth, and ultimately for love.

These three relationships require attention and healing if we are to be successful at helping those who struggle with addiction. Our interventions should target all three relationships, which I should add, are hardly independent, but linked together in a seamless system. Work on one relationship impacts the others. There are two broad paths or categories of interventions: 1) the path of action, and 2) the path of non-action or contemplation. The first path is what we are accustomed to associating with typical interventions and treatments. The path of action happens in our waking states, when we “do” things. I believe there are five broad actions that are important on this path: motivate, evaluate, manage, resolve and create.  The path of non-action or contemplation is equally important, and involves using meditation practices to detach from objects of addiction and embrace our spiritual nature. If you consider meditation an action, then I guess you could make an argument that perhaps there is only one path. But doing contemplative work in essence is about “just being” which takes us back to a path of non-action. If it sounds a bit confusing, it is to me too. And to round out this discussion, both paths meet in consciousness. More about this to come.

As a parting thought on this topic, engaging all three relationships allows us to incorporate all we know about addiction. We can incorporate insights from neuroscience, medications, and healthy living into our treatments and interventions. And, we can evaluate outcomes more holistically when we consider how our interventions impact and change the three relationships.

You’ll never be the same again

February 1st, 2012

A couple more videos…

October 10th, 2011

A few months ago, I ventured into the world of video, posting some clips from a presentation I did about addiction and treatment. The initial clips were focused on understanding addiction, and since then, I have been meaning to get back to the lecture and do the same for treatment. Recently, I did go back and review the lecture and realized that I can speak much more clearly about the nature of addiction than I can about how to deal with it as a problem. I think this is because there is not one way to help someone with addiction. We have multiple treatments, methods, medicines, and programs that can all contribute to good outcomes. At the same time, I believe the number of choices also can become paralyzing and unhelpful when all that someone really wants is to be given clear direction on what to do. Sometimes 12 steps, 7 habits, and even 5 actions can be overwhelming. Enough said. I did find a couple of clips that pertain to treatment, but they don’t discuss the overarching 5 Actions framework that I am now evolving as a way to think about intervention. But soon. Check these out and let me know your thoughts.

All you need is love, love, love is all you need.

August 30th, 2011

At a training not long ago on CRAFT, the presenter, Dr. Robert Meyers, told a story that I want to pass on to you. But first, if you have never heard of CRAFT, it stands for Community Reinforcement and Family Training which is an evidence-based approach that family members (or friends) can use to facilitate getting an unmotivated loved one struggling with addiction into treatment. I am most fond of this approach because, unlike traditional interventions that rely upon coercing a person into treatment through harsh group feedback, CRAFT relies upon using basic behavioral strategies to rearrange the world of the addict so he or she internally reaches the decision that treatment is necessary. We have known for a long time that external motivation gets the job done; interventions do often lead to treatment. But unfortunately, once there, the person we so badly care about does not engage in treatment, does not really want to be there, and often drops out. We are back to square one and saying that treatment does not work. It is a vicious cycle.

In these situations, treatment fails because of a lack of internal motivation. Those who need to change their behavior have to want to change their behavior, which is why CRAFT is so powerful. It works to increase internal motivation for change by eliminating the positive reinforcement for acting out in an addiction, and enhancing positive reinforcement for non-acting out behaviors. If you don’t understand basic behavioral approaches to change using reinforcement, then it is time for Dr. Meyers’ story.

A woman who had been admitted to a psychiatric ward was driving the staff crazy. From the time she woke up until the time she went to bed in the evening she would scream her head off. The staff tried everything they could think of to get her to stop screaming, but nothing worked. She had to be placed in a room alone, away from the other residents, and restrained at times. Although medications could have been used to sedate her (and probably were at times), they were not the answer. After many frustrating weeks of listening to her loud cries, a doctor was brought in to see if he could help. His name was Nathan Azrin.

Nate walked down the hall to the woman’s room as staff likely snickered about how he possibly could make a difference given all that had been tried. When he arrived, the woman was sitting on the edge of the bed rocking back and forth screaming like she did throughout the day. He stood at the doorway for quite some time. He may have thought about why she was screaming, but also knew that whatever the driving reason, she could not speak and exploring the why would likely be a long journey. Instead, being a behavioral psychologist, he considered her behavior and what he wanted her to do instead of screaming. Well, this was easy, he wanted her to stop screaming. Then, he considered the times when she was doing what he wanted her to do: eating, sleeping, and breathing. During these activities she did not scream. As he stood in the doorway, he began to focus more on the immediate moment to moment rhythm of her screaming and breathing. Then he got an idea…

Right at the moment when she stopped screaming to take a breath, he walked over to her and gently stroked her hair. After she inhaled and began screaming again, he slowly moved back to the door and waited until she had to take another breath. He then repeated the movements with every breath: move close to her, look her in the eyes, gently stroke her hair, and then move away as she screamed. Nate knew, that at our core, we all have one unifying need: love. And he believed that by reinforcing the moments when she was not screaming, even though they were just seconds, with loving touch, that just maybe…maybe, he could alter her behavior. While staff had isolated her, restrained her, and stayed clear of her, he moved closer to her. And his approach worked. By that evening, he was sitting next to her on the bed, gently stroking her hair, and the screaming had stopped. He told the staff that when she woke up the next morning and started to scream, someone was to sit next to her and gently comfort her. In fact, anytime she began to scream, the antidote was the same.

