Sections: Abuse
and
Addiction;
Abuse-Addiction Prevention; Abuse-Addiction Treatment; Critique of 12-Step Approach
(AA/NA); Opiate
Addiction Treatment
updated 4/2012
Abuse and Addiction:
Summary
Introduction Abuse-Addiction, Definitions and Conceptualization
Conceptualization, Biology of Human Behavior and Ethics
Addiction as
Disease or Mental Disorder
Addiction and Psychiatric Disorders -
Anorexia Nervosa
Summary (updated 4/2012)
Paradigms used in the study of substance abuse are problematic.
Abuse-addiction disorders should be conceptualized as psychological
disorders defined by a pattern of self-reinforcing harmful
behaviors, associated feelings, thoughts and behaviors, and distorted
priorities; they are usually associated with other psychiatric disorders. There
are biological correlates and predispositions, but these do not
constitute the disorder. The term dependence refers to the
physiological adaptation to certain substances, many of which are not
addicting. Different drugs have different effects, and correspondingly,
self-medication of psychiatric symptoms is often associated with
specific drug addictions.
Drugs do not directly lead to unethical behaviors, but unethical
people tend to use alcohol and/or illicit drugs. Unethical behaviors,
committed while under the influence of a drug, were previously thought
about and vicariously enjoyed. Alcohol then makes it easier to act out
unethical fantasies; psychostimulants may worsen risk taking and
violence. However, distortions of priorities often leads to unethical
decisions. Structured, regular use of addicting drugs, as in heroin
maintenance treatment (Switzerland and other European countries),
hardly leads to unethical behaviors.
Addicting substances vary greatly in their adverse
effects, and different addictions need different treatment approaches.
AA works
fairly well for alcoholics but little for opiate addicts. Opiate
addiction treatment should usually include methadone or buprenorphine maintenance for at
least two years. Methadone maintenance treatment is not a continuation of the
addiction and allows, in proper dosage, normal functioning. Side
effects include decreased aggression and sex drive. Opiate
detoxification has a poor prognosis and is dangerous (high risk of overdose).
We have overwhelming anecdotal evidence that
methadone, even in low dosage, is very effective in the treatment of
anorexia nervosa.
Abuse prevention and treatment should emphasize
ethics because 1. abuse is, by definition, unethical; 2. abuse
typically rewards and reinforces incompetence and/or negative and
unethical thoughts, feelings and behaviors; it slows or prevents
emotional growth; 3. if patients start or continue to vicariously enjoy
unethical acts, the enjoyment of such fantasies may become a
psychological addiction, and if lapsing, particularly if drinking
alcohol, patients may act out the unethical fantasies; 4. humans
inherently want
to be 'good' or 'right'. Particularly adolescents vacillate between
being self-centered and idealistic.
There are major problems in how abuse behaviors,
abuse disorders and 'substance dependence' have been defined and
conceptualized. Health professionals, politicians and lawyers broadly
misunderstand substance use disorders. Clinical implications of
misconceptions are pertinent
for both treatment and prevention approaches.
Introduction
This article describes personal experience and salient anecdotal
evidence regarding treatment of opiate addiction-multiple diagnosis
patients. Physicians have been persuaded that "evidence based"
treatments, following what is demonstrated in prospective double-blind
studies, is equivalent to good treatment. We tend to forget that many
studies are misleading, very limited in scope and/or poorly designed.
It is most important that studies show what does not work, where
placebo does as well as the traditional treatment. However, most
progress in medicine and the behavioral sciences resulted from
clinicians' or researchers' keen observations and intuition. For
example, compare progress in obstetrics (The New Yorker, 10/9/2006, Annals of Medicine, "The Score – How childbirth went industrial" by Atul Gawande).
Abuse-Addiction, Definitions and Conceptualization
updated 4/2012
Abuse is a behavior that feels good but is known to be bad. "Feeling good"
meaning experiencing joy, thrill, "high", or relief of anxiety,
anguish, boredom, pain. "Bad" means unethical and/or benefits do not
outweigh likely direct and indirect negative consequences to self and
others. Abuse behaviors are positively motivated and self-reinforcing,
consequently, in addition to the behaviors themselves, associated
thoughts, feelings, behaviors and experienced environments are
remembered, perceived as positive and later sought. Generally, the patient feels in control
and may consider abuse behaviors a calculated risk worth taking.
[The large majority of people who start using alcohol and/or illicit
addicting drugs do not progress to absue-addiction disorders.]
Misuse may be defined as inappropriate or illegal self-medication.
In abuse disorder,
the abuse behavior dose not occur in isolation and there is a pattern
of
abuse and associated behaviors with significant negative consequences.
Abuse disorders are a major ethical issue: by definition, abuse is
itself unethical, 'cheating' the emotional system and culture,
additionally abuse usually reinforces many unethical thoughts and
behaviors; these other unethical behaviors, which are also enjoyed, are
often more problematic than the substance use itself.
An addiction disorder is a pattern in which the abuse behavior became one of the patient's
first priorities, along with priorities such as being a good parent,
spouse and employee or student, living essentially within the laws of
one's culture, being essentially safe and healthy.
Lapse [versus relapse] means, key stimuli combined with remaining craving,
lead to impulsive substance use or attempt to find drug; the patient
almost immediately regrets having fallen victim to old habituation.
Relapse refers to
not only moving towards abuse-addiction behaviors, but mentally
consenting to it. The patient may
rationalize that he/she now deserves exceptional use and can handle it.
A belief that every lapse is a relapse often is a self-fulfilling
prophecy: he/she
immediately gives up, believing "once and
addict, always an addict – why trying to stop". Relapsing may be
compared with Pierre Abelard's concept of sin (French Medieval
theologian-philosopher): he maintained that the sin of (sexual)
wrongdoing consists not in the illicit act, nor even the desire for it,
but in mentally consenting to the desire. Craving and lapsing is not
the sin, mentally consenting to desire, plans to act and action are.
Abuse-addiction disorders may be understood to be a lack
of emotional strength to follow own ethics and values; the emotional
pull of the drug's false good feelings is more powerful than the
emotional strength of healthy goals. A patient may drift into addiction
when lacking strong goals or feeling worthless and hopeless, but ceases
to be an addict when finding a positive goal with strong emotional
value, e.g. falling in love, expecting a child, finding a religion.
While positively motivated, learned stimuli that are associated with
abuse-addiction behaviors weaken, and over following years, the danger
of return to abuse behaviors becomes minor unless lapsing
thoughts and behaviors maintain the abuse memories.
Abuse-addiction behaviors are primarily positively
motivated, even though fear of withdrawal may contribute to the
chronicity of the disorder and/or add a compulsive component.
Withdrawal symptoms are not the reason patients stay addicted. Patients
usually know that, if they decrease the amount of the abused drug by
one third and later taper it further, they would have craving but
hardly withdrawal. [Many substances lead to physiological dependence
without being addicting and many addicting drugs do not lead to
physiological dependence: there is overlap between addiction and
dependence but they are not the same.] Generally abuse behaviors are
planned, not impulsive, to some degree habitual (i.e. following
conditioned responses without much awareness), but generally not
compulsive. Obsessive-compulsive behaviors are negatively motivated and
hardly enjoyed (usually egodystonic). They unsuccessfully try to
alleviate exaggerated and/or irrational fears, e.g. fear of contamination.
Abuse disorders tend to become addictions, if patients have no good reason to check or stop the abuse pattern, e.g. if patients are confused and lacking goals ("drifting"), if they are
very depressed and unable to think positively about their future, if
they try to self-medicate psychiatric symptoms, or if they live in a
(sub)culture that condones if not encourages the abuse.
Abuse: Consideration of the Biology of Human Behaviors and Ethics
updated 4/2012
Abuse is about feeling good through behaviors that include ethics
violations. Basically, humans feel good from 1. instinct fulfillments,
and, closely related, 2. cultural fulfillment, or 3. abusable/addicting
drugs.
