Saturday, November 2, 2013

Is Procrastination Addictive?

Well, let’s not go quite that far – we are probably already applying the term “addiction” to too many phenomena that really are not equivalent. But, in my view, there is an important aspect of procrastination that overlaps with addictive behaviors.

A key type of procrastination involves a chronic pattern of avoidance at the moment when it is “time to get something done.” The individual says to him- or hersself (as I myself have done countless times), “I’m too [tired, drained, sick, etc] to do this right now. Instead, I’ll [take a nap, watch TV, play a video game, etc] and I’ll do this task at a later time.”

The three central elements here are (1) anxiety [something about this project that gets you nervous], (2) rationalization [as described above] (3) avoidance [the decision to walk away from the assignment].

More than one of my recovering patients has told me that the moment of rationalization when avoiding a task feels very similar to the moment of rationalization (e.g., “This time will be different,” or “I deserve this”) preceding the decision to drink or drug.

These behaviors happen repeatedly (and typically with increasing frequency) because they are highly reinforcing. It is well known in the field of behavioral psychology that immediate reward is much more reinforcing than delayed reward. In this case, in the split-second when the individual decides “I’ll skip this for now,” there is an immediate reduction in anxiety, just as with the first drink, even though the result is likely to be an increase in later stress (just as drinking tends to generate more negative consequences that must be faced later).

That is part of what makes the temptation to avoid so potent. What, then, is to be done? There are too many aspects of the situation to address here, but some key components of working one’s way out of severe procrastination and facing overwhelming tasks are: (1) breaking big projects down, by stages, into smaller and smaller pieces, so small that they are manageable even when one is very anxious; (2) doing one piece at a time; (3) self-rewarding each accomplishment (e.g., making that nap or video game conditional on completing the small task).

Monday, October 21, 2013

Needed: More Sober Settings for the Non-Wealthy

Even for those with health insurance (made possible for more people, though certainly not all, by RomneyCare and hopefully to be enhanced by ObamaCare), when it comes to substantial help for the newly sober, available help is quite limited. 

Health insurance will usually cover something like weekly sessions with someone like myself. But more many, that’s not much more than a drop in the bucket.  Covered inpatient services generally consist of a few nights in detox (just until observable withdrawal symptoms have diminished).  After that, one may be able to access an “intensive outpatient program” (IOP, often 3 or 4 evening groups a week) and, if they have “flunked” IOP recently maybe 2 weeks in a Partial Hospital (Day) program.  Generally speaking, residential options are self-pay, and the options for low to moderate income people are very limited and typically unappealing.  For well-maintained and staffed residential sobriety programs, expect to pay multiple thousands per month.  These are, of course, usually profit making enterprises.  (For less money, there are so-called sober houses, which often are little more than rooming houses.) 

Yet for many, it will be very hard to sustain recovery without a structured sober environment, where they can get more consistent support and avoid the plethora of stimuli that are powerfully conditioned to alcohol or drug use.  Obviously, neither premium payers nor tax payers will feel inclined to foot the bill to subsidize such resources for all who need them.  But the fact is that people who are able to stay sober won’t be committing alcohol/drug related crimes, injuring themselves or others, showing up in emergency rooms (or destroying their organs and generating more medical costs), etc. – my guess is that this is a net savings,  but we tend not to see the big picture.

Thank goodness that at least there are self/mutual help groups like AA and SMART Recovery, driven not by profit but by actual humanistic motives, that to some extent can fill in the gaping holes in funded/covered care to those struggling to overcome addictions.

Wednesday, September 11, 2013

Bigger than Molly

News of recent deaths linked to the use of “Molly” (a variant of ecstasy)  has generated increased attention to the use and dangers of so-called “club drugs,” frequently used by young adults in music/dance club settings.  The use of these substances has accelerated in prevalence in the past several years.  Deaths may result largely from dehydration and also, importantly, from adulteration with unknown and potentially lethal compounds. 

