Recent Developments in Addiction from NIDA

We are all fortunate for the ongoing work of the National Institute on Drug Abuse, a division of the National Institute of Health.  Dr. Nora Voklow, who has long been directing NIDA, certainly does not sit on her laurels, but is constantly monitoring all aspects of substance use disorder in the United States, and she has been vocal about how the addiction and addiction treatment scenes have been evolving during the pandemic. 

In this video recorded for the Psychiatry and Behavioral Health Learning Network and this video for the McLean Institute for Technology in Psychiatry, she notes that pathological substance use and substance-related deaths have increased quite significantly since COVID came into our lives, partly in connection with social isolation, as presumably the higher baseline level of anxiety we have all experienced, and partly because Fentanyl, the killer drug that has infiltrated the supply of opioids and caused so many overdose fatalities in the past 20 years or so, now appears in supplies of cocaine, meth, and even some ersatz prescription pills.  In addition, the chances of reversing overdoses via the use of Naloxone (Narcan) dramatically decline when drug users are in isolation, away from potential rescuers.  In addition, she presents evidence that individuals with substance use disorder, including those who use high amounts of marijuana, are quite significantly more likely to develop severe and potentially fatal levels of COVID.

 

On the other hand, as she notes, this has also been a time of creative development of strategies to potentially reverse these trends through various innovations such as more flexible availability of Suboxone (Buprenorphine) and Methadone, and telehealth.  (Unfortunately, and this is my comment, not hers, the use of telehealth is greatly thwarted by outdated rules that require clinicians to be licensed in the every state where they are reaching patients, and the process of obtaining these licenses is cumbersome, time-consuming, and expensive.)  She even sees signs that a treatment like Transcranial Magnetic Stimulation (currently used mostly for depression that has not yielded to other treatments) may help reduce addictive urges and behavior.

 

If there has been any upside to the opioid epidemic it has been a broader understanding that those with addictive disorders deserve treatment and support rather than blame; similarly, the widespread prevalence of anxiety and depressive symptoms that has come with the COVID pandemic and the measures taken to stay safe have brought widespread recognition that it’s a good idea to recognize and get help for mental health conditions that have so often been subject to stigma.

Is Cocaine Making a Comeback?

 

As most of my early addictions training (and indeed most of my professional addictions work) has revolved around alcohol, which of course is by far the most widely used drug, I recall how cocaine began to show up as an issue for my patients sometime around 1980.  At that time, believe it or not, cocaine was not regarded as addictive, even though we know that, a century earlier, Sigmund Freud had confronted its addictive qualities.  (What he first thought was a wonderful antidepressant for his patients became an consuming, addictive burden.)  In fact, during the early 1980s, snorted cocaine was fashionable and associated with the rich and famous.   

It didn’t take long, however, before treatment facilities began to fill up with cocaine addicts to the point that their numbers edged out those coming to the hospital wrestling with their inability to stop drinking.  (Much the same phenomenon has occurred in more recent years with opioid addicts becoming the majority population in many detoxes and rehabs.)  By this time, it became clear that cocaine was actually quite addictive, partly because of its quick, rewarding effect, followed by a steep drop-off, leading users to want to use it again.  Individuals’ early experiences with cocaine were highly reinforcing – they often felt much more confident (bordering on grandiose), energized, and productive.  Later on, when it became much harder to refrain from using, those rewarding effects diminished and continued use was driven by the addiction itself, sometimes resulting in consequences like paranoid psychosis, shredded nasal passages, and heart attacks.  I was working in an inpatient setting at the time, and many of those who sought help reported that they were motivated by the death of a co-user.  Others were inspired by what happened to some of the rich and famous, such as the death of basketball star Len Bias, or the severe injuries to comic genius Richard Pryor when he was “free-basing.”  (That method, like the use of “crack,” were ways to get even higher even faster by inhaling rather than snorting.)  

After a few years, if my recollection is correct, alcohol was back as the number one addiction represented in hospital settings – until the prolonged opioid crisis (delivered to us largely courtesy of pharmaceutical and medical interests who denied the dangers), which continues to this day, though thankfully the rates of prescriptions and hospitalizations seem now to be declining.  

In my own Boston-area practice, I frankly have not encountered cocaine addiction for at least 20 years, but apparently it’s been making a comeback.  What brought it to my attention, I’m embarrassed to say, was not keeping up with CDC or NIDA stats, but learning that cocaine addiction (as well as alcoholism) was the subject of the Intervention and 2020/21 rehab year of wonderful comedian John Mulaney.  
Indeed, it appears that cocaine is back.  According to the National Center for Drug Abuse Statistics, cocaine/crack was used by 6.3 million Americans in 2018, and, according to NIDA, cocaine was involved in over 19,000 deaths in 2020 (couldn’t find matching stats in the same year).  There is one crucial difference between the cocaine of the past and the cocaine appearing now – like much of the heroin, it is often mixed with fentanyl, which of course makes it much more deadly.  