Drugs, bypassing any thoughts or
actions, feel good as if fulfilling an instincts. When addicted, drug
use feels instinctive. They "cheat" nature and culture.
- Tranquilizers and alcohol make person feel good as if conflicts were
resolved, there is peace, one believes to deserve rest.
- Psychostimulants imitate the (immediate) anticipation of something positive and/or big.
- Opiates seem to feel nurturing, as if held by family, clan, loved ones.
Abuse, by definition, feels good and consequently is
self-reinforcing. Preceding and concomitant feelings thoughts and
actions are also reinforced and start feeling 'right' and/or good.
Abuse-addiction and related behavior are learned patterns that soon
feel natural or like part of one's culture. Most people restrain or
stop abuse behaviors and do not develop abuse-addiction disorders
because of insight, including ethical considerations, and because of
positive goals that exclude the abuse behavior.
Ethics violations are perceived by the abuse patient. Typically,
- The patient would not recommend his/her behavior to a close relative,
friend, or peer, and particularly not to his/her own child.
- The patient would feel embarrassment, shame and/or guilt discussing the
behavior with a true peer who does not display same or similar
behaviors and pathology.
- The patient recognizes that no wise, benevolent friend or counselor
would advise him to continue the behavior. If another person is
involved, the patient recognizes that friends and relatives of that
person would disapprove.
- The patient has a sense that he/she will sooner or later regret the behavior.
Virtually all people show some abuse behaviors but
most do not progress to abuse disorders and addictions. Often, people
become addicted because they have psychiatric disorders that decrease
insights and motivation to pursue healthy goals. Much drug abuse starts
as attempt to self-medicate. A legitimate pain medication may be
recognized to alleviate loneliness and/or psychiatric symptoms.
Men are more likely than women to abuse drugs and
become addicted, and there is usually less psychopathology. Humans have
an instinctive propensity toward some irrational behaviors.
Particularly males' competing for rank order (and for females) includes
an instinctive urge to show off with outlandish behaviors and taking
major risks. This instinct may be the reason why some addicts show
little other psychopathology and why males are about twice as likely to
become addicted than females although females have about twice the rate
of anxiety and mood disorders. Women tend to use drugs to self-medicate
and generally take much less senseless risks, except when complying
with males.
Addiction as a Disease or Medical Disorder
The notion that addiction disorders are diseases marked by
changes in brain structure and functioning (imaging studies), is not
helpful. Addictions may be conceptualized as pathological learning
"patients learned something they should never have learned". Any
learning that involves new information, emotions and motor skills leads
to significant changes in the central nervous system. Learning to ski,
play the piano or boxing, becoming sexually active, or going through
law school undoubtedly changes the person's brain, and areas that are
vital in the learning process may expand in size.
The Diagnostic Statistical Manual's
(DSM IV and IV R) concepts and criteria for abuse, dependence and
impulse disorders appear inadequate and in places inappropriate. The
implied close association of substance abuse-addiction disorders and
physiological dependence is inaccurate1 and suggests inept treatment2.
Addiction is commonly considered progressive and
often lethal, like a malignant disease. Actually courses of addiction
disorders vary greatly; treatment may be crucial but many addicts
improve and recover without professional or other interventions.
Recovery may be related to life experiences; addiction treatment should
include fostering broad learning and maturation3.
It is also problematic to consider addictions
genetically transmitted. Psychiatric disorders are not inherited,
though predispositions often are. In the case of propensity to
addictions, there are primarily less protective factors, such as
personality traits of a planner who wants to feel in control, being
sensitive to drug side effects, etc. Many psychiatric conditions may
predispose to addictions disorders, e.g. patients with ADHD, mood disorders, PTSD, borderline personality
disorder, but probably not antisocial personality disorder(?).
Generally, humans have adequate insight to avoid moving from abuse to
addictions, but everybody may, in unfavorable circumstances, develop an
abuse or addiction disorder. It is easy to get laboratory animals
addicted to many types of drugs. In principle, humans are similarly
susceptible. Regarding antisocial behaviors: opiate addicts sometimes
learn to behave in antisocial ways while becoming addicted. With
methadone treatment, most improve rapidly and think more ethically.
Concerns over medicalizing unethical behaviors have
been raised with the fear that psychiatric diagnosis may be used to
excuse behaviors. We never need a mental disorder diagnosis to excuse
behaviors: scientifically, we must be essentially determinists. [If
having free will is part of a person's religious and/or moral thinking,
he/she may believe that there is a small "unclaimed" space – science
cannot fully explain how animals (and humans) make decisions.]
Basically, our behaviors are determined by genes; by previous helpful,
neutral and pathological learning; and by the present environment. We
should never fool ourselves, believing we could voluntarily commit
crimes that contradict our upbringing, nor that we could have acted
differently in the past without the hindsight we have now.
By design, humans are virtually always in conflict
with fellow beings, and humans suffer much "normal" physical and mental
pain, particularly women. Whether we consider a human being's condition
worthy of therapeutic help is a matter of pragmatic compassion, not a
response to a judgment as to whether the patient's pain is voluntarily
self-inflicted versus due to a disease or accident.
Addiction and Psychiatric Disorders, Anorexia Nervosa
updated 3/2012
Psychiatric disorders are frequent in patients with abuse-addiction disorders, particularly in women.
Women seeking treatment for opiate addiction often relate
major abuse histories and bad experiences with intimate partners.
Psychiatrically, we see much depression, anxiety, PTSD, self-injurious
behaviors, anorexia nervosa, etc. Generally, times of extreme
loneliness appear to cause vulnerability to developing opiate
addiction. An interesting observation has been that we admit much less
twins than statistically expected (in the age range of our patients,
one in 40 people has a twin and the big majority of twins grow up with
this close sibling. It appears that having a fraternal or identical
twin may decrease the vulnerability towards opioid addiction because
phases of extreme loneliness are less likely4.
Opioid maintenance gives these patients structure and an
environment where treatment is possible. It makes the emotional
loneliness more tolerable while patients learn to become more socially
connected.
In some patients, we noticed antipsychotic effects of
methadone: when slowly tapering methadone, paranoia appears. This
effect is dose related.
We believe to have strong anecdotal evidence that
methadone even in low dosage, probably also buprenorphine, rapidly and
significantly decreases most or all symptoms of anorexia nervosa, and
that symptoms may not return when, after extended time of maintenance
treatment, methadone (or buprenorphine) is slowly tapered and
withdrawn. I believe that methadone maintenance should be considered as
safe and well tolerated treatment of anorexia nervosa if not the
treatment of choice. However, further studies are needed.
_______
1 Many nonaddicting substances lead to physical dependence,
including seizure, hypertension and nonprescription pain medications,
some antidepressants, and high dosage salt intake. People may be
dependent on insulin because of food addiction and/or addiction to a
physically lazy lifestyle, but they are not addicted to the insulin.
2 The focus on physiological dependence supports the assumption
that discontinuation of the drug constitutes successful treatment.
3 The DSM III research summary on course of opioid dependence
stated (page 172): " Among those who survive, increased abstinence is
found with the passage of years, with final cessation of dependence an
average of about nine years after its onset." (I do not know what
studies this was based on but it is hardly accurate for most U.S.
opiate addicted patients.) It also mentions the excellent prognosis of
heroin addicts returning from VietNam. We tapered many patients off
methadone and we know of some that they did very well for at least 10
years.
CDC statistics of incidence of use of alcohol, tobacco and
street drugs, based on age, show a steady decline with age (maturity).
Valiant described the natural course of alcohol addiction: many
alcoholics stop drinking or even return to social drinking without
specific treatments. Many smokers stop without professional help or
peer/support meetings.
