My Approach to Treatment for Addiction

No one really knows what addiction is. Brain imaging studies help researchers get closer to understanding brain structures and functions involved with what is experienced on the individual level as wanting to slow down, switch, or stop, and not being able to. We may never know exactly what goes on in a brain’s 86 billion neurons and perhaps a similar number of glial cells. In this context, differentiating between cause and effect – this thing caused that thing – and correlation – these things happened at the same time but are unrelated – is difficult.

Illustration of DBT's States of Mind

Not knowing what causes problems makes them difficult to solve. With substance use problems, many beliefs, opinions, and theories underlie treatment protocols. What is meant by “treatment” and “cure”? Harm reductionists advocate for what’s termed “safer” use on the individual level, which may range from abstinence to supervised injection. The criminal justice system, child protective services, medication programs, insurers, and many employers and family members may mandate proof of abstinence via urine drug screen, whether or not that’s medically or therapeutically sound. Individuals may seek to abstain for their own reasons.

But estimates of rates of return to use with most methods range from 60% to 80%. Then there’s the confounding factor of what’s termed “spontaneous recovery.” A significant number of people “age out” of addiction without treatment. Why are some people able to moderate or eliminate use on their own, while some cannot? And why is “recovery” so variously defined and so variously achieved?

In such swirling uncertainty, I find Steven Covey’s guidance reassuring and clarifying: “Begin with the end in mind.”

What can we do together to increase the likelihood of achieving the end in mind?

If you are considering counseling, or have been mandated to counselling by authorities, we’ll assume that abstinence from banned, illegal, or non-prescribed substances is your objective, or that lessened use, within a range tolerated by authorities, is your end in mind.

The purpose of research is to use the wondrous logic and treasure of human minds to design and implement experiments whose results suggest what would be helpful to most people, most of the time, better than other things, and better than nothing.

Research is clear on what can help people limit substance use. However we define addiction, whatever mechanisms are at work in the human brain, whatever neurobiological, developmental, social, environmental, or historical forces are at play, people can learn and implement specific skills that may result in decreased substance use.

I am working on a book manuscript with a co-author to describe this process for those who prefer a self-help guide. In the meantime, I post resources and excerpts on this site, and offer individual and group counseling for those who prefer interactive learning and support.

Briefly, what research suggests helps people limit substance use begins with medical care. Specific medications are available to assist with some specific substance problems (alternately termed substance misuse, substance use disorder, and addiction). For example, the media is currently interested in opioid use disorder, for which the medications buprenorphine and methadone are the first-order standard of care. In some cases, medication is sufficient to help people meet their goals; counseling may not be necessary. Since stress is correlated with increased use, or recurrence of use, and untreated physical and mental conditions cause stress, individuals need medical care for whatever ails them, even if it’s an itchy rash or trouble sleeping. What medical care can ease needs to be eased.

In the context of receiving on-going medical care, individuals can then mobilize their strengths to help them do more of what they intend to do, or what they are required to do.

On their own, or with the aid of a counselor, individuals can begin to learn, and to implement, techniques that help them with what’s at the heart of many mental and emotional challenges: insufficient skill with emotion regulation. In a nutshell, this involves becoming aware of to what one is giving one’s attention and deliberately deciding whether or not to continue or discontinue that focus; identifying feelings and thoughts; adjusting the inner “volume” on one’s feelings; sorting one’s thoughts into “helpful” or “unhelpful” categories, then shifting attention to the “helpful” ones; and becoming aware of physical sensations and reducing discomfort.

Research suggests that these straightforward techniques – what I term “awareness skills” – acquired with deliberate practice and implemented consciously, offer remarkable strength in managing the emotional states and thinking patterns that, if left untended – while they may not cause recurrence of use – are correlated with a return to use.

Except with some medications for some substance use disorders, we don’t know how to directly treat the brain for addiction. While some methods are posited to directly ameliorate problems in the brain, the pace will be too slow for most people who want or need to reduce use now.

As they begin to use awareness skills, individuals can explore concerns related to substance use, including environmental cues and social capital. While people with addiction can often will themselves to choose to postpone use, compulsive use is the primary symptom of the illness. (This is another reason why medications for specific substance use disorders are invaluable. The lack of medication for methamphetamine use plagues many with amphetamine use disorder who attempt to cut back or abstain.) The brain alterations caused by addiction interfere with what we term “will” and “choice.” What strategies does one use in a double bind game of needing a function to address an illness that can compromise that very function?

Whether termed craving or longing, absence of the substance creates an intolerable state akin to pain for many people with addiction. Learning and using emotion regulation skills under such pressure, at the same time trying to discover and engage with replacements for the purposes served by substances, all the while continuing to interact effectively with one’s partner and children, and to hold down a job – well, it’s all very difficult.

And most people with substance use issues have experienced trauma, particularly in childhood. Over half have been diagnosed with mental health issues.  Many have physical pain. When substance use ameliorates these conditions, in the absence of substances, symptoms can escalate to unbearable levels.

Where can we turn for help with this Gordian knot? The research on addiction is actually quite clear on what is helpful. Comprehensive reports on addiction research were released in 2016, first by neuroscience journalist Maia Szalavitz, and then by the U.S. Surgeon General. Evidence-based treatment is at hand.

And no wonder research suggests that, coupled with medical care, skills-focused therapies – rather than personal analysis – can be helpful to people with substance issues who want to reduce or eliminate use. If I have substance use issues, personal insights might be helpful, but only if they free me to take action. I need something to do right now. Addiction is defined as a  brain disorder. Addiction is not a problem with the self.

