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  (Unfortunately, and this is my comment, not hers, the use of telehealth is greatly thwarted by outdated rules that require clinicians to be licensed in the every state where they are reaching patients, and the process of obtaining these licenses is cumbersome,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.)

The Role of "Self-Help" Meetings in Alcoholism/Addiction Recovery

Many, many outcome studies (including my own, decades ago) have shown a significant correlation between attendance at “self-help” groups and better alcohol outcomes (and, by extension, addictions to other substances, but this post focuses on alcoholism, which is currently being subsumed under the label of "alcohol use disorder" by those in charge of naming diagnoses). 

These groups would be more accurately labeled “mutual” or “peer support” groups – they are distinct from professionally run therapy groups and derive their impact from the power of community among people who are “in the same boat.”  And yes, correlational findings don’t prove causation, but I like to make an analogy to cardiac, orthopedic, or obesity patients advised to exercise – it seems obvious that those who join a gym and keep going are more likely to achieve sustained fitness. 

Note, too, that the fact that attending self-help groups improves your odds of improvement does not mean that no one is ever successful without such groups.  And some people probably also sustain fitness just by having a treadmill in the house. 

12-Step Groups.  Among self-help groups, of course, the most available and utilized program, by far, is Alcoholics Anonymous, the original 12-step program that, in the 1930s, grew out of the Oxford Group (what was then a recently formed American Christian organization).  AA emphasizes the importance of a “higher power,” which may be defined as a Judeo-Christian God but also in a variety of nonreligious ways.  The 12 Steps comprise a program of personal growth through processes including honest self-examination, acceptance that there are things beyond one’s control, and helping oneself by helping others.  But these steps are phrased as “what we did,” rather than “what you must do,” and there are no rigid rules or requirements other than a goal of abstinence from alcohol.  The myriad of healing factors in AA (many of them shared with other self-help groups) are too numerous to summarize here.

CBT-Based Groups.  In Massachusetts, where I practice, the main self-help alternative to AA for those who wish to stop drinking (or drugging) is called SMART Recovery (SMART stands for Self-Management and Recovery Training).  Like AA, meetings are free and the goal is abstinence, though people who are still drinking are not turned away (nor are they in AA).  SMART’s leaders have some training in running groups, and the program collaborates with affiliated volunteer treatment professionals and bases its techniques on the same kinds of strategies employed by practitioners of cognitive behavioral therapy (CBT).  Unlike AA, SMART has no steps or references to a higher power or spirituality.  There is also much less emphasis, in comparison to AA, on connecting with and relying on others in making one’s way on the path to recovery.  SMART grew out of Rational Recovery, a program that now eschews grew meetings in favor of website and publication dissemination of its methods; its primary method focuses on identifying and resisting the “addictive voice.”  Although AA certainly uses a number of techniques that could be considered types of CBT, it can be considered to place more emphasis on “heart,” “spirit,” and human connection, while the CBT-based programs emphasize techniques for changing one’s thinking.  As you may know, there are many, many more AA meetings available, no matter where you are, than any other kind of meetings addressing alcohol or drug problems. 

Secular-Emphasis Programs.  A nonprofit agency called S.O.S. (Secular Organizations for Sobriety) presents itself largely as a non-religious version of AA.  It was the brainchild of a man who had been raised in a oppressive Baptist family, and who could not find comfort in a religiously-toned program.  In addition, there is a sort of confederation of AA groups specifically geared for atheists and agnostics, known as WAAFT (We Agnostics, Atheists and Freethinkers in Alcoholics Anonymous).  Neither of these programs lists any meetings here in Massachusetts, but S.O.S. offers online meetings. 

Women for Sobriety.  This program has been around since 1976, also nonprofit.  Open only to women, it puts forth 13 affirmations that tend to place a greater emphasis, in comparison to AA, on loving relationships and self-esteem, but like AA promotes the idea of personal growth.  I know of no current WFS meetings in Massachusetts, and the WFS website does not seem to provide a meeting list (though it does offer and sell literature).   

 

Moderation Management.  MM is a program that, in a group format, allows people concerned about their drinking to monitor their attempts to drink in a non-problem way.  It seeks to prevent drinking from progressing to the point of alcoholism (which would imply that control of consumption is not consistently possible).  Many people who attend MM later conclude that the goal of moderation is not realistic for them and move onto an abstinence based program.  There appear to be no active MM meetings in Massachusetts. 