4 A larger survey of our patients is in progress. Our experience
has been that much less than one in 40 of last few hundred admissions
are twins, and the last three twins have been very atypical. In
one pair (identical, female) both had major depression with the more
successful and never addicted twin having completed suicide by hanging;
in another (fraternal, males) the patient’s twin brother is reportedly
severely schizophrenic with brain damage secondary to suicidal OD
[antipsychotic medications].
Abuse-Addiction Prevention
Primary drug abuse prevention includes preventing abuse
behaviors, deceasing vulnerabilities and strengthening protective
factors. Secondary abuse prevention seeks to avert the development form
minor abuse to abuse and addiction disorders. Tertiary abuse prevention
is relapse prevention during and following treatment for addiction; it
may include preventing or treating secondary addictions, such as food
and nicotine addiction while in treatment for alcoholism or opiate
addiction.
Many factors pertain to primary drug
abuse prevention. For a healthy development within their society,
children need stable attachments and opportunities to learn and
practice social skills, including broad empathy and an understanding of
cultural values and traditions. Children have inherited temperaments,
talents and predispositions, and they may have some lasting problems
from early childhood traumas and under- or over-stimulation in
critical periods of development. A major task for children is to learn
to compensate for shortcomings and to develop potentials that are
beneficial within their societies.
Children benefit from different gender parental
figures, a stable group of peers of different ages and access to
natural environments - these components in the young child's
environment are less and less available with yet unknown consequences.
Children's natural propensity to exercise their bodies, express
themselves artistically and to meditate and contemplate are often
suppressed. Major problems in early childhood include a folklore that
raises false expectations, e.g. good things happen to good children,
bad things happen to bad children; working hard, you will reach your
goal and be happy ever after. Western folklore also reinforces black
and white thinking, rather than recognizing good and bad, yin and yang,
male and female traits in virtually everything. Probably most traumatic
is abuse that clashes with cultural expectations, leading to shame,
guilt, disgust and horror, a sense of dread, unpredictability and
loneliness.
Accepting and dealing with realities is important
from an early age on. Fate is random (no god or guardian angel
intervenes personally on a person's behalf); we can only influence our
environment and future; we never can control or predict anything.
Children may deal with issues in more or less solitary play and social
interactions; however, many children handle stresses poorly. It is
probably reasonable for children of certain temperaments to rely more
on leader figures. Some children benefit from a very structured
environment. Dissociation and/or wishing strongly that reality can be
changed, should at most be a very temporary response to extreme
situations.
Inability to adjust to micro- and macro-environment,
and/or a mismatch between temperament, individual shortcomings and
environment, leads to psychiatric disturbances. Most psychiatric
problems considerably increase the probability of youngsters' slipping
into abuse-addiction patterns; early and effective treatment is likely
to make a significant difference.
Later, primary, secondary and tertiary abuse prevention focuses on dealing with negative stress, i.e. negative
anxiety and depression (most anxiety and stress is mixed or positive),
with ethics, positive motivation, and with psychological and
psychiatric problems.
- Approaches in stress
management include cognitive therapy, healthy lifestyle, interpersonal
therapy that fosters good human relationships (relationships with
animals are also helpful), relaxation-meditation techniques
(particularly autogenic training) and self-hypnotic techniques.
- Focus on ethics: humans inherently want to be "good" and/or "right."
Particularly adolescents are ambivalent, often not realizing how
self-centered they are but, at other times, highly idealistic and keen
to be ethical. Abuse is, by definition, unethical. Abuse-addiction not
only "cheats" nature and culture, it reinforces incompetence, unethical
behaviors, pain, etc. Teaching may stress how abuse-addiction "work
against nature", derails healthy developments, reinforces young
person's feeling bad, keeping him/her "stuck" in immature state.
- Regarding cigarette smoking (usually a 'gateway drug'), raising
positive motivation is most important. Teaching addresses immediate
effects and the ugliness of smoke versus clean breath, clean and
natural smelling clothes and hair, etc. To explain intermediate
and long-term health effects: smoking cessation means that the gradual
decline of body systems (lungs, blood vessels, heart, taste sense
organs, etc.) first rebounds some, then the normal decline is slow as
in a nonsmoker with healthy habits. Considering ethics, smokers may be
reminded that buying cigarettes pays for the advertising of cigarettes:
advertisements targeting children and the most vulnerable people, young
Third World women.
- Particularly in girls, confusion about sex and poor self-image leads to
vulnerability towards drug abuse and addiction. Media, other girls and
guys incite young girls to become sexually active. Girls may agree to
sex in an attempt to ensure a lasting boyfriend relationship, but are
dropped after they had intercourse. At least for girls, sex is not an
experiment; early sex usually lowers their self-image. Sex is much less
rewarding and more dangerous for girls than boys. Sex should be the
last step in a courtship. Guys should learn empathy, not exploit
insecure girls who foolishly seek sex, and never pressure a girl. Many
girls need support regarding their self-image and they should learn to
assess when sex is right for them.
- For adolescent and young adult males, drugs are often part of male risk
taking and rebellious acting out against cultural values of parents and
teachers. Usually, there is a sense of being in control, able to stop
at any time, however, often there are no adequately powerful motivators
to stop patterns of abuse. Men need positive goals and their ambitions
should be directed. If there are no good role models in their families
and schools, school counselors and mental health workers should find
mentors and helpful organizations.
_______
1 Sometimes, antidepressant medications are indicated.
Abuse-Addiction Treatment:
Insight and positive goals are most important in all types of
abuse-addiction prevention and treatment. People need a perception of
meaning in life, and a sense that abuse behaviors are contrary to
personal goals and family and personal culture. (Most people do not get
addicted when using abusable drugs because of insight – they recognize
that other behaviors are more meaningful, that drugs would soon be in
the way.)
Steps in treatment probably should include the teaching/learning of the following:
-
Patients need an understanding and belief in scientific data concerning
the plasticity of the brain or mind. Past does not determine future;
many shortcomings can be overcome by new learning and/or be compensated
for.
- Abuse behaviors are learned and cannot truly be
unlearned. They change the brain in the same way as complex cultural
activities do (e.g. studying law or evolution, military training).
Becoming sexually active includes learning that changes the brain.
However, there is no inherent necessity to practice what was learned.
- The naïve brain contains many pathways. Reinforcement from
enjoying instinctive actions, cultural fulfillment or drug use,
strengthens pathways that lead to the good feeling, making them into
"highways", while pruning unused paths. When drug addiction established
"superhighways" that lead to the drug use, it takes years of nonuse for
"grass, and later bushes, and trees to grow on the highway". Another
comparison is snow with frozen parallel tracks: it must snow many times
until it is easy and safe to freely ski on that slope. Instincts,
cultural behaviors and addictions are reinforced with use, but weaken
with nonuse. There is no inherent necessity to be aggressive or acting
on sexual instincts, and the longer a person goes without fighting or
sex, the less likely he/she will act out, impulsively and/or planned.
-
Patients must understand: abuse is never o.k., it is not a matter of
opinion, religion or dominant culture. It is a matter of ethics; abuse
diminishes one's humanness.
- Abuse is unethical because it
competes with and 'cheats' nature (social instincts, etc.) and culture
(mostly civilizations' adaptations of instincts): abusable drugs feel
good 'for no good reason'; addiction is a core disturbance of our
emotional-behavioral system.
- Abuse behaviors reward 'bad' feelings, thoughts and behaviors;
it leads to neglect of self and loved ones; addicts learn more
destructive rationalizations (people are generally "pseudo-rational",
believing that instinctive and cultural behaviors are done for rational
reasons).
- Learning aspect of abuse-addiction include: good feelings or
"highs" reinforce "bad" moods, thoughts, behaviors, etc.; all aspects
of abuse behavior patterns are reinforced, start to feel natural, etc.
- Abuse-addiction behaviors halt psycho-social development and
positive learning; it leads to regression (reverting to or being stuck
in adolescent conflicts).