If you or someone close to you has been seduced by the reinforcing properties of cocaine, be alarmed, be careful, and consider meeting with an addiction specialist.

ALCOHOL HAS FOUND A NEW WAY TO KILL PEOPLE 

Here we go again, as the Coronavirus picks up speed all over the country and the world, even in places where quick shutdowns had flattened the curve early in the crisis.  And as time has provided more insights, as of now it appears that surfaces are less dangerous to us than close or prolonged contact with others who, often unbeknownst to themselves, are spreading the disease, not only through coughs and sneezes, but through speaking and exhaling. 

Turns out that face coverings are the most potent form of prevention of contagion, and that universal use of masks or shields might well make it possible to reopen much of the economy.  But we see, not only on news broadcasts but when we simply take a walk to get some exercise, many instances of individuals and groups who are congregating, playing casual team sports, having parties and nights on the town.  These people are, at those moments, in a state of denial.  Like the rest of us, they’ve had enough of putting much of their lives on hold, and they have pent-up demand for fun and human interaction.  Putting dangers out of their minds, they are offloading inhibitions and caution in order to feel good. 

Let’s see, what is the most common tool for discarding inhibitions and acting on impulse without thinking through consequences?  Could it be….. alcohol? 

Indeed, when we see people engaging in behavior that looks as if they are on a mission to spread disease, whether at house or pool parties or in and around bars, drinking tends to be the common denominator.  That’s not to say that nondrinkers are devoid of denial – I’ve heard a few long-sober people refer to COVID as little more than another flu bug – or that drinking is the only enabler of risky behavior (e.g.,some passionately religious gatherings).  But it seems pretty clear that if alcohol were subtracted from the picture, COVID rates and outbreaks would be significantly reduced.  And I don’t hear this mentioned much, at a time when, from what I read, beer, wine, and liquor sales have boomed. 

Although in some cases, increased drinking during the restricted COVID lifestyle has been fertile ground for the progression of alcohol use disorder, I’m not referring here mainly to those who are addicted, but to “social” drinkers.  Everyone’s chances of accidents, injuries, physical altercations, and acting on dangerous impulse are augmented when they drink. 

Drinking, of course, is embedded in our society (though something like 14% of American adults don’t drink at all).¹  People find the effects rewarding, at least when they begin – alcohol temporarily reduces experience of many kinds of pain and discomfort, and since that includes social anxiety it is often used as a “social lubricant.”  In the longer run, of course, over-use tends to exacerbate the problems that drinking appeared, at first, to dissolve.

No one is saying that non-alcoholics shouldn’t drink at all.  Wait, I take that back, as some recent uber-studies have reached the conclusion that zero drinking is the best recommendation for people who prefer to live longer and healthier lives. ^{2, 3} On the other hand, another large-scale study⁴ suggested that “moderate” drinkers were overrepresented among those who lived past age 90 (most likely because they were moderate in their approach to a variety of health-related behaviors).

The American landscape has long been littered with the debris of human residue of alcohol over-use (illness, injury, death, lost careers and families, etc.).  COVID19 now invites us to add to that wreckage in a big way.  That’s an invitation worth rejecting.

Relapse Risk vs Healthy Coping during COVID19

It’s hard to think of a time when day-to-day life has been as disrupted as it has during the COVID19 crisis that persist and may continue to persist for some time.  At first, we were all pressed into rising to the occasion; then the isolation at home, ongoing worry and uncertainty, became our new-yet-temporary normal.  I was encouraging people to maintain their daily routines, but even I am beginning to lose sight of just what my routine is or was (despite my ongoing clinical work, which has of course shifted to “tele-health”). 


Many of us are drawn to the constant flow of news, which is more or less all COVID, all the time, while realizing that immersion in this news can fuel anxiety to the point of feeling overwhelmed and rudderless.  The isolation also tends to bring an increase in boredom, and restlessness.  Naturally, we seek to escape from all that, and to find a source of cheer.  We turn to streaming services (Netflix is apparently on fire), perhaps music, ideally forms of exercise that can be done in isolation, even reading (so 20^th century), but many people are also turning to alcohol.  According to one survey, drinking is up by 55%.  The World Health Organization suggests that some people even have the (completely incorrect) belief that consuming alcohol can kill the virus!  In actuality, heavy drinking has an adverse effect on the immune system, and might make you more susceptible.

For those in recovery, of course, this situation can present risk.  People involved in 12-step and other mutual support groups have quickly migrated to online meetings, which is certainly the best option under the circumstances, and the process has even allowed them to connect with peers in far-flung locations.  


