I’ve got this friend……
One of the by-products of doing a lot of teaching in the world of psychoactive drug use and addictions is having individuals who contact me about specific medical advice. This is always problematic, as physicians who offer opinions regarding specific medical situations about which they have only sketchy details often do more harm than good. It can be heartbreaking, as people try to seek help for their son, daughter, friend or spouse, who are trapped by the disease of addiction. The purpose in writing this article is to give some general advice around “best practices” concerning addiction assessment and treatment, and to try to help, as best I can, those individuals who are looking for further assistance in dealing with this difficult disease.
Is it really a disease?
It seems odd to start with this question, but it is fundamental to understanding addiction. For centuries we have understood addiction in different terms. Generally, in the past, people who suffered from this disorder were viewed as incorrigible, morally bad or weak individuals who needed incarceration or punishment to “straighten up and fly right”. Alternatively, they were hopelessly defective individuals who, despite the very best medical care, would always return to their drug of choice and the lifestyle associated with it, and so should be institutionalized. Happily, we now recognize that neither of these extremes are true. Addiction is now viewed as a chronic, incurable mental illness, which can be treated and controlled and allow individuals suffering from it to lead a normal, happy and productive life. Why the big change?
Unfortunately, medicine is as guilty as any other identifiable group in failing to study, and treat addiction effectively. Various “cures” down through the centuries ranging from electroshock, through a variety of potent but ultimately ineffective drugs, to psychotherapies of dubious utility have been employed by doctors and psychologists. This contributed to an aura of frustration amongst mainstream medical practitioners, and biases, some of which persist even to this day. Addiction medicine is generally not taught to undergraduate medical students, and the only addicted individuals that most physicians come across in their training are profoundly ill and profoundly dysfunctional, leading to the common misunderstanding that the disease cannot be treated and will not go into remission. Physicians often react badly to the dishonesty and manipulation which are so much a part of this disease. The unfortunate, unspoken attitude is too often “you did this to yourself, so you deserve whatever happens to you…”. Fortunately, however, the profession is slowly waking up to this subtle bias, through better research and better training - and better treatment outcomes.
The first breakthroughs in changing these entrenched attitudes actually came from the world of neurophysiology. Through the 1950s and 1960s, various chemical packets and chemical messengers within the brain, called neurotransmitters, were described and their function gradually understood. This is an active area of research today, as there are well over 4,000 neurotransmitters, and only several hundred of these have been well characterized or understood. Additionally, from the world of functional neuroanatomy, came the understanding that various areas within the primitive brain governed emotions, memories, feelings, and more complex behaviors such as that of seeking out a drug. From this research came early animal studies which showed that susceptibility for addiction could be genetically determined, or bred into certain lines of research animals. Geneticists gave us the knowledge that up to two thirds of human alcoholism appears to be genetically determined.
The ability of certain chemicals, termed addictive drugs, when placed directly into the various areas of the brain, to cause addictive behaviors was also described by researchers. From this, we began to understand that people, exposed to addictive drugs, actually “rewire” their brain, in some cases permanently, to change how they thought and behaved about these substances. Those readers interested in further research, or pursuing this topic further, are referred to the works of Dr. Elliott Gardner, one of the premier neurophysiologists working in the field of addiction today. His writings are widely available on the World Wide Web or by looking in the American Society of Addiction Medicine textbook.
Along with the newer understandings provided by neuroanatomy and neurophysiology, psychiatrists were also beginning to rethink addictions, and now classifying them as a separate psychiatric disorder. More recently (DSM IV), the terms “addiction” or “alcoholism” were understood in psychiatric terms as referring to “substance dependency”. A person addicted to alcohol, who might colloquially be called “alcoholic”, is labeled by a psychiatrist “alcohol dependency disorder”. This has now, even more recently, changed with the introduction of DSM 5. We no longer refer to “abuse” or “dependency” but instead “Alcohol Use Disorder” – which may be characterized as mild, moderate or severe.