In summary: Abuse behaviors are by definition unethical. Abuse means
doing something that is 'bad' with the goal to relieve tension, feel a
thrill or "get high"; and abuse behaviors generally reward and
reinforce bad feelings, thoughts and behaviors. Abuse behaviors are
immature (adolescent): selfish, risk taking, rebellious (cultures are
correct when seeing alcoholism and drug abuse as bad).
- If
the patient (temporarily) lacks protective mechanisms, e.g. lack of
insight and sense of directedness, depression with little appreciation
for the future, abuse behaviors tend to become more frequent and grow
into psychiatric disorders.
- Sobriety, abstinence from abuse behaviors is not for the
patient, it is for his/her loved ones, including future friends and
relatives that are not born yet.
-
Patients typically enter treatment for negative reasons: pressures,
fears, etc. The human mind does not respond well to negative factors;
cautious behaviors due to negative factors are generally short-lived
unless there is an instinctive component, such as fears of snakes or
deep water. Patients need to move from primarily negative to primarily
positive motivation, mainly through learning, better understanding of
human nature (instincts, culture, abuse) and through changing
perceptions, thought patterns and values. At the same time, patients
should explore and recognize what is positive and negative about
abstinence versus use, acknowledging that a drug-free life is often
hard (no relief when there is stress and pain), while during addiction,
the quality of life is good (excitement and "highs" while dangers and
adversities hardly bothersome). The main difference is meaning in life
versus lack thereof. This aspect of treatment mainly deals with growth,
learning and maturing.
- Patient must define all misuse/abuse
behaviors (that may become addictions). [Social drinking and cigarettes
are probably main factor leading to relapse in drug addiction
patients.] Any potentially abusive and addictive behaviors may
interfere with progress, worsen, and/or lead to relapse after
discontinuation of opioid maintenance treatment. Abuse behaviors
include many drugs and medications, nicotine, food for stress relief,
gambling, inappropriate shopping or sex, etc. Patients should set clear
guidelines, e.g. sweets allowed in culturally appropriate situation, as
deserts, with guests; coffee not dangerous for person. Patients must
find positive motivations to stop them, and, possibly with specific
help (e.g. buproprion for nicotine and psychostimulant craving), stop
behavior completely before leaving treatment. Particularly groups may
be effective in helping patients gain insights and motivation.
- 12-step models (AA/NA) may be counterproductive. If a belief in
a "higher power" seems right to a patient, this "higher power" must not
be an external god, a meeting or "whatever"; it has to be the core of
his/her being, the part of the human mind that wants to be ethical, in
some ways "right" or "good". Religious people may benefit from the
Quaker concept of "that of God" or "the Light" being in everybody;
focusing on "the inner Light". Advertising an abuse history to
strangers is not helpful, abuse histories should be very private, to be
revealed to psychotherapists and spouses, possibly adult children and a
rare confidant, not friends and distant relatives. Former drug
addiction patients must not believe in having a permanent "disease" and
being permanently in "recovery", they must not become dependent on
meetings, they need to mentally move on, not become professional
patients.
- Lapse versus relapse: Patients should learn to distinguish
between impulses, including lapsing feelings, thoughts or behaviors,
versus going into unethical fantasies, enjoying them, mentally
consenting to them, and, in specific circumstances, executing them.
Mentally consenting to thoughts of drug use, thinking it is now o.k. or
giving up ("once and addicts-always an addict") is typically the root
of a relapse. Patients must assume that lapsing thoughts and actions
may occur at any time, even though they usually decrease over time.
Lapses are recognized as 'wrong', the person knows that a turn of at
least 90 degree is needed; lapses are rarely leading to relapse.
-
Treatment should strengthen motivation for education: academic,
artistic, etc. Young people then should recognize how a good education
allows them to do what they are interested in and get paid well for it
while lack of education forces people to do what they may not like,
getting paid poorly.
- Ethical viewpoints: counselors and
teachers should deal honestly with problems in our culture - laws
are wrong in principle and law enforcement is bad in execution, there
is no justice (everybody is different, fate is random, same treatment
of different individuals is not justice), social political systems are
deficient; then move on to pragmatic acknowledgment of what seems to,
more or less, work, how the presently unchangeable judicial system
functions, how each individual needs to work on improving his/her
personal culture to an ethically higher level than present standards,
etc.
- "Stress", meaning negative stress, negative anxiety, conflict,
typically translates into drug craving and/or withdrawal thinking. When
in conflict the person is uncomfortable and the mind scans what worked
in the past for relief. In extreme stress, the person shortly
regresses, feeling like an infant, small child, then like and
adolescent. Approaches in stress management include cognitive therapy,
interpersonal therapy that fosters good human relationships
(relationships with animals are also helpful), healthy lifestyle,
relaxation-meditation techniques (autogenic training, self-hypnotic
techniques, contemplation). Meditation is defined as narrow mental
focus, e.g. on breathing alternately through right and left nostril,
and non-judgment, i.e. not judging temperature or noises, letting an
ache be, etc. Contemplation consists in looking at facts, past, present
and probable future, without judging, without guilt, disgust or revenge
feelings.
- Patients may need to understand weight problems since some
people revert to psychostimulant abuse when overweight, and foods
themselves may become addictions. Hunger means that the body's
physiology switches from burning nutrition in the gastrointestinal
tract to using glucagon reserves in the liver, then burning fat. Hunger
also follows rhythms that a person developed and there are often
conditioned reflexes. Biologically, people normally want to eat much to
build up reserves when food is available and stress is relatively low.
Appetite is suppressed by stress (positive or negative) except when
people find easily digested, calory-dense "comfort foods". Weight
problems are aggravated by the ready availability of foods to be
designed to stimulate appetite (salty, spicy appetizers) or to be eaten
on a full stomach (deserts) and generally by calory-dense,
overprocessed foods. Frequently feeling hunger is normal but temporary
and much of the time, we may acknowledge hunger without acting on it.
Focusing on other activities that are positively stressful (physical,
exciting to person) allows losing weight. Weight loss due to stress is
similarly temporary and usually not a problem.
- Patients may need to understand chronic intermittent pain which
often leads to opiate addiction. Chronic pain is a misnomer, it
is greatly misunderstood: the CNS is designed to tune down and ignore
irrelevant continuous or intermittent information, including bad smells
and pain stimuli (there is, however, progressive pain e.g. with cancer
or rheumatoid arthritis). People with completely rotten teeth eat
sweets and become obese. Nursing home patients with miserable backs
often smile and walk, carefully, around. Most of the time, people
should be able to distract themselves from pain stimuli, forget their
disorders and even sleep without pain medication. People have chronic
pain when they assume/were convinced that their pain will be
persistent, when there is a lack of meaning in their life, and when
there is secondary gain. High functioning people without depression
learn to tune pain out, may be use self-hypnotic techniques, but hardly
ever need narcotics.
-
Treatment is like initiation into true adulthood, a level of maturity,
a stage where adolescent behaviors become taboo. For young people, it
is normal to at least consider ignoring guidelines, overstepping rules
and laws, and adult people, hopefully more cautiously, do the same.
However, young people often questioning taboos and/or have not
established taboos for themselves, adults should have and obey cultural
taboos. (Taboos defined as cultural laws that have been proven over
time to be meaningful with no exceptions; if pondered and researched,
the result will always be that the taboo is correct. Obviously, they
are sometimes overstepped – otherwise nobody would talk about them –
not following taboos is an indication of immaturity and/or mental
disorder.) Adulthood includes accepting many behaviors, which may be
open to question or acceptable to adolescents, into the category of
taboos. Most important: suicide, other than in final stage of a
terminal illness, is unethical and must be considered taboo; if suicide
is considered, relapse becomes much more likely. Other example of
taboos in adulthood include physical fighting and other forms of using
physical force (e.g. in rape); promiscuous thoughts and behaviors, any
sexual behavior with a child or first degree relative. The primary
positive motivators are meaning in life, ethics, and a higher standard
of personal culture (as opposed to culture at large and drug
subculture).