Beyond that, it’s important for all of us, whether or not we have histories of addiction, to maintain a schedule and enforce daily structure even though nothing forces us to do so, connect with others the best way we can (in some ways, a phone call can be more relaxing than a video call), and have a menu of healthy distracting/rewarding/relaxing activities.  


And most of us mental health/addictions professionals are now available online, providing confidential services.  Somehow, it may not feel like a time to initiate seeking help, but it’s actually a good time -- a way to connect, to disclose thoughts and feelings that you might not disclose to friends or family, and to brainstorm on ways to cope.  (For those who are experiencing withdrawal symptoms, detox programs are still open.)  

Although this stressful period won’t end quickly, and there may be a “new normal,” this, too, shall pass. 

Thank You, John Oliver! (Ripoff Rehabs)

Around my house, John Oliver’s weekly HBO show, Last Week Tonight, is a must-see.  He has found his own way to combine comedy with incisive and often illuminating exposés on a range of subjects important to all of us.  On his May 20 show (https://www.youtube.com/watch?v=hWQiXv0sn9Y), he focused on the too-prevalent abuse of vulnerable individuals, families, and health insurance premium payers by a large number of facilities calling themselves rehabs (and also sober residential programs) which offer either minimal help or actually promote harm. 

In the late 1980s, with the advent of managed care, health insurance, which had previously covered inpatient rehab treatment for virtually anyone with a drug or alcohol problem, dramatically cut back on coverage.  By 1990, most Massachusetts-based plans covered only detox (usually less than a week, the process of physically withdrawing someone safely from an additive substance), and even that only if the person showed signs or history of withdrawal symptoms.  With some exceptions, “rehab” (usually a month-long program that followed detox with a heavy schedule of educational and therapy groups as well as peer support meetings and medical oversight) was available only to those with money.  (At present, a month-long self-pay stay at a nice rehab can easily cost over $60,000.)  Instead, most plans covered (and still cover) a few weeks of intensive outpatient treatment followed by regular outpatient treatment (the latter usually meaning one weekly session).  Fortunately for everyone, self-help groups are much more available and supportive, at no cost.

With the advent of the frightening opioid crisis (itself largely an outgrowth of medical overprescribing encouraged by pharmaceutical companies) and the astounding number of deaths, some health insurance plans have begun covering rehab stays again. With that we have seen a new surge of crooks.  The Boston Globe recently ran a series on how some Massachusetts-based individuals have recruited addicts to fly to Florida, which seems to be the current ground zero for ersatz treatment, where rehabs and residential programs make big profits on frequent urine tests and foster recurrent relapses, creating more business for themselves.  (Relapse is a common feature of addiction in any case, but ostensibly most treatment facilities seek to prevent it.)

John Oliver notes that the term “rehab” itself is not controlled.  (The same is true for “therapist” or “psychotherapist” – you can bill yourself as a therapist or a rehab tomorrow if you’d like to.)  Further, he notes that many of these places are not offering so-called evidence-based treatments.  I’m afraid I have to add that even those that say they are doing evidence-based treatments may not be doing them in the way they were done in the original studies.  In addition, there are ways of getting treatments certified as evidence-based that really are not relevant to real-life needs of real individuals.  And other treatments that no one has had certified as evidence-based may actually be quite useful.  I’m a fan of science, but just cautioning that “evidence-based” is no guarantee of quality.

To my mind, in evaluating a rehab, you’d want to answer questions like these:

·         Upon visiting the facility, does there seem to be a lot of treatment going on?

·         Does the treatment seem to be professional and relevant to the disorders of addiction/alcoholism?  (For example, the program known as “Narconon” actually provides indoctrination in the teachings of the Church of Scientology.)

·         Who are the staff, what are their credentials/training, and what is their history of providing care over time?

·         What kinds of feedback about the program has been forthcoming from former patients in the program being considered?

·         To what extent does the advertising emphasize slickness and luxury?  (These features draw customers but are often not indicative of therapeutic mission.)

·         How long has this facility been in business and to what extent has it earned respect over time (especially if not recently acquired by another corporation)?

·         When they say they take insurance, what does that mean?  Only for certain services or the first few days?  What will the patient’s actual cost be?

When I meet with people, often family members of individuals who are actively mis-using alcohol or drugs, I don’t pretend to know about all the facilities in the country (especially since new ones keep popping up), but I share what I do know of those facilities that have been around for a while, especially those for which I have heard “reviews” from prior patients.  I also attempt to help them sort out whether the inpatient level of care is actually necessary and likely to have a positive impact to justify its cost.  Less expensive levels of care (including a combination of outpatient and residential, which is not the same thing as inpatient or rehab) are sometimes a better match.  I am friendly with representatives of various systems of care who do a lot of networking with professionals in my field, but I myself have no financial relationship with any facility, so the input I provide to those who consult me is the simply my best effort and the same I would give to a member of my own family.  You should be able to find unbiased addiction-savvy professionals in your neck of the woods, too, clinicians who have spent years not in the research lab or the business world, but on the front line with suffering individuals and families.