A 2012 study of university students found that 12.5% had at least tried club drugs at some point in their lives.  But about 20% had used opiate painkillers (such as Oxycontin), representing a much greater danger of serious, life-shattering addiction (and potential overdose).  Not surprisingly, about 25% had at some point taken stimulant pills (ADHD medicine, widely misused by college and graduate students) and 58% had used marijuana.  But another study found (again, to no one’s surprise) that 88% of college students had consumed alcohol in the previous year. 
Alcohol and prescription drugs (when prescribed) are legal, but they destroy many more lives than club drugs or even methamphetamines.  Alcohol, while used safely by most drinkers, has the potential to harm almost every bodily system, and kills people regularly via overdose, impulsive/dangerous and often violent behavior, intoxicated driving, etc.  So yes, we worry about “Molly” and her friends at the club, but some greater dangers lurk closer to home.

Thursday, June 27, 2013

Suboxone -- A Tool for Persistent Opiate Addiction, Useful but Imperfect

As always, let me begin by reiterating that I am a clinical psychologist and not a medical doctor, biochemist, or active scientist/researcher; most of my perspectives are derived from 30+ years meeting with actual patients. 

Both heroin and painkillers (like Oxycontin, Percocet, Dilaudid, Vicodin, etc) are opiates or opioids (the 2nd term coined to include drugs synthesized rather than derived directly from the poppy plant).  All of these drugs are highly addictive, though they are also powerful agents in reducing pain.  Along with pain reduction, especially when used in larger dosages than necessary, many people experience a kind of euphoria and cushion from the world’s slings and arrows that keeps them coming back for more.  Some physicians perhaps don’t worry enough about the addiction risk when prescribing pain medications.  (Lighter pain meds like Tylenol and ibuprofen are not in this category.)  It is often extremely difficult for people who have become addicted to opiates (some of them originally interested only in pain relief when they began), and the rate of relapse is very high. 

In light of that problem, the notion of a kind of controlled addiction came along years ago in the form of methadone, and in recent years in the form of Suboxone (in which the main ingredient is buprenorphine).  Most individuals I have run across strongly prefer Suboxone, which is administered by prescription in the offices of specially certified physicians, rather than at methadone clinics, which are environments that I’ve never heard described in favorable terms.  The idea is that the Suboxone, which is an opioid, quells cravings for opiates while producing little or no “high,” so a person is in a reasonable frame of mind to go about his or her work and family life.  The whole concept of this kind of controlled addiction falls under the broader category known as Harm Reduction, essentially meaning, “if we can’t get the most desirable outcome, in this case total abstinence, let’s settle for an achievable level of improvement.”   

Since I generally favor whatever helps and doesn’t hurt, I have found Suboxone to be a useful tool.  (I am not a prescriber, but a number of people who have seen me for “talk therapy” have also been on Suboxone.)  I have seen it truly help stabilize their lives of people who are motivated to sustain stable lives which, if not free of drugs, are at least free of drug abuse.  There are also some real problems with Suboxone, and this is far from a complete list: 

(1)  Many individuals find it difficult to ultimately taper and discontinue Suboxone without relapsing.  One hears increasingly of recommendations to remain on Suboxone perpetually.  That may still be the best option for many people, but perhaps not what they had in mind.

(2)  Part of the reason for (1) may possibly be that people are relying on Suboxone as their sole treatment and, in particular, not connecting with sober support networks such as 12-step or other supportive networks and life environments.

(3)  There are way too few certified Suboxone prescribers (under 3% of physicians), and the number of patients that each can treat at a time is limited by law.  As a result, it can be very difficult to find a provider when you’re seeking one, and you can anticipate being placed on a waiting list.  But not if you’re wealthy (see #4).

(4)  For a number of physicians who might be viewed as either entrepreneurial or exploitive, Suboxone provision is a gold mine.  They can decide that each (relatively brief) visit costs hundreds of dollars, and to require self-payment rather than use of health insurance.  (The medication itself may still be covered by insurance.)  If you can afford these kinds of fees, you can get Suboxone in very short order.  Of course, this is only one of many, many examples of the fact that the wealthy get greater access to care (and housing, and lawyers, etc.)  But it can be particularly frustrating to the addict who has reached a threshold of motivation to get off drugs and can’t get a kind of service that might help a lot.