Professionally Led Therapy Groups.  Therapy groups, unlike self-help groups, involve a fee, to cover for the therapist’s time and overhead.  Health insurance may cover group therapy, but because the reimbursement rates tend to be very low, many group therapists only accept self-pay.  Groups can be led in many different kinds of formats, but in general there a less fixed format and more opportunity for so-called “crosstalk,” since a trained professional is in a better position to keep all such interactions constructive.  For reasons I cannot really explain, there are many fewer professionally run sobriety or early-recovery therapy groups (of the weekly, outpatient kind) than there were years ago.  Of course, time-limited inpatient and intensive outpatient or partial hospital programs are composed largely of therapist-led groups. 

“It Doesn’t Work.”  I’ve heard this phrase in relation to multiple kinds of self-help groups as well as other treatments.  To be sure, there will be aspects of any self-help group that will feel useless to a given individual at a given point in time.  But this phrase would usually be better phrased as “I didn’t find a way to make good use of it.”  Recovery isn’t something that happens to you; it’s not like getting a shot of penicillin.  It’s a process that requires sustained commitment, attention, and legwork.  You wouldn’t say (or perhaps you would), “exercise didn’t work for me.”  You might prefer biking to running, or you might feel more comfortable at Planet Fitness than at Gold’s Gym, but getting healthier depends primarily on daily continuity of effort. 

Eyes Open in Pain Control and Avoiding Relapse

 I commend to you the first-person account of journalist/science writer Seth Mnookin in the June 9 edition of the Boston Globe, in which he recounts his experience of coming very close to opioid relapse in the course of his recent emergency treatment for kidney stones and the accompanying excruciating pain.

Mr. Mnookin handled the situation as recovering people are advised to do – he told his care providers repeatedly of his addiction (which had been in remission for over 15 years) to opioids, and arranged for his wife to hold and dole out his pills.  He was receiving treatment from Mass General, a renowned and Harvard-affiliated hospital among whose services are an addiction clinic (at which I was on staff way back around 1980) and Addiction Consult Teams to attend to patients across treatment units.  Yet, as his pain persisted because of complications/infection following surgery, he was given prescriptions for more and more painkillers, and was feeling worse and worse – eventually, he realized that much of his discomfort was caused by opioid withdrawal symptoms – his physical addiction had returned after all those years, despite the fact that he had only followed doctor’s orders (including those from a surgeon who had not noticed the addiction alert posted prominently on his medical chart).  At that point, he declined a further prescription that was offered.

For many years, surgeons and other physicians railed against the addiction worrywarts such as myself who expressed alarm at how readily addictive painkillers have been prescribed.  Supported by cherry-picked research information provided largely by pharmaceutical companies, they were damned if they were going to allow their patients to endure pain unnecessarily.  Painkillers have been offered to me personally at most ER visits, usually for very annoying but far from intolerable pain, and many

times by dentists after root canals and such (don’t get me started on how many hours I’ve logged in the dentist’s chair).  Over 30 years ago, after I wrenched my back and could barely stand up, I was introduced to Percodan (the predecessor to Percocet), probably in too high a dosage, and loved it so much, felt so happy with life, that I knew (because I was already doing addiction related work) that I’d better avoid it from then on, and that if I were to become addicted to something, opioids would be my drug of choice.  Even without a history of previous substance abuse (my interest in the field, dating back to college, was originally motivated by growing up in an alcoholic household), I was at risk.    Many times over the years, I have asked doctors and dentists why they showed so little caution in prescribing these medications.  Until the middle and upper class opioid epidemic of the last few years, and the publicity about all the overdoses, my comments generally elicited a kind of dismissive laugh. 

Of course, opioid medication is a godsend when necessary – some patients would probably not survive without it – but prescribers and patients alike need to reckon continuously with the relative risks and dangers of overwhelming pain on the one hand, and serious addiction on the other.  Quite often, a combination of non-addictive medications such as acetaminophen and ibuprofen can do a surprisingly good job of making pain manageable.  When it is insufficient, use of opioid painkillers should be kept to workable minimum, with eyes open to the emergence of withdrawal symptoms and/or craving even in individuals who have been in recovery for years.  