[To explain: guidelines are least important,
regulations and laws are usually followed but often overstepped, taboos
are considered absolute, to be followed even if no uninvolved person
can find out.]
-
Patients need an understanding of human nature including inherent need
to be "right" or "good". Normally, humans want their children/next
generations to do better, that civilizations develop and become more
humane.
- Patients need to create rationally an image of how they want to be in future.
- They then are to learn feeling how reaching goal state would
be, through meditation, contemplation and visualization. Some aspects
of previous life may need to be grieved. Goals may need to be
fine-tuned.
- For changes: self-monitoring (avoiding automatic and
thoughtless actions), observing rhythms of high and low tension and
danger; doing 'reruns' of situation where one failed, imagining how it
would have felt to do 'right' thing; structuring behaviors; changing
habits, settings and environments around times of high risks (when
behavior anticipated), usually without telling others why routines are
changed; etc.
- Leaning that the more intense a feeling/emotion (craving,
anger, manic feeling, attraction to person) the more one has to
acknowledge and accept feeling, letting it slowly go, without acting on
it, expressing it or talking to others about it; simply staying
friendly. Finding reasons for feelings reinforces them. [Craving
contagious; when showing bad feelings towards others, there are usually
retaliatory feelings; if feeling very good, easily bad promises made or
exaggerated expectations raised. Positive feelings and criticisms maybe
verbally expressed and discussed after some observation and
contemplation.]
- Patients must address psychiatric and psychosocial issues that
lead to vulnerabilities. Virtually all drugs seem to alleviate sense of
negative stress, turning anxiety positive or decreasing it. Opiates
serve particularly to alleviate sense of loneliness, not being part of
family or clan, human relationships lacking meaning. Many or most
opiate addicts need work in this area (interpersonal therapy and/or
treatment of posttraumatic stress symptoms, exaggerated shyness, etc.)
Critique of 12-Step Approach (AA/NA), and proposed adjustments 4/2012
Introduction and general issues:
Specific problems with AA/NA:
Proposed adjustments to 12-step approach:
Introduction and general issues:
In summary, the 12-step community is very helpful to many patients;
however, it is not "evidence-based treatment"; it is essentially a
religion that needs reformation. Some aspects of the 12-step doctrines
appear counter-therapeutic. Some adaptations of the teachings are
proposed.
12-step groups help many people by offering a community of
like-minded former addicts who struggle with their abuse thinking,
problems with positive motivation to stay drug-free, poor coping
skills, etc. The sense of belonging can be healing. Fostering patients'
religiosity within this church-like organization is often helpful,
particularly if it includes meditative practices. Many people benefit
from pursuing a religious culture and finding support by people who
profess membership of the religion, even if their lives in no way
reflect their professed beliefs.
The assumption that AA members accept new members in a
nonjudgmental way is helpful though unrealistic; people with primitive
religiosity judge pantheists and agnostics (and vice versa); and people
do not consider different drugs equal. However, attenders of AA
meetings may accept and discard any comment and statement and in this
way broaden their 'tools' to stay sober and/or process new insights at
a later time. This process is possible in any support group and is not
specific to AA/NA.
Within the AA/NA community, members as well as
professionals tend to misunderstand the nature of abuse and addiction,
seeing it usually as a progressive disease caused by the use of toxic
drugs and the physiological reactions to them. It is more helpful to
see addiction as a psychological disorder with varied prognosis, often
associated with a difficult phase in life, other emotional problems and
immaturity. Many people overcome addiction without any counseling,
treatment or support group attendance. The political decision by the
DSM commission (of the American Psychiatric Association) to call
addictions 'dependence disorders', was less than helpful. Obviously,
humans are dependent on many things: water, calorie, protein, mineral
and vitamin intake and also the sense of being part of a clan or
community; many medications lead to adaptations, that is, after
short-term use, more medication is needed to maintain efficacy and
sudden discontinuation leads to an uncomfortable physiological
imbalances - however, neither tolerance nor abstinence symptoms occur
in certain addiction disorders but are characteristics of physiological
dependence. AA members, psychiatrists, psychologists and academic
scientists rarely agree on a definition of abuse or addiction disorder,
and AA members are particularly prone to consider medication use
'addictions', while they continue smoking with overuse of coffee and/or
engage in eating or sexual conduct that others would consider abusive.
AA must not be considered 'evidence based treatment'; it
is always a treatment adjunct in which social support and the patients'
prior propensity to religiosity may improve the patients' prognosis.
Claiming that the AA teachings are treatment, a specific cause of the
improvements, is akin to stating that dictionaries in a household make
people literate: religious people seeking support groups of people who
want to change are likely to do better than isolated, cynical people,
whether they follow Islamic religious texts dealing with alcohol use
and ethics or the AA book; similarly, people owning dictionaries
correlates with literacy and helps improve literary skills, but buying
a dictionary does not give an illiterate person the ability to read.
Furthermore, the time investment, promise of recovery and religious
talk has benefits comparable to those of faith healers.
Specific problems with AA/NA:
- AA is a religion that demands reformation. A book, written by two
alcoholics some 80 years ago, has been revered like a holy text. It
offers a religion-based model of alcoholism that is tailored to the
founders: affluent white males who basically rationalized continued
drinking because they were aware that they had some control over it.
[The founders were influence by a patient of the Swiss psychoanalyst
Carl Gustav Jung; Jung was not able to help his patient with
traditional psychoanalytic therapy and advised him to seek guidance in
his religion; focusing on his religion helped him to stop drinking.]
- The concept of being powerless over alcohol or drugs is meaningless:
being 'in control' is relative. Scientifically, there is no free will,
or at least there is virtually no space for free will. Will is always
relative; sober people often do things that are, objectively, "out of
control", when 'powerless' concerning their emotions; conversely, worst
addicts sometimes chose to seek treatment or suddenly find emotional
insights that make them stop the pattern of abuse behaviors. People
always feel partly free, and they typically feel freest when following
'spontaneously' an instinct.
- The mandate that patients have to admit powerlessness over the drug
and turn control over to a god is unacceptable, even offensive, to the
depressed female patient who drinks because her life was
out-of-control, and because her religion did not help her when she felt
most alone and hopeless. However, since women are more prone to
pragmatically comply with their culture and religion, no matter how
male chauvinist, many women still seek comfort in AA groups - they may
then be helped by the acceptance and support of the group and the
changes in their perception of themselves within their communities, not
by specific teachings of AA/NA.
- Asking a personal god to intervene in one's life is a primitive
religious act; it is not 'spirituality'. If people believe that prayers
are responded to by a personal god' s intervention, they are likely to
be, sooner or later, disappointed, when loved, good persons have bad
luck without their god saving them. People adhering to such primitive
religiosity also appear to be oblivious to the extreme 'injustices',
with many beautiful children suffering horribly and dying without
having reached any meaningful goal, frequently not even a meaningful
level of maturity [compare the beautiful article by Frank Bruni,
"Rethinking His Religion", NY Times 4/24/2012].
- The 'disease' concept is dangerous and often becomes a
self-fulfilling prophecy. When patients leave our clinic and, after
years, relapse, we sometimes hear the explanation "I guess I stopped
going to meetings" - these patients have not moved into a new stage in
life and adhered to the 'permanent disease' concept. Disease generally
refers to damaged tissue that takes time to heal or, due to genetics or
later damaged, faulty physiological function. Addiction competes with a
healthy use of the mind, it may temporarily alter balances in brain
chemistry, but it does not destroy 'the hardware' in a different way
than other, undesirable learning. It is not unusual that an emotionally
powerful motivator pulls a person out of addiction with no (slow)
healing process or any treatment, and some patients fluctuate between
patterns of addiction and healthy priorities. It is much more helpful
to recognize abuse, addiction and healing as stages in life; the person
learned something he/she should never have learned and then may
fluctuate for some time between old pre-addiction functioning,
addiction patterns, and mature priorities and functioning. Everybody is
susceptible to become addicted at times when stress is great and the
environment may move people close to the abuse behaviors; and former
abuse disorder patients are more likely to become addicted again than
people never having had problems with abuse disorders. However, a
person who is in some danger of becoming addicted is not suffering from
and addiction 'disease'.