So, in summary, no matter who looked at the disease, from neurophysiologist, to psychologists, to psychiatrists, drug dependency or “substance use disorder” is very much a disease, and is not a moral weakness or failing. The most casual student of history would see this point proven again and again, because no matter what horrific punishments alcoholics or other drug dependent people are subjected to, inevitably they return to their drug of choice. They are ill people struggling to be well – not bad people struggling to be good.
So if it can’t be cured - how is it treated?
Parallel with this new understanding of neuroanatomy and neurophysiology was a group of dedicated individuals, all of whom suffered from the disease of addiction, who worked out the principles behind 12 step recovery. This relatively simple, cognitive behavioral approach to what had formerly been viewed as a moral defect provided outcomes vastly better than any other traditional treatment of the day. 12 step recovery groups, such as the original Alcoholics Anonymous (1934), have often been misinterpreted as “treatment”, a claim that is inaccurate. Rather than claiming to treat the disease, such groups provide support and critical rethinking about addictive behaviors in an environment of acceptance and forgiveness so critical to escaping the clutches of this disease. This allows other forms of treatment to be much more successful.
A good example is psychotherapy. Unfortunately, insight oriented psychotherapy often involves digging up material from a person’s past which is quite painful. Someone with the disease of drug dependency knows how to handle pain - take drugs! So the treatment which was meant to help get rid of past emotional baggage leading to drugging/drinking, itself promotes the very thing we’re trying to fix. Generally, insight oriented psychotherapy should not be undertaken in early recovery. The individual may not be thinking very clearly, and experiencing the residual effects of their drug of choice, and therefore not able to make much use of the therapy. Secondly, the emotions stirred up by the therapy itself may lead straight back to using. Rather, therapy should focus on the more behavioral process of substituting new behaviors for the old drug-using behaviors. Recognition of high risk situations, and how to deal with them in new, constructive ways, are the cornerstone of early addiction recovery.
Additionally, an addiction therapist will focus on an individual’s readiness to change. There is a lot of research on change behavior done by two scientists, Prochaska and Diclemente. Searching these names on the Internet will get a lot more information about their “stages of change model”, but basically many people entering into addiction treatment don’t really see that they have a significant problem, and therefore are not particularly interested in changing. The challenge is to get them to understand that the source of much of their life difficulties stems from drug use, and to show them that not only is change possible, but will result in a much happier life. This sounds simple, but is actually quite complex. For instance, putting people in the earliest stage (pre- contemplative) of change into an action oriented treatment program is highly likely to fail.
Along with early recovery psychotherapy, individuals in treatment need to learn about what their drug of choice has been doing to them, and to others. It has been said with a great degree of truth, that people who are addicted stop maturing at the age that they start becoming heavily involved with drugs. For many individuals this can be the early to mid teens. Imagine what it would be like in your own life if you missed all of the experiences from age 15 to age 30? You would have no idea how to get along with other people, you would have no idea how to run a romantic relationship or be somebody’s spouse, and you would only dimly be aware of how to behave so as to gain success in your chosen profession or as a parent. Life would be confusing and painful, and your drug of choice would be a soothing harbor to run to whenever things seemed to be unraveling. As your addiction progresses, things seem to unravel more and more easily! As an example, one of the simplest things individuals with the disease of addiction fail to understand is how to have fun without getting intoxicated. They have to learn how to play again, and do many of the things all of us take for granted.
In addition to all of the psychiatric, psychological and neuropsychological problems associated with drugs of addiction, there are a wide variety of physical problems as well. These are generally unique to each particular type of drug. Some of them are generic, such as poor nutrition, obesity, physical deconditioning, and some of them may be highly specific, such as cirrhosis of the liver. These will have to also be addressed in treatment, and a new, healthy lifestyle involving proper nutrition, exercise, and medical care constructed.
Since most inpatient addiction programs last 21 or 28 days, it should become immediately obvious that there is no way that all of these huge tasks can be completed in that brief period of time. Residential treatment has, as its primary goal, detoxifying the individual from their drug or drugs of choice, assessing where they are at in terms of stages of change, and contracting for next steps. Residential treatment is often misunderstood as “curing addiction”. At best, it can only be a good beginning. It generally takes an addicted individual six months to begin to sort out their life, and understand what needs to be done.