Don't Forget the Alcohol

All of us in the U.S. have become all too aware of the devastating impact of opioid addiction and overdose in our population.  A problem that was once found more around the margins of our society, thus more easily ignored, now affects all kinds of people in all kinds of American environments, and as a result we are more willing to devote attention and resources to our fellow human beings whose brains have been hijacked.  In many cases, the original pushers and dealers have been physicians and pharmaceutical companies who chose to minimize or ignore the risks of addiction.  Don’t get me started on the string of prescribers, in medical and dental practices and emergency rooms who found it laughable years ago when I raised this concern with them.

Yes, the scourge of opioids is frightening, and there is no cure-all for it.  But, with all our attention on that, it’s easy to forget that alcohol is still our biggest drug problem and killer.  The most recent government statistics indicate that, while drug overdoses are killing close to 64,000 Americans a year [CDC], tripling between 1999 an d 2016, 88,000 of us per year die of alcohol-related causes [NIAAA]. Another 10,000 deaths result from drunk driving.  Perhaps unquantifiable are the consequences of foolish, impulsive decisions made by people under the influence of alcohol, which anesthetizes the part of the brain largely responsible for judgment, reasoning, and inhibition.

Alcohol, of course, is not only legal, but a well-embedded part of social life.  Commercials encourage us to use beer, wine, and liquor, and when talk show guests mention getting drunk audiences applaud enthusiastically.  There are even some indications that moderate drinking (currently defined as 7 drinks/week for women or 14 for men) may have some beneficial health effects – less publicized are indications that drinking has negative cognitive effects – with a couple of drinks a day maybe you’ll gain months but lose IQ points (sorry – gross oversimplification). 

The good news about alcohol, as I’ve found among those I’ve been privileged to see in my practice, is that in many cases the challenge of overcoming the grip of addiction is somewhat more surmountable for those with alcohol use disorder than for many opioid addicts.  It’s not easy, by any means, and often not free of relapse, but there is a range of helpful treatment approaches, supports, and resources, and the company of millions of Americans whose lives are no longer ruled by their drinking.  We are also finding more effective responses to opioid addictions, but don’t kid yourself – alcohol is still our most pervasive drug problem.

Your Therapist: It May Be More Who S/he is than What Kind of Treatment S/he Provides

There is now plenty of evidence that, on the whole, therapy/counseling is helpful to people with a range of problems, such as depression, anxiety, and addictive behaviors.  (The evidence was not always clear; way back when I was in grad school, there was a bunch of research questioning the value of talk therapy – but it turned out that lumping all therapists and patients together kind of averaged good and bad results.)  

Most of the research on the effectiveness of psychotherapy tends to focus on comparing this treatment with that treatment, or with no treatment.  Thus, you have a myriad of schools of therapy with their own particular techniques, each making a case that their approach is the most helpful one.  (They can’t all be right, of course, and findings that are not replicated across researchers and settings are of questionable value.) 

My own doctoral dissertation study compared a cognitive-behavioral alcoholism treatment with a “traditional” treatment.  I was not at all surprised to find, when I followed 50 people for a year after treatment, that there was no meaningful difference in their outcomes.  One recurrent finding is that the type of treatment makes less difference than many of the characteristics of the individual, such as whether s/he is employed (i.e., has structure), married (i.e., not alone), and hangs out with heavy drinkers. 

But probably the most important factor about therapy (though it is the subject of many fewer studies) is not the treatment model but rather the specific therapist and the therapeutic relationship.  A former classmate of mine, now a celebrated psychology professor, reminded me about this at a recent reunion – it’s not a new discovery, but resurfaces in different forms every several years.  The importance of the provider’s personality and the treatment relationship, in fact, also applies to strictly medical providers  – there is an increasing body of literature on how doctors’ and nurses’ attitudes and interpersonal behavior affect patients’ confidence and outcomes.

Generally, people beginning therapy, which sometimes means sharing some private information for the first time, need to feel that they are heard and understood, and to develop a sense of trusting the therapist.  Decades ago, the then-prominent Rogerian school of therapy emphasized that, crucially, a helpful therapist  shows a combination of empathy, genuineness, and warmth (or unconditional positive regard).  These conclusions have held up over time.  It appears that patient characteristics matter as well – those who make harsher judgments of themselves may also find it harder to trust or respond positively to a therapist.

It’s still worth learning about the treatment orientation, and particularly the experience, of your new therapist.  But if, after a few sessions, you don’t feel understood or trusting, it may be worth trying another therapist.  (If it happens repeatedly with one therapist after another, however, that’s can be a signal to examine what barriers you may be bringing into the sessions.)