Treatment and abstinence can arrest addiction, but once the brain has been changed by repeated, addictive substance use, it is as if addictive brain circuits are dormant, but not erased – they can be reawakened.  I should also mention that there is a certain transferability to this awakening – for example, countless times I have heard from alcoholic individuals that using prescribed painkillers was followed within days or weeks by a relapse to alcohol, their substance of choice.  Be careful out there.

Is Rehab Back, for the Non-Wealthy?

Prior to the large scale entry of managed care into health care coverage (yes, I’ve been around long enough to remember), mental health/substance abuse professionals regularly referred actively alcoholic/addicted individuals to rehab.  In fact, the term “treatment” used to imply rehab, meaning typically a month-long program, often in a very nice setting.  In those days, insurance covered rehab routinely.   

Suddenly, with the advent of mental health managed care (which happened to come in most aggressively to Massachusetts, a high-utilization state), suddenly (a) most patient could not be approved for any kind of inpatient treatment and (b) inpatient care for those with addictions was usually limited to detoxification (less than a week, and only applicable to those subject to withdrawal symptoms).  As a result, the two most highly regarded rehabs at the time in New England (Spofford Hall in New Hampshire and Edgehill Newport in Rhode Island) both folded.  Those facilities that survived received much reduced daily insurance payments, and were not able to maintain the same quality of care and were not sustained in the same physical/aesthetic condition. 

I became accustomed, for over 2 decades, to telling families that their alcoholic/addicted members could only go to rehab if they had significant funds (and of course with no guarantee of success, since alcoholism/addiction is a condition prone to relapse).  Instead, they could get detox, if physically indicated, at times followed by 2 or 3 weeks at an outpatient day program.  (A couple of such programs provide basic lodging at a nominal fee and can be called “residential”, but do not offer the kind of 24-hour care available at a rehab – because insurance is paying mainly or solely for the day program at a fraction of the cost of inpatient treatment.) 

Although I have missed the days when people without a lot of money could be advised to “go to rehab,” I do understand the reasons why these changes came along.  Health care as a whole has become insanely expensive (largely because of technology in physical health treatment), and behavioral health treatment was the easiest to cut because it is so much less tangible than, for example, treatment for pneumonia.  In addition, at least half of those who were routinely referred to rehab had a good chance of doing well with a less expensive level of care.  (Not to mention self-help groups, a key resource that’s free!).  But in some cases, especially where less intensive interventions have resulted in frequent and repeated relapses, it became painfully obvious that the rich got better treatment.  Rehab costs range from something like $20,000 to over $60,000 for a month.   

But there seems to be some good news on the rehab front.  I have received no announcements from health insurance companies about any changes in coverage, but over the past year patients have begun to report to me that they managed to get covered for a month in rehab (typically in Florida), suggesting that their Massachusetts based managed care companies had developed contracts (meaning hefty discounts) with certain facilities.  Even more recently, a marketing representative from a new detox/rehab in Massachusetts itself told me that they have been able to serve patients covered by PPO or POS plans.  (In these plans, the patient usually has a deductible, after which insurance pays something like 80% -- but that’s much more than zero.)   

Why is this happening?  I can only guess.  Certainly, there has been increasing publicity about the impact of addictions, and it has become one of our governor’s prime issues as increasing numbers of individual die of overdoses.  (Suddenly managed care companies that used to allow me about 8 authorized outpatient visits at a time are authorizing many more, if the diagnosis is alcohol/drug related.)    So, to those of you whom I myself may have discouraged with regard to how much treatment you could get: don’t give up.  Call your health insurance provider and, if rehab is needed, try to get them to cover it.  And please email me to let me know how it goes, and if they covered a facility that was truly helpful.  The individuals and families I see need to know.

Alcoholism vs Heavy Drinking: Who's On First?

Individuals and families come to me all the time seeking guidance and answers about their loved ones (or themselves) who have drinking problems.  There is no problem finding treatment providers who have the answers – except that there are many different, sometimes conflicting answers to be found.  Some are based on personal experience.  Others are based on studies – but studies vary a great deal in what they find (and in what they emphasize and how they are designed).