The first year of recovery has to be devoted to not using, and substituting healthy behaviors for addictive ones. Making new friends, surrounding oneself with a healthy support network, and slowly reintegrating into the most basic units of life such as marriage and worksite are all tasks which are tackled within the first year. The second-year, or “middle recovery” is a time for examining some of the deeper psychological issues which may have fueled the addictive behaviors in the first place. As well, the addiction itself will cause the individual to behave in potentially shameful ways, or even commit criminal acts, and all of these will have to be dealt with. Lastly, beyond middle recovery, comes the issues of late recovery. These may be as profound as choosing a new direction in life, or trying to change some of one’s basic personality and philosophies. Late stage recovery potentially stretches on throughout the rest of an individual’s life.
Unfortunately, things can also move in a negative direction. Addiction is a disease which inherently can involve relapse. Relapse refers to an individual returning to old addictive behaviors and patterns of thinking. Often these behaviors and patterns of thinking show up long before the individual starts actually using their drug(s) of choice again. Given our understanding of neuroanatomy and neurophysiology, we recognize that the brain has been rewired by addiction, and tends to return to its old ways, unless constant vigilance is exercised. Relapse is not inevitable, but is a well understood risk of addiction recovery. It needs to be approached non-judgmentally, taking a careful look at what went wrong, why, and addressing that. Often, a further stretch of residential treatment is required.
How do I get my (son/daughter/spouse/friend) help?
Firstly, before any treatment is contemplated, it is essential to get a good assessment. This is easier said than done. In most Provinces, including Alberta, there is a waiting list for qualified addiction trained physicians and psychologists, however appointments can usually be obtained in a reasonable timeframe. A referral to an appropriate assessor should be sought through one’s family physician, or employee family assistance program. A list of physicians with expertise in addictions can be obtained from the appropriate College of Physicians and Surgeons for the Province that is relevant. Likewise, the Provincial Association of Chartered Psychologists can provide names of addiction psychologists. All of this is easier said than done, if the addicted individual does not see themselves as having a problem. Once the basic homework has been completed, as in who will do the assessment, and when and where, an attempt should be made to get the affected individual to agree to the assessment. This can be difficult. The best approach to take is one that is firm, fair, and nonjudgmental. It is usually advisable to discuss this with the individual in a neutral private setting, and usually advisable that more than one person shares their belief that the affected individual requires assessment. In a “one-on-one” setting an individual who is heavily into denial will usually brush off any concerns fairly easily. What is being discussed here is an intervention of sorts, but on a very low level. With a very sick, or resistant individual, a higher level of intervention will be required, and it is most inadvisable to attempt this without professional assistance. The recent popularity of the television show “Intervention” may lead some individuals to believe that they are perfectly capable of confronting an individual with an addictive disorder in a highly emotionally charged and combative atmosphere. This is an unfortunate misunderstanding, and is likely to do far more harm than good. Should a high-level intervention be required, obtaining the services of a professionally trained interventionist, usually a psychologist, is mandatory. Once the assessment is done, and assuming the assessor agrees that the individual in question requires treatment, the rest is fairly straightforward.
What to do if the affected individual will not accept assessment, or will not accept treatment, and reacts angrily to any attempts at intervention? Obviously, this is a tragic situation which is not uncommon. It is important, then, to treat the individuals we can treat, which are those directly affected by the addiction. Spouse, family, children, all are affected by this disease. All such individuals are going to need careful counseling on how to deal with the ill person, how to avoid becoming “codependent” (a regrettably overused term which, legitimately, means preventing an addicted individual from experiencing the negative consequences of their disease through misguided attempts at “helping” – giving them money, alibis, bailing them out, thereby encouraging them to continue on with their addiction and avoid treatment).
