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.

Lessons from Philip Seymour Hoffman

Is it that some of the most talented among us are drawn to opiates, or that we only hear about the famous, admired figures?  Before Philip Seymour Hoffman, who was certainly among my handful of favorite actors, there were others like Health Ledger, Chris Farley, River Phoenix, and Jim Morrison (to turn back time further), and Robert Pastorelli (whom we remember best as “Eldin,” Murphy Brown’s painter who never quite finished the job).

According to the Center for Disease Control, the rates of fatal opiate overdose have more than tripled in the past 2 and a half decades.  Of course, the incidence of death reflects an increase in the number of individuals using these substances.  As I’ve seen in clinical settings during that time, initial exposure to painkillers like Oxycodone (Percocet) or Hydrocodone (Vicodin) too often leads quickly to addiction, characterized by powerful cravings and painful withdrawal symptoms relieved by repeated use.  People who thought they were just following a surgeon’s orders or having fun with drugs in college or neighborhood settings fail to recognize their addictions until they become severe.  Many proceed from pills to heroin, which is much less costly though also more likely to cause overdose (because of unpredictable variations in purity).

If you are concerned about your drug use or that of someone you care about, there are a number of treatment approaches that can help in the very difficult path to sustained recovery.  The process starts with a clinical overview, either with someone in private practice like myself or at an appropriate clinic.  Not every clinician knows much about addictions, which does not prevent them from saying that they do.  Look for either experience working in an alcohol/drug-focused setting or a certification (CADAC or CAS) or alcohol/drug counseling license (in Massachusetts, called LADC).  

If only we had reason to hope that Philip Hoffman’s tragic death would be a turning point for our society, just as the death of Len Bias in 1986 seemed to puncture the myth that anyone was immune to the dangers of cocaine.