Then there is our own national ambivalence about drinking.  A major film fan, I decided to catch a glimpse of the Hollywood Film Awards recently televised for the first time on CBS.  On hand for commentary were two of the 3 newscasters from CBS This Morning, the only major morning news program that actually emphasizes news.  Yet on this occasion they not only seemed to be auditioning for Entertainment Tonight (does that still exist?) but to join in the frequently mentioned advice to the audience to be sure to drink a lot.  Drinking is apparently the major appeal of these awards, as exemplified by Johnny Depp, who was either very drunk or convincingly acting  very drunk, for our viewing pleasure.  One week later, the same CBS This Morning crew interviewed Dr. Holly Phillips as she noted that heavy drinking, while not equivalent to alcoholism, is dangerous to multiple organ systems in the human body.  No wonder so many people are confused.  I’m confused, and I’ve been working in alcoholism treatment for decades.

On top of that, there’s a new diagnostic manual in town, the DSM 5.  (The criteria used I the CDC study came from the DSM IV, as it was known – Roman numerals are so last year.)  In the DSM 5, the whole distinction between Alcohol Abuse and Alcohol Dependence has been replaced by one diagnosis, “Alcohol Use Disorder,” which can vary in severity.  Well, we’ll see where that goes, but it kind of undercuts the thrust of this study.

The fact is that there seem to be many genes and biological traits that contribute (along with many psychological, life history, and environmental factors) to a person’s problems with alcohol consumption, so that in a sense no two cases are identical.  (Yet one has only to attend a self-help group meeting to realize how much people who self-diagnose as alcoholic do have in common.) 

Perhaps the most crucial feature of those who have been designated alcoholic or alcohol dependent is known as “loss of control.”  The term does not refer to uncontrolled drunken behavior, but rather to the ability to regulate consumption, which most of us do in a relatively automatic way.  Those deemed alcoholic are often unable to do so – once they get 2 or 3 drinks in their systems, they are “off and rolling;” there seems to be no internal feedback loop to shut off alcohol consumption after a certain blood alcohol level is reached.  Although remaining very self-aware may enable a person to override loss of control (that is, to regulate cognitively rather than systemically), it’s not easy and that approach tends to fail over time.  For that reason, many individuals with loss of control over drinking ultimately choose abstinence as the only stable, reliable goal.  Heavy drinkers without signs of loss of control may have a better chance of learning new, less problematic patterns of drinking.

One thing the CDC study seems to be pointing out is that there are many, many people who don’t have loss of control (other other criteria such as tolerance or a pattern of proximate negative consequences of drinking) but drink a lot, enough to be considered “binge drinking” (now defined as more than 4 drinks per occasion for men or more than 3 for women) – and that heavy drinkers, even if not alcoholic, are just as susceptible to the many medical problems associated with too much exposure to alcohol.  These conditions include: 

•  Liver disease (you knew about that one)
• Lowered resistance to infection
• Heart disease and stroke
• Osteoporosis
• Breast cancer (a more modest connection)
• Brain damage (including to the white matter -- new study from Harvard Med School)

For the individual who comes to the office of an addiction professional, the question often boils down to:  I’ve run into trouble with my drinking, but I like to drink; what are my options, what should I do, and how?  This study suggests that it’s not only alcoholics who need to ask themselves those questions.  Answering them often involves another kind of research – the kind you do on yourself, perhaps with a therapist as your co-investigator.  

Alcohol/Drug Rehabs and You

I've recently added a series of blog posts to the blog for my half-time job, Lawyers Concerned for Lawyers of Massachusetts (no, I'm not a lawyer, but I've learned a great deal about them) on the subject of alcohol/drug rehabs, and thought I would highlight here some of the points I made there.  I know that many of those (especially family members) who come to see me (or visit my blog) are thinking about trying to get their loved ones into rehab.  Here are some of the important things to know:

• The term "rehab," in the alcohol/drug field, refers to an extended inpatient stay, usually around a month, that begins with detox (withdrawing the individual from his or her substance while preventing the most serious withdrawal symptoms) and proceeds to a structured daily routine of group therapy, some individual counseling, medical/psychiatric evaluation, often some family contact, and usually exposure to self-help groups.  Aside from the treatment per se, being away from one's usual habitat and immersed in the culture of recovery, while bonding with others in more or less the same situation, can provide a nice inspiration and jump-start to establishing a life free of bondage to addiction (though there is no guarantee and rehab is only one stage of movement toward recovery).