- Sponsors and former addicts serving as primary counselors is often
problematic. For them, it is very hard to be objective and see the wide variety
of problems and needs addicts have, the many ways abuse-addiction
disorders develop, etc. Too often, sponsors want to explain to addicts
what their problem is, why they got addicted (talking about how they
perceive themselves) and what the way of recovery is. Reasons why
addictions develop include: too much testosterone (with urge to show
that one can get away with stupid, dangerous, counterproductive
behaviors), ADD/ADHD with difficulties to ascertain likely future
consequences of a behavior, suicidal and parasuicidal thinking that
interferes with looking at the future in a positive way, PTSD with
sense of absolute loneliness and fear of the future, utter loneliness
because of (temporary) anger at all 'loved ones', seeing own culture as
collapsed, inability to make sense of one's position and/or inability
to make crucial decisions with, consequently, hard to tolerate anxiety.
Actually the question is not: why do people who found an abusable drug,
continue using it?, but: what gives many people the strength, to stop
before they wasted precious time and resources, started hurting their
loved ones and overstepped cultural limits? Once found, using drugs
feels like an instinct, and we need a strong reason that is supported
by our emotions in order not to follow that drive.
Proposed adjustments to 12-step approach:
- Patients may look at abuse patterns like any unethical behavior that
has a powerful inherent attraction. As with instincts, following a
specific instinct strengthens it and with repetition, an internal rhyme
develops where the behavior feels periodically necessary. The longer
the behavior was missed, the less powerful a key stimulus is needed to
elicit the behavior and the more intensely the person seeks a stimulus
(an opportunity to exercise the behavior). Only when frustrating the
urge for an extended time will it weaken. However, any lapsing thoughts
and behaviors strengthen the urge again. The mind has a tendency to
move towards instinctive and addictive behaviors; the closer we come to
key stimuli, the more powerful they are. Like with a heavy piece of
metal and a large magnet, at some point, while gradually moving closer
to it, the magnet is so powerful that we can no longer hold the metal
away from the magnet. Mind and body automatically fulfill the instinct
or substance use behavior; at that point, the sense of loss-of-control
is very real.
- As a model of addiction development, we may consider learning in
layers: there is functional or cultural learning, we learn ways of
fulfilling instincts in a natural and culturally appropriate way; we
also have 'bad' learning, e.g. enjoying instincts out of context
including unethical sex, dangerous and aggressive sports, vicarious aggression in computer games, or food
abuse; additionally, people learn using substances that feel good as if
an instinct were fulfilled.
- If looking at the concept of a 'higher power', it must be the
core of the being, not some god in the universe or anything with
symbolic meaning. A 'higher power' may be, as in Quaker tradition 'that
of God' in every body, 'the Inner Light'; or in secular thinking, the
part of the person that makes the individual social animals part of a
larger clan or group. In the folkloristic sense of 'brain', 'heart' and
'gut', the heart, which seeks and gives love, trust and care, would be
the higher power.
- The substance of the recovery process consists more in the
establishment of a higher personal culture with taboos, than in working
the steps per se. Counselors must be careful in working step four. The
traumatized and depressed patient does not need guilt, even if
symbolic steps to make amends may be helpful. Generally we must accept:
the past 'just is', not 'good' or 'bad'. Given the circumstances, the
patient did his/her best, but because of learning and changed personal
culture, he/she will not, nor can, repeat the past.
- A diligent review of ethical principles may be most helpful, with the
recognition that abuse, by definition, is unethical. [compare:
Natural Ethics, chapter 3.4] Abuse-addiction is like a devil's
contract, as in many fairy tails [particularly the tales collected by
the brothers Grimm]; the abuse feels good, the loved ones suffer first,
eventually the negative consequences also reach the abuser-addict.
-
When having reached psychological changes, the patient should consider
him/herself 'cured' but in some danger of re-addiction, quantitatively
but not qualitatively different from a person who may be in danger to
become, first time in his life, an alcoholic at a later age. Patients
should keep their addiction history secret towards most people, while
able to assertively clarify that they do not use legal and/or illegal
addicting drugs that may be offered.
- While in AA/NA meetings, the issue of patients being on slow-onset,
long-acting drugs such as methadone or time release alprazolam, should
not be mentioned. However, high dosage patients should consider to
taper their dosage as soon as they reach a certain level of stability,
and, for most patients, treatment with such medications should be a
phase of life, more than a few months, but not decades.
Opiate Addiction Treatment
1.
Short summary of conclusions of literature and overwhelming anecdotal
evidence I found in my work with opiate addiction-multiple diagnosis
patients:
- Opioid abuse and addiction are mental
(psychiatric) disorders that tend to be progressive if there is not
good, comprehensive treatment and/or if the environment is very
difficult. However, some patients improve without major intervention,
some go through multiple episodes of abuse-addiction to opiates and/or
other drugs.
- Treatment generally requires years (opioid maintenance or
possibly long-term placement in therapeutic community), but the
prognosis with long-term treatment is often good. Unnecessarily long
opioid maintenance is a concern (some patients feel trapped and
dependent on methadone, afraid of withdrawing). Other concerns are
overmedication with multiple medications (including tranquilizers and
muscle relaxants), and non-treatment of other psychiatric conditions.
- For most opiate addicted patients, opioid maintenance is the
treatment of choice (methadone is the 'gold standard'2, buprenorphine is in most patients inferior3).
- Detoxification is not treatment; it is very dangerous. There is
overwhelming anecdotal evidence that many patients, following
withdrawal in a hospital or jail, overdose lethally and/or destabilize,
leading to major deterioration in many areas. Detoxification does not
address the psychological addiction.
- Detoxification disrupts all functions that have been maintained
during the addiction; children may need foster care, careers are
disrupted, etc.
- Patients who leave treatment prematurely have high rates of
relapses, move to other addictions (particularly alcoholism), morbidity
and deaths that are directly related to drug abuse, worsening of
psychiatric conditions, and suicides.
- Methadone maintenance treatment has multiple psychiatric
benefits, including decrease in aggression and sexual acting out (due
to decreased testosterone level) some antidepressant effect
(serotonergic) and, in some patients, significant antipsychotic
effects. Methadone, in proper dosage, does not interfere with normal
feeling and thinking; intellectual functions are not impaired.
- In many patients, methadone treats the addiction but patients
continue some substance abuse (usually at least ten times less than
when addicted). Patients who are not yet willing or ready to address
abuse patterns may function quite well but would relapse into addiction
if withdrawn from treatment.
- Proponents of alcoholics and narcotics anonymous (AA/NA)
usually claim that opioid treatment programs (OTPs) make patients more
'addicted', that methadone is merely a legal continuation of the
addiction. Obviously we must distinguish between medication that makes
the patient more functional versus abused drugs that interfere with
functioning. However, some OTP patients feel dependent and stay
primarily on methadone because they fear withdrawal and/or an erroneous
belief in an endorphin deficiency. In additions, many OTP patients
function poorly due to use of, tranquilizers, muscle relaxants and/or
alcohol. OTPs should utilize treatment approaches that allow many
patients to taper off methadone with an excellent prognosis.
- Addiction professionals must not go along with the 12-steppers'
"terminal disease-permanent recovery" model. Neither should we
propagate the "endorphin deficiency" model. OTPs must compete with a
better model. Addiction is not a progressive, terminal illness and
opiate addicts do not have an endorphin deficiency.
- OTPs must not run like franchise-style non-medical "programs",
with by non-clinician administrators conceived policies and procedures;
over-regulated, and with contrived treatment plans and treatment models.