I love this story because so often when we are challenged in life we tend to overlook the obvious. We seek out expensive treatments, elaborate self-help strategies, or engage in complex change regiments only to become frustrated when change eludes us. Dr. Azrin is among the most cited psychologists of all time, and although he may go down in history for his popular read, Toilet Training in Less Than a Day, for me, he will go down as an individual who taught me about love.

Investing in Addiction Treatment: Is it Worth the Cost?

June 11th, 2011

I recently talked with a Huffington Post reporter about the Real Tab for Rehab: Inside the Addiction Treatment Biz. In our discussion, I pointed out that to a large extent we still have an addiction treatment system that provides short-term (acute) treatment for a long-term (chronic) problem (this key point did not make the article). In addition, the current system treats less than 10 percent of those who could benefit from some kind of intervention at a cost that will likely reach $34 billion by 2014, more than double the spending from 2005. In my opinion, a lot of money is being spent on helping a minority of those who struggle with addiction, and sadly being spent on expensive residential treatment stays that research indicates is not more effective than less expensive outpatient care. Bottom line, the billions being spent could be invested in those who struggle far more wisely.

Not too many years ago I was attending an addiction conference where a number of  treatment centers were advertising their services. I struck up a conversation with one of the marketing reps of a well-known residential program. She explained to me that because of the escalating cost of treatment, her team had developed a program that was only ten days in length, thus reducing the total treatment cost to about 15K while maintaining the effectiveness of a longer residential stay. As I always do in these situations, I asked her about proof that the program worked. She had a well-rehearsed answer, but like most treatment programs, no reliable and valid measures had been employed to measure outcomes. Even if some had been used, we know that 10 days hardly scratches the surface of what needs to happen to help someone with addiction.

Am I opposed to residential programs? Not at all. At times I believe these programs are life-savers and provide a strong foundation upon which to build a solid outpatient management plan. Many employ very skilled, compassionate, and hard-working counselors that know how to help patients stuck in addiction. Some charge reasonable rates for their services and avoid the “spa-like” add-ons that contribute nothing to long-term outcomes. What I am opposed to is marketing that feeds on the vulnerabilities of the populations that seek out their help. Many parents will go to the ends of the earth to help their addicted child and not think twice about mortgaging their home and draining their savings if someone tells them their program will save their kid. Even for those with money, the idea that one can “buy good outcomes” if just the right program is utilized is simply not true.

What can you do? You can spend your time understanding the nature of addiction, what science has to say about treatment interventions, and then spend your money wisely on what will result in the best possible long-term outcomes. What are some of the best financial investments in treatment? This slide from a recent presentation provides you a quick reference point for understanding how a number of treatment interventions rank in terms of scientific evidence. Notice that brief interventions, addiction medications (Campral, Revia), the Community Reinforcement Approach (CRA) and motivational enhancement interventions all rank very high in terms of evidence. Also notice what ranks far down the list: residential treatment, Alcoholics Anonymous (AA) and 12-step facilitation therapies, and general counseling. Note that it is not that these things cannot be useful in overcoming addiction, they can be very helpful. But when you compare their effectiveness through the lens of science to other options, and take into consideration the cost of each, it is clear we could be spending the billions of treatment dollars far more wisely.

The goal is to maximize the best possible intervention outcomes over many years (and for some a lifetime), not a few weeks or months. To do this, we need to employ the best interventions at the lowest cost. Combining free community resources, outpatient therapists, medications, self-help groups, and motivational incentives will give you the biggest bang for your buck.

Video, Video…and more Video!

April 15th, 2011

I learned recently that the number one online  activity is watching videos. My initial guess was email, but as I thought more about how we have grown-up watching television, and that the average American now spends more than five hours a day in front of a screen (TVs, computers and mobile devices, non-worked related), this outcome is hardly surprising. Email actually ranks third behind online banking. These statistics got me thinking about the most effective way to provide you science-based, easy-to-understand information about addiction and how to overcome it as a problem. Call me a little slow, but if watching videos is where all the action is online, then it seems to make sense that I go there as well. So I am excited to tell you that I have taken the leap and completely updated this site with lots of video! You will now find many short snippets, most just a few minutes long, on a wide range of addiction-related topics.

A few words about the clips. Last year I joined the Board of Shangri-La, a nonprofit organization dedicated to helping Oregon’s most vulnerable populations with housing, employment, and a multitude of other needed services. What an amazing group of people! I can’t say enough great things about how they are making a difference in the lives of so many people at a time when so many are struggling. One reason for my involvement has been the increasing prevalence of addiction among the populations they serve. To help out, I presented some material about addiction to about 80 of their managers and staff, and in return, they taped it so I could use it on this site. Thanks again guys!

The first set of clips I am posting are primarily aimed at helping you better understand addiction. Here is one of them focused on addiction being about relationships.