  

  Lindsay Lohan

• With few exceptions, health insurance no longer covers rehab -- usually the only inpatient treatment it will cover for alcohol/drug addiction is the "detox" phase, generally a few days, more or less depending on the severity of withdrawal symptoms.  This means that most of the time at rehab (often payable in advance) must be paid out of pocket, and exceeds $30,000 or $40,000 for the month. There are some less expensive options, which I can discuss with you, which are achieved by cost-cutting means such as (a) a lower percentage of doctoral-level staff; (b) less medical/nursing coverage; (c) locations in areas where it is less costly to operate, including outside the U.S.
• There are some options that emulate aspects of rehab which are often covered by insurance -- mainly, day programs ("partial hospital") offered in such a way that the patient attends daily but lives at home, or pays a reasonable fee for room and board on the facility's grounds.  For those of us without wealth, this is the main intensive kind of option to be considered.  
• Hundreds of rehabs have glossy web sites or brochures -- they are profit-making enterprises and they

  

  Robert Downey, Jr.

  want your business.  It is very difficult to know what facility to choose.  Generally, the more grandiose their claims (very high success rates, "cures" for addiction, no need for abstinence or self-help programs, disparaging other approaches) the more likely they are to be bogus (much like late night infomercials about getting thin with a pill, getting life insurance in old age for pennies, or making a killing in real estate).  Though expensive and by no means perfect, two of the oldest and best known facilities are probably also the most reliable:  Hazelden in Minnesota and Caron Foundation in Pennsylvania (both have satellite programs in other locations as well).  I have also heard positive reviews for Mountainside in Connecticut, which may also be a bit more affordable.  Many facilities will also claim to be covered by insurance, yet demand the up-front payment of a large deposit.  Be wary.
• Rehab can be a great start for those with plenty of money.  It is almost never worth the money for

  

  Amy Winehouse

  families that must struggle or borrow to pay for it.  The fact is that, no matter how wonderful the treatment, alcoholism/addiction is a condition characterized by relapse, and there is no magic. Regardless of their claims, less than half of those graduating from rehab will still be completely alcohol/drug free a few months later, but your poverty will persist.  Inpatient rehab, or some facsimile, becomes more worth considering when other, less intensive measures have repeatedly failed, and when the individual's addiction becomes quite serious.  Even then, however, recovery takes a lot of motivation on on the part of the addict.  I've seen too many people go to a long string of even the finest facilities with no lasting impact, and I've also seen many people who seemed "hopeless" get sober at unpredictable points in time in ways that cannot be attributed to treatment.
• While it can be extremely helpful to be removed for a time from the environment in which the addiction has developed, what makes the biggest difference in the long run is ongoing involvement in a non-addictive lifestyle.  The components of that lifestyle often include:  (a) outpatient therapy/counseling; (b) self-help groups; (c) healthy activities not associated with drinking or drugging; (d) daily structure and routine; (e) frequent contact with healthy friends/family; (f) connection to community and sense of meaning, which can come in many forms; (g) exercise and meditative activities.  (That's not to say that all of these are essential for any individual.)  

Some people come to meet with me (in Newton or Boston) just once or twice to brainstorm about all these options.  I have no obligations or financial connection to any particular facility, group, or treatment, and I respect your ability to make your own decisions (even better when more more informed).

“Don't Trade a Headache for an Upset Stomach” – For Families of Addicts, it's Not Always Black and White

The title quote, from a decades-old Bufferin commercial, captures a situation in which the solution to one problem (headache) causes another (aspirin-induced stomach irritation).  The reality is that similar dilemmas arise frequently in the world of behavioral problems including addictions, though there is never a shortage of people offering black-or-white advice.

It’s usually quite burdensome to be dealing with an actively alcoholic family member.  Aside from the scars that the experience tends to leave on children (who grow up to become ACOAs, Adult Children of Alcoholics), for adults involved there are the unending demands to manage and navigate a situation characterized by irrational and sometimes unpredictable behavior.

The term “enabling” refers to anything that other family members (usually most focally the spouse) do that shield the alcoholic (or addict, of course) from the naturally flowing consequences of his or her behavior.  This concept took off around the 1960s (by my recollection), and treatment providers urged family members to avoid enabling, since it tended to prolong the alcoholism by preventing the alcoholic from “hitting bottom.”  True enough, and generally a good idea, but at the time it was particularly hard for wives of male alcoholics (many of whom did not have their own income) to step out of their enabling roles, since it might well mean not having the means to keep the family fed and sheltered.  In real life, most decisions are not black and white. 