- OTPs must not look for psychiatric clinics to treat their
patients: they treat psychiatric patients, they are psychiatric clinics
and they should treat all psychiatric problems of their
multiple-diagnosis patients (what can be treated in outpatient
settings).
- OTPs must treat pain in their patients.
- Patients dosages must be highly individualized in a very wide
range (about 20 - 300mg). Stabilization dosages vary greatly over
time. Of concern is that the higher the dose range, the more patients
use/abuse benzodiazepines (hardly a cause-effect relationship).
_______
1 Raw statistics indicate that most patients who leave methadone
treatment relapse. However, if we look at raw data of patients leaving
methadone, there is, according to our anecdotal data from patients, a
very poor prognosis for four reasons 1. the patient leaves for
non-therapeutic reasons (e.g. pressure by relatives, law enforcement
and other and agencies, lack of financial resources/support, move,
shortly jailed), 2. the conditions of patients are such that there is a
poor prognosis (e.g. still nicotine, alcohol and/or benzodiazepine use,
psychiatric problems that were not properly treated), 3. inflexible,
relatively rapid tapers when patients want to leave treatment (or are
assumed to be rehabilitated and ready); the patients may then perceives
withdrawal symptoms and returns mentally back to abuse-addiction
thinking, 4. the patient embraces the "disease/permanent recovery
model" but gets tired of attending meetings; he/she then feels
defenseless when, unexpectedly, drugs become available; the relapse is
a self-fulfilled prophecy (I often ask: "Why do you think you
relapsed?" some patients answer: "I guess because I stopped going to
meetings.")
Our own survey of many patients who properly withdrew and,
years later, relapsed due to medical prescription of pain medications
(mostly after surgery) indicated: they had good quality of life off all
drugs/medications; they were glad that they tapered off methadone even
though they eventually relapsed. They returned to treatment
before there were major problems due to their re-addiction (i.e. not
using prescription medications properly and/or using shortly heroin
again).
2 Medical withdrawal (detoxification) is, for most
patients, an obsolete treatment. It may be compared to treating
tuberculosis with surgery.
3 Much has been written about the 'partial agonist' action
of buprenorphine making it less addicting. Obviously, no opioid is ever
used as full agonist: fully agonizing endorphin receptors leads to
immediate coma and death. Buprenorphine is weaker and longer acting
with consequently more drawn-out withdrawal symptoms, similar to low
dosage LAAM [no longer available].
Broad Benefits of Widespread Use of Opioid Maintenance Treatment:
Methadone and, to a much lesser degree, other opioid maintenance
treatment has been extremely successful in my native Switzerland,
decreasing the deleterious consequences of heroin addiction and
minimizing contagion. With most addicts in treatment, new addiction
dropped in the nineties to one fifth.
In the USA, the biggest problems with opioid maintenance treatment are:
- misconceptions and public attitude discouraging opioid maintenance treatment,
- lack of knowledge by professionals (including physicians, supervisors
and clinicians in a broad range of state agencies) and in the health
care profession itself
- inadequate access to and poor quality of clinics.
Short Summary of Literature Regarding Detoxification from Opioid Dependence
Large
Italian study by Marina Davoli et al., (Article first published online:
19 Nov. 2007 DOI: 10.1111/j.1360-0443.2007.02025.x):
10,454 heroin users who entered some form of treatment were followed,
in the average, about one year. Most patients were much or all of the
study period in long-term treatment including opioid maintenance.
While in treatment, mortality rate was 0.1%/year; out of treatment
(after short-term treatment), mortality rate was 1.1%/year; in the
month after leaving treatment, the risk of lethal overdose was 2.3%, in
subsequent months, the risk of lethal overdose was 0.7%. Independent of
treatment type, treatment was protective of overdose deaths. [Since
mortality rate is highest in the first few days of entering opioid
maintenance treatment (sometimes suicidal or parasuicidal), long-term
opiate overdose risk is even less than 0.1%/year. Other studies
document that length of treatment, independent of type of treatment, is
the best predictor of a good prognosis.]
British study by John Strang et al., published in the British Medical Journal 2003; 326 : 959 (5/3/2003):
In follow-up of 137 opiate addiction inpatient admissions (28 day
program), only 37 completed treatment, of these three died of overdose
within four months. 57 left prematurely after detox; of these two
patients relapsed and died within a year of causes other than overdose.
43 left during detox, none of these died during the one year follow-up.
British study by M Gossop et al.,
published in The British Journal of Psychiatry 1989; 154: 348-353,
titled: Lapse, Relapse and Survival among Opiate Addicts after
Treatment, A Prospective Follow-up Study
In this study of 80 young opiate detoxification patients (inpatient, 21
day methadone), there were, on six month follow-up, many opiate
abstinent patients, but two had died of overdose shortly after
discharge.
Canadian study by Benedikt Fischer et al.,
published in the Canadian Medical Association Journal 2003 171 (3)
(8/3/2004), titled "Determinants of overdose incidents among illicit
opioid users in 5 Canadian cities":
Drug treatment in the past 12 months was one of three predictors of
opiate overdoses. The other two were homelessness and non-injection use
of hydromorphone in the past 30 days.
Irish study by Bobby P. Smyth, published in The British Journal of Psychiatry (2005) 187: 360-365
Retrospective study involving 149 consecutive admissions with primary
diagnosis opiate dependence in Dublin Ireland 1995-96. Median age of
patients: 23 years, median duration of opiate abuse 4 years, 60% living
with parents, 5% with other relatives; 6wk. program including 10 day
methadone detoxification, with long-term follow-up treatment (few
stayed long in treatment). 81% completed methadone detoxification but
58% did not complete six weeks treatment (medium 14 days).
Of the 149 patients, 5 died within the study period, and 109 of the
remaining 144 completed a follow-up structured interviews 18-42 months
(median 29 months) after the treatment episode: 23% were abstinent
without methadone maintenance at the time of the interview, 15% used
heroin daily, and 57% were in methadone maintenance (no data as to how
many patients went to methadone immediately after discharge or later
after failed or completed treatment). 50% reported recent misuse of at
least one opiate, 43% reported no recent misuse of opiates, (study
gives no indication of drug testing, no data on other treatment between
discharge and interview).
The paper concludes that "Abstinence remains an attainable goal", and 5
deaths is reportedly the expected ratio of deaths in this population,
however it is the expected ratio in untreated heroin addicts: the
treatment did not decrease the high death rate in young opiate addicts.
This indicates that the treatment helped some (and many sought
appropriate, safer treatment), but several patients appear to have died
due to the treatment.
[Some studies seem to indicate that many patients enter some form of
treatment when they seem ready to move into a new phase in life and
consequently do relatively well. Some studies show good results for
decreased use of opiates without evaluating alcohol or other drug
misuse.
I am not aware of a U. S. study, but the overwhelming anecdotal
evidence, as reported by patients and relatives, confirms the
conclusions of these studies.]
2. Treatment admissions and treatment adherence; treatment levels, transfers to other treatment facilities:
The goal of OTP treatment is ready admission and treatment
adherence until the patient is safe to get off opioid maintenance.
Opiate addicts who seek treatment are emergencies and must never be put
on a waiting list. They are patients who need medical-psychiatric care
as urgently as a patient with out-of control diabetes or in acute
psychosis. Withholding access to treatment may also be compared with
having thieves and violent offenders put on a waiting list to serve
their prison sentences. Interim maintenance is CSAT's answer to the
problem, however, few, if any OTPs that should utilized this treatment
actually offer it. Furthermore, there are still widespread funding and
treatment criteria that lead to hardly justifiable expenses, offering a
few patients supposedly superior treatment while keeping most addicts
on long waiting lists. Damages to the communities, including costs of
emergency room visits and hospitalization, harm to patients' children
and other relatives, contagion of addiction to younger people, are hard
to underestimate.