During the relentless, downward spiral that is the disease of addiction, there will be opportunities to reach out to the individual with offers of assessment and treatment. These may initially be rebuffed, but they should be firmly and calmly offered again, in the future, when some negative consequence of the disease has momentarily rendered the individual more open to considering such treatment. There is no way, in a free society, that we can force individuals to undergo assessment or treatment against their will except by court order, and these are exceedingly rare. Rather, the emphasis should be on boundaries, fairness, expressing concern for the ill individual while not supporting their choice to continue outside of treatment. The ill individual must be permitted to experience the full brunt of their disease, as this is one of the factors that will assist them in moving towards assessment and treatment. That does not mean that punishing or hurting an addicted individual will result in anything positive, because it will not. Ultimately, and tragically, this is a disease which often has lethal consequences if untreated. Watching a loved one die from addiction is one of the most emotionally painful experiences a human being can undergo, and I would strongly urge you, if you are in such a situation, to seek help for yourself.
Controversies in addiction treatment.
Even the most casual search of the Internet will show a bewildering variety of treatments, and many websites, often in complete opposition to each other, offering a wide variety of opinions on how this disease should be approached. How to make sense out of all of the noise? Firstly, in any field of medicine, doctors acknowledge that, particularly for a complex neuropsychiatric disease like addiction, a wide variety of people may respond to a wide variety of treatments. There is no telling exactly what will be successful for any one particular person. So faced with this, how can one proceed in a reasonable manner? There are some general principles of addiction treatment which can be stated with reasonable confidence. Some of these bear on the controversies so prevalent in this disease.
Can one learn to drink or use in a controlled fashion again?
No, one cannot. Despite the assertions of some practitioners, research behind controlled drinking or control drugging has been uniformly disappointing. Short-term results are often impressive, with individuals learning to drink nonalcoholically, for instance, for six months or a year, but inevitably they return to alcoholic, self-destructive drinking patterns, and the disease progresses.
When I wanted to quit smoking, I just quit. I didn’t use any drugs or therapy. Why can’t people do that with other addictions like alcohol?
There is no question that some individuals who meet the diagnostic criteria for alcohol dependency, have decided to simply stop drinking. A few are even successful. There is no question that it can be done. The open question is by how many, and with what degree of success? The fact that civil war surgeons were occasionally successful at removing gangrenous limbs with a hacksaw under crude conditions and no anesthetic or sterile technique, is no proof that this is an advisable or effective way to proceed in treating gangrene. The vast majority of individuals who attempt to stop using psychoactive drugs without any other therapy or assistance fail to do so. A further minority enter in to what is called “a dry drunk” state. This is an individual who is technically abstinent from their substance of choice, but is miserable and unhappy. There is much more to recovery than simply not using a drug. All of the past damage caused by the drug, and drug fueled behavior, has to be addressed and resolved. Simple abstinence fails to do this. If it works for you, congratulations! I begrudge no one their successes. I cannot, however, in good conscience, counsel a technique that works for so few, and works so sporadically.
I heard that AA is a cult…
Alcoholics Anonymous certainly has its vocal, although relatively small group of detractors. Rather than get sucked into a fruitless debate over what constitutes a cult, and what doesn’t, I always remind patients of the seriousness of the disease that they are up against. Addiction is a relentlessly progressive, often lethal disease which devastates individuals and families. Anything which offers a significant chance of promoting recovery should be explored with an open mind. Ultimately, Alcoholics Anonymous may not be suitable for everyone, but in my experience as an addiction physician, the vast majority of people objecting to Alcoholics Anonymous are actually not really objecting to AA at all, they are objecting to stopping drinking or drugging.
Whatever excuse, or smoke screen can be thrown into the mix, particularly if it involves an emotional and fruitless debate, serves to further an active addict’s purposes, which is to continue drinking or drugging. It is not their fault, it is just a defense mechanism, and it needs to be seen for what it is. Try Alcoholics Anonymous for six months. As they say, if you don’t want what they offer, your misery will be happily refunded. Virtually every one of my healthy, recovering patients are active in some form of 12 step recovery group, and credit their involvement in the group as a significant factor in saving their lives. Judge for yourself.