In recent years, I have often found myself addressing the dilemmas and emotional pain faced by parents and (grown) children of alcoholics/addicts.  Take, for example, the parents of a 20-something young adult addicted to opiates (usually a combination of heroin and painkillers).  If they continue, as is their natural inclination, to provide financial subsidies to their child, they may be “enabling”  – it makes it that much easier for the younger person to sustain the addictive behavior.  At some point, the parents may really need to withhold such support until their child is genuinely in treatment and on a path toward recovery.  On the other hand, they also know that withdrawal of financial help could increase the likelihood of their child’s being homeless, engaging in illegal activity to get the substance, and becoming more socially marginalized.  It is one of life’s many no-win situations, and none of us is in a position to judge those who confront it.

Another example is an alcoholic woman I saw, pushing 80 yet still in very good physical and cognitive shape (when sober).  Her adult children, who at my suggestion met with an addiction specialist of their own, moved her from her apartment and into one of their homes indefinitely, well aware that, by track record, on her own she was likely to resume drinking and let her health slide.  While their efforts were potentially life-saving, there was also an element of angry frustration.  (I remember similar feelings, borne of repeatedly being disappointed and lied to, toward my own alcoholic father many years ago, and I was not inclined to be nearly as sacrificing of my own life.)  The other side of the story is that this elderly woman, who herself had made great sacrifices to raise several children (now successful adults) now felt slapped in the face, in a sense imprisoned and robbed of respect and decision-making power in her own life.  In reaction, she became more depressed (though abstinent), and seemed destined to spend the rest of her life that state (but at least alive).  It was sad and ironic for me to feel the greatest sympathy and alliance with my patient, even though I, too, saw that her commitment to sobriety was iffy.  

That story has not yet reached a conclusion.  But I raise these examples to highlight the fact that life, even in cases of severe addiction, there is no one, clear answer.   This is why, as a therapist, I join individuals and families in wrestling with their situations, and attempt to provide information, perspective, and emotional support, but I seldom give one-size-fits-all advice.

Perhaps the Most Useful Studies are Your Own

There are so many internet posts, as well as a number of books, taking polarized and sometimes rabid positions about questions like (a) whether sobriety is necessary for alcoholic/addicted individuals and (b) whether AA [the most widely recognized kind of help] is the greatest vs the most awful resource available for those who do seek sobriety (meaning ongoing abstinence and improved life).  Much like MSNBC vs Fox, it can be very difficult to tolerate both, and each position draws those who are inclined in any case to embrace the perspectives offered. 

Attempts at scientific investigation, while always laudable, so often also seem to fall in line with the expectations or views or those either performing or reviewing studies.  For example, the large scale study known as Project Match (an 8-year effort that began in 1989) is recurrently put forth as proving both that the AA approach is a bit better than others or that AA offers nothing.  (My own reading at the time was that no particular approach was impressively better than any other, and that attempts to predict which approach would work best for a specific person failed.)

Those of us such as myself who work all the time with people trying to overcome alcohol and drug problems develop our own points of view based on experience, but of course our conclusions are also skewed by factors including (a) our own preexisting views and (b) the particular patient population that we see.  (For example, community epidemiologic studies indicate that many people stop drinking on their own; these people rarely show up at my office, and I would never have known.)

But if you have been concerned about your own drinking or drugging, you probably have already been doing your own experiments.  You may have tried changing beverages, using only on weekends, setting a daily limit on amount consumed, seeing a therapist (either with or without specific addictions expertise), attending 12-step meetings, attending SMART meetings, using online recovery resources, acupuncture, various kinds of medications, etc.  Since you are the only one with your unique brain composition, there is something to be said for running your own “studies” on yourself.  Since you’re probably doing so anyhow, why not get a little scientific?  Write down your objectives, and how you will measure success vs failure of your approach; record the things that you have done, how often, when, etc., and keep track of the results.  Trying to remember without keeping records may not be the best method, since memory is so prone to distortion.  At some point, you may decide to pursue this process with the help of a professional with experience in addictions.  Ultimately, what will matter to you is not the opinion of various alcohol/drug pundits (even those who aren’t so angry) but what works for you.