Dropping prematurely out of
treatment, premature medical withdrawal, administrative withdrawal and
other disruptions of treatment must be avoided whenever possible; they
are very dangerous and wasteful: previous treatment gains are lost,
dysfunctional behavior patterns that were distant memories are again
regularly practiced and compete with all life functions.
Rather than having two levels of treatment: interim
maintenance and comprehensive treatment, multiple levels are needed,
including treatment that includes case management, groups and TH
privileges (needed for work and to reduce unnecessary travel time and
costs), but no individual counseling.
3. Main aspects of treatment and treatment stages include:
3.1 Screening/admission:
Treatment should start when the patient applies for treatment, no
waiting lists, no delay in medical, psychosocial and psychiatric
evaluation; the intake is often the beginning of psychotherapy;
occasionally a patient has to be referred to an emergency department at
time of screening (e.g. for indications of generalized infections
and/or possible endocarditis).
Review of systems,
health history, physical examination including V. S., chest
auscultation, inspection of skin and check for enlarged and/or tender
lymph nodes and dipstick (clinistix) urine analysis are to be performed
on day of admission, if possible when patient drops in and applies for
treatment. Treatment programs should immediately start comprehensive
treatment of severely depressed, PTSD, and other acute multiple
diagnosis patients. Private OTPs should never have waiting lists,
publicly funded and non-profit OTPs with limited capacity should put
patients without pregnancy or major psychiatric disorders into "interim
maintenance". If the OTP is not capable to treat a patients'
psychiatric conditions, it should have close cooperation with
psychotherapists and psychiatrists; referrals should be timely and
effective. [Sadly, many mental health professionals are afraid of
dealing with OTP patients and they may not understand what treatments
are inappropriate; cognitive behavioral therapy, EMDR, sometimes
hypnotherapy should be first choice treatments; physicians must
consider dangers of certain medications , e.g. compound side effects,
(no naltrexone for alcohol craving or bulimia!)]
3.2 Medical treatment of acute withdrawal (approx. first week of treatment).
In early treatment, patients often need multiple dosages,
e.g. receiving first dosage when intake essentially completed and
second dose approx. 3 hours later. On following days, patient may
receive first dosage at 6 a.m., second and possible third dosages at
9:30 a.m. and 1 p.m. Patients should receive adequate dosages to
treat withdrawal for most of 24 hours. For follow-up dosages, a 4-7-10
or 5-10-15 rule may be used: low dosage if no withdrawal but patient is
alert and fears later withdrawal; middle dosage if subjective
withdrawal, high dosage if some objective withdrawal.
To judge indication for same, higher or lower dosage on days 2,
3, 4, and 5, we must consider when and which opioid the patient last
used before admission: is the patient expected to be in early, worst or
late withdrawal? Did the patient use illicit methadone, buprenorphine
or another agonist-antagonist medication? If the patient has not used
opioids for over 30 hours and/or if he/she recently used buprenorphine
(SUboxone), second or third day dosage may have to be decreased to
avoid buildup of methadone serum level (Dilaudid withdrawal is most
acute and shortest, most popular pharmaceutical opiates have somewhat
slower onset and longer duration of withdrawal than heroin;
buprenorphine partly antagonizes methadone for up to three days).
3.3 Time of stabilization of methadone dosage:
This time may include dosage increases when the patient still handles
stress poorly. Patients may continue to complain of withdrawal
(methadone "not holding"). Obviously, since heroin withdrawal lasts six
days, patients have after the first week no longer withdrawal, no
matter whether they get placebo, 40mg or 100mg of methadone, but they
still have craving and feel stress. Patients must learn that, early in
treatment, stress is perceived as craving , and craving leads to
psychosomatic withdrawal-like symptoms. Dose decreases often lead to a
fear reaction that is perceived as withdrawal. [If patients ask
to go on a blind "detox", patients often complain that the taper is too
fast before the first dose decrease went into effect.]
3.4 Stabilization of all mental and life functions:
Counselors/case managers, social workers, psychotherapists
and psychiatric physician help patients with the following issues,
individually and in teaching and therapeutic groups:
- practicing a healthier lifestyle and learning relaxation,
meditation and possibly also self-hypnotic techniques;
- patients addressing psychosocial, legal and medical problems;
- patients are to receive and cooperate with effective treatment
for psychiatric problems including psychotherapy (EMDR often
indicated), psychotropic medications, usually antidepressants, mood
stabilizers, possibly antipsychotics, rarely long-acting slow-onset
benzodiazepines.
Often non-pharmacological pain management is indicated.
Sometimes patients benefit form TCA or seizure medications for specific
pain conditions.
Patients may benefit from support when dealing with social
agencies, school or work, legal issues, etc., but OTP staff should
primarily guide and encourage, not make calls for patients. Sometimes
patients need help when discriminated against/mistreated and
inappropriately referred, e.g. by CPS or drug courts, or when needing
special consideration because of ADHD and/or other psychiatric
disorders.
3.5 Patients need to deal with specific tasks:
- Patient must define all misuse/abuse behaviors (that may become addictions).
- Patients need to perceive abuse behaviors, and life in a broad sense, differently.
- If patient is benefitting from NA, adjustments are probably
needed. The "higher power" must be inside the person. The addiction
must be moved into the past and, except for very rare situations, be
kept secret.
3.6 For many or most patients, eventual withdrawal from maintenance treatment is indicated.
Many stable patients falsely assume they need continued treatment to
maintain abstinence. When more mature, having done well for 1-2 years,
patients should decrease methadone or buprenorphine dosage
significantly, e.g. to 2/3 dose of methadone or 1/2 of buprenorphine,
then test themselves (enjoy more intense perception of nature and art,
better bowel and sexual functions, higher pain tolerance). Then they
may decrease dosage in further steps, until they feel good on what
previously would have been considered a placebo dosage. At that point,
discontinuation of maintenance treatment is safe, with an understanding
that "in case of lapse-relapse, it is never too early or too late to
return to treatment."
3.7
For many or most patients who tapered off opioid maintenance treatment,
continued group attendance and some follow-up individual counseling,
continuation of psychiatric treatment, etc. is helpful, if not needed,
and should be offered by OTP at low fees or no charge. [Former patients
tend to be an asset to teaching and counseling groups.] However,
follow-up is not meant to be permanent relapse prevention. Patients are
informed that they may return at any time: it is never too early or too
late to return when the patient feels he/she may benefit from further
help.
4. Treatment strategies:
Strategies, including medication dose levels and offering TH
privileges (often exceptions form SAMHSA needed) must be very flexible,
adapted to the patients' life circumstances, work and/or studies,
psychosocial conditions and emotional readiness to address
psychological issues. The therapist may benefit from a problem list
that includes all issues that appear problematic (including old traumas
which the patient is at the time unwilling to work on or considers
resolved). We must never limit counseling to the issues the patient
wants to change (most patients are not eager to change sedentary
lifestyles, stop certain drugs and junk food addictions, etc., nor do
they want to address obvious anxiety issues which they treat with
benzodiazepines as prescribed by some MD). The therapists educate and
motivate, as much as possible in groups. Rewards for group attendance
may be valuable incentives (e.g. unearned TH dosages for convenience,
if patient is assessed to be able to safely handle them). Individually,
the therapist continues to evaluate the patient and works on all
problematic issues as the patient allows and/or shows readiness.
Treatment plans are rarely very helpful. Often, the therapist is
surprised how the patient changes, how situations change, and how new
problems surface. Asking patients to spend time writing an essay as to
how they see themselves in six months may bring insights not easily
reached in a treatment plan session. Some patients may then
spontaneously work towards change. "Pushing" them and/or giving "no
progress" evaluations in the next treatment plan session, may have
paradoxical consequences.
In long-term treatment,
patients tend to stagnate and resist change for extended times. Group
leaders may introduce material that changes the patients' views and
motivates them. Progress is usually unpredictable and influenced by
many factors OTP staff has no control over and which may never be
known. |