My pastor says prayer can cure my addiction…
I have treated a wide variety of individuals, from a wide variety of faiths. I am also a person of faith myself, and therefore have no qualms about discussing this area with my patients or their families. With that as background, I offer the following comments concerning religion in recovery. Firstly, our society often confuses spirituality with religion, and they are really quite separate and distinct. It matters nothing to me whether you find solace and guidance within the Tao, Buddha, or Jesus Christ or something unique to yourself. The point is, some form of spiritual exploration is essential to recovery, while any particular religious structure is not. This spirituality will be as unique as each individual, and it may certainly be found within any religious belief system (or outside it as well!). There is no right, or wrong way to spirituality and recovery. That being said, religion and religiosity can often be used as a defense mechanism. The implication is that some form of religious magic is going to cure an addicted individual without any of the hard work inherent in recovery. In my experience, it just doesn’t happen. Someone who is active in the disease of addiction can effortlessly play off a priest or pastor against their medical treatment team. It requires maturity and diplomacy on everyone’s part to circumvent this attempt at derailing recovery. There is absolutely nothing in the 12-step approach to recovery which is offensive to any of the world religions with which I’m familiar. Going even further, if you have a religious advisor, priest, Pastor, Rabbi etc., they are an essential element of your recovery team. There are certainly fringe individuals within various organized religions who claim to be able to “cast out the demon of addiction” along the lines of faith healers. Unfortunately, their statistical track record is no better with addiction than it is with breast cancer, or any other devastating physical illness. That being said, it is my understanding that a loving and personal God (Higher Power) wants nothing more for you than freedom from this devastating disease, and to be all that you were intended to be.
I heard that XXX clinic has a revolutionary new treatment program that works way better than anybody else’s…
As with any other service, or product, buyer beware. If it sounds too good to be true, it usually is. The world of addiction medicine is vibrant and active with research. Where there is research, there are competing ideas, and new processes. The best ones become standard, and the ineffective ones fall away. Within that, most residential treatment programs are equivalent. So how does one choose between programs? Success rates are notoriously unreliable statistics, and can be manipulated by almost anyone to make a program look either unrealistically good, or unfairly poor. Rather, consider the following:
Does the residential treatment program adhere to an abstinence-based model, or do they try to teach controlled drugging or drinking? Abstinence is best.
Do they embrace peer support group such as Alcoholics Anonymous or other 12-step processes? The 12-step process has the longest track record, and, year in, year out, is the best approach to addiction recovery.
Does the treatment program have a “one-size-fits-all” approach to addiction treatment or do they make an attempt to understand each individual, as an individual? Obviously, in a disease that cuts across psychological, social, spiritual and physical boundaries as does addiction, one size does NOT fit all.
Do they have an aftercare or continuing care component to their treatment?
Research shows that the single most important criteria for continued abstinence is ongoing aftercare, not the brand of residential treatment.
Are they excessively permissive, or excessively punitive? This seems like a terribly subjective question, but listen to your gut. The idea behind addiction recovery is not an enjoyable stay at a country club. A certain level of healthy confrontation is going to be necessary, if a person reaches residential treatment in a deep state of denial. Any such confrontation should be carefully considered, never done out of anger, and respectful and loving in its motivation. Do not be misled by a variety of recreational activities available to participants in recovery programs. These are actually very important, and essential in helping an individual discover new, drug-free ways to have fun. On the other hand, “boot camps” may appeal to the angry or hurt emotions within relatives of the affected individual who have been harmed by the addiction. The problem is that pain does not cure addiction. If it did, the disease would cure itself. Simply putting someone into an excessively harsh environment and being brutally confrontational is not associated with any degree of success, nor does it make any sense that it would be. Are you looking to treat, or punish? If you really want to hurt an addicted person, simply leave them in the depths of their disease. It will destroy them more effectively than any punishment you could design.
Do they have an element to their program which encourages graduates to return? It can be very uplifting, when one is in the depths of despair in early addiction recovery, to spend some time with people who have made it out. Likewise, issues may arise in middle or late recovery which may require treatment centre assistance. If all the Treatment Centre offers is early detoxification, they are not likely to be very helpful with these issues.
Is there a spiritual component to the Treatment Centre’s program? Research shows that this is a disease with a strong spiritual element, and ignoring that decreases the effectiveness of the treatment program. Spirituality should not be confused with religion or religiosity.
Do they have a family component in their program? After the addicted individual themselves, the family is the most profoundly affected by the disease. Failing to address the family, and their role in perpetuating addiction, as well as the damage which has been done to them by the disease, is a huge oversight in addiction treatment. It has been said that addiction is a family illness.
Do they have treatment options which are of sufficient duration? It can take upwards of two months for someone dependent upon cocaine to experience sufficient brain recovery to make use of a lot of the information being offered them by the Treatment Centre. Releasing a cocaine addicted individual after two or three weeks is highly unlikely to be successful.
Do they have the ability to address other psychiatric problems which may be complicating the disease of addiction? Individuals who suffer from underlying psychiatric disorders, such as bipolar disorder, have what is known in addiction medicine as “a dual diagnosis”. These are a specific subset of addicted individuals that require very specific services. Putting them in a “one-size-fits-all” treatment program is unlikely to be successful. Their underlying psychiatric disorder, which most likely has been exacerbated by their drug use, also needs to be addressed. That being said, do not be confused by the fact that most individuals with the disease of addiction feel either very anxious, or depressed. They may even have been prescribed antidepressants by physicians who did not recognize the existence of the underlying addiction. This does not mean that they suffer from anxiety disorder, or major depression. These mood disorders may disappear quite rapidly once the substance is no longer in the affected person’s system.
- Wow! What a thicket of choices, how am I ever going to make sense of this?
Relax. Any reasonable residential treatment program is going to be preferable to leaving the affected individual in the depths of their disease. If the program turns out not to be the best fit, or have some elements that are missing, this can always be addressed later. There is nothing to say that an individual cannot go to more than one residential treatment program, if the first one is found wanting. The important thing is to stop using, today. Start addressing the issues, and worry about the details later.
Your website, and your presentations seem to be heavily oriented towards drug and alcohol dependency. What about problems like gambling, sex addiction, food addiction etc.?
Initially, the earliest research on addiction was done in the field of alcohol addiction. That is why we know the most about it. Secondarily psychoactive drugs like heroin, cocaine etc. were studied. Obviously, the impetus for much of this research was the destruction and havoc wreaked by these drugs on the lives of the individuals who took them, and those around them. More recently, through work of researchers like Dr. Patrick Carnes, we are coming to understand that behavioral addictions can be just as devastating, and express themselves in very similar manners, to drug addiction. In many ways, research and treatment into these entities are still in their relative infancy. We know that approaches that work for drug dependency, such as 12 step recovery programs, also can work quite successfully in gambling or sex addiction. That being said, there are some unique qualities to behavioral addictions which differentiate them from substance addictions. Insurance companies, and legal authorities certainly view them as quite separate and distinct. Just to make things even more complex, behavioral addictions often coexist with substance addictions. It is not unusual to find somebody so guilt ridden over their compulsive sexual behavior, that they must be intoxicated in order to engage in it. In this case, the sexual addiction would be the primary addiction, and the alcohol addiction might be secondary. Any good addiction assessor will also look at the field of behavioral addictions (sometimes also referred to as process addictions) in making their assessment. These will have to be dealt with in treatment, alongside any substance disorder. It is important to know that treatment is available, and there are clinicians who specialize in process addictions.
So – there it is in 10 pages or so. This is the best generic advice I can offer to individuals or families facing the disease of addiction. The best wishes I can offer you, and your addicted family member is contained in the promises of Alcoholics Anonymous:
If we are painstaking about this phase of our development, we will be amazed before we are half way through.
We are going to know a new freedom and a new happiness.
We will not regret the past nor wish to shut the door on it.
We will comprehend the word serenity and we will know peace.
No matter how far down the scale we have gone, we will see how our experience can benefit others.
That feeling of uselessness and self-pity will disappear.
We will lose interest in selfish things and gain interest in our fellows.
Self-seeking will slip away.
Our whole attitude and outlook upon life will change.
Fear of people and of economic insecurity will leave us.
We will intuitively know how to handle situations which used to baffle us.
We will suddenly realize that God is doing for us what we could not do for ourselves.
Are these extravagant promises? We think not.
They are being fulfilled among us - sometimes quickly, sometimes slowly.
They will always materialize if we work for them.
From ‘Alcoholics Anonymous’ - 4th. Edition - Page 83 - 84 ( Copyright © Alcoholics Anonymous World Services Inc. )