Research reports that these therapeutic modalities can be helpful to people with trauma, mental health issues, and/or substance use issues: cognitive behavior therapy (CBT) and its varieties, including Cognitive Processing Therapy (CPT), dialectical behavior therapy (DBT), Motivational Interviewing (MI), contingency management (CM), and mindfulness-informed therapies, all offered in the context of, as Maia Szalavitz puts it, “Love, evidence & respect.”

Individuals can study these methods on their own, or work with a counselor, individually and in groups, to use these approaches to address their concerns. A primary skill to acquire is distress tolerance to endure the opposites that are true for many people with addiction: “I want to use AND I don’t want to use.”

Simply put, in tandem with medical care, if I have a substance use issue, if I’m aware of what’s going on in and around me, and have some skills to take action on what might be helpful to me, some supportive people in my life, and adequate resources, I may be able to gently – or muscularly if need be – help myself use substances with less risk, perhaps not at all.

Denigrating, devaluing, and dehumanizing through confrontation, humiliation, and incarceration do not reduce substance use, whether inflicted by others, or through one’s own thoughts. Some beliefs we hold about addiction are simply wrong.

Discussions about addiction treatment and policy seethe with controversy, debate, and acrimony – a lot of emotion dysregulation! I try to slide those aside like dusty curtains to see what’s possible out the window.

To achieve the end in mind – to reduce or end substance use, either by preference or mandate – in my work with myself and others, I have found kindness to be the most helpful modality. Self-kindness and other-kindness. Next would be acknowledging reality without shame or judgment.

If I am working with you, or will in the future, it is my honor, privilege, and delight.

. . . . .

Coloring page interpretation of DBT’ “States of Mind” by Christy Mackie. Downloadable .pdf coloring page opens in a new tab here.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

When We Are Mandated to Abstain

Payers for addiction treatment – insurance companies, the criminal justice system, and child protective services – increasingly require abstinence as the treatment outcome before they’ll pay their bills. Addiction is a medical illness, however, whose primary symptom is compulsive use. If people with addiction could refrain from compulsive use, they would be in remission from the illness and not need treatment. This double bind of failure results in ghastly costs in human suffering and over $600 billion for the U.S. economy.

Our open heartsWe label people with addiction as “addicts” and “alcoholics,” as “them,” not “us.”

Brain research reveals we are all in this together.

The brain alterations enacted by addiction involve some of the same neurocircuitry involved with human bonding. Without the substance, scientists term the induced state “craving.” Yes, perhaps, there’s craving for the substance, but medications and behavioral therapy can help, just as they help people with obesity handle cravings for food.

Also present, though, through an unknowable combination of predisposition and brain alterations, is abject longing. As Maia Szalavitz puts it, the brain, at essence, has learned to love the substance instead of a person. Mandated abstinence can create a profound state of grief akin to loss of one’s beloved through traumatic, truncated attachment.

The greatest works of art, literature, and music convey what people do with the unbearability of loss – and deals they do with the devil or the gods to regain what’s missing. But for people with substance addiction, relief from that unbearability is at arm’s length. We’ve all experienced unbearable grief from loss. It can seem an act of mercy to return to use.

Abstinence can require a level of forbearance, and a tolerance for suffering, that many people simply don’t have.

Further, refraining from use, or abstinence, is not a treatment for addiction. The first-line treatment for substance use disorders, and for the mental and physical illnesses that can accompany them, is medical care, including medications for each individual as determined by a medical professional. Much addiction “treatment” in America is mandated abstinence and group therapy, the latter also not an evidence-based treatment for addiction. Rates of return to use after this kind of “treatment” are nearly 100% in year one.

And “use” of substances actually isn’t a problem. People have been using substances for 10,000+ years for pleasure, relief, and escape. Of people who use any substances, in any way, 70-80% do not become addicted to them. We’d never know it from media coverage, but the risk of developing addiction from substance use is low.

I think society’s predominant view of people with addiction is that they use substances to, essentially, masturbate with them. Hence the moral and criminal approach to “treatment,” the resultant stigma, and mandated abstinence.

What if we let science help us see that addiction is a very human problem? What if our addiction treatment focused on medical care first, then the trauma that most people with addiction have experienced and the mental illnesses that more than half have as well? And what if we viewed mandated abstinence as a state of grief? How might our own bereaved hearts open to our brothers and sisters?

Watercolor by Jesi Pace-Berkeley

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

How to Help People with Addiction Who Are Mandated to Abstinence

1. Help them get medical care and needed medications to achieve physical and mental stability.

2. Help them substitute the word “longing” for “craving.” Ask, “What are you aware of longing for? Try to be as specific as possible.” With compassion, and without judgment, help them figure out, other than to stave off withdrawal, what wants and needs the substances met.

3. Help them discover “good enough” replacements so they can still get their wants and needs met.

4. Help them figure out how to stay away from it, its items, its people, and its gathering places.

5. Help them come up with plans, and to access resources, to increase the stability of their living situations, finances, and relationships.

6. Help them learn skills that may help people abstain in any situation, regardless of their problems.

7. Help them identify addiction myths and realities* so they can help themselves get evidence-based care, and not get sidetracked by belief-based practices.

8. If you’re a person with addiction attempting to help others, “Walk the talk.” Provide skillful support. Share what’s working for you, and share what you’re working on and why. Show that support, skills, and stability work – not folklore, criticism, confrontation, punishment, shame, humiliation, and stigma.

Help that helps

*Addiction Myths and Realities

Myth: You became addicted because you’re a bad person and you’ve done wrong. To become un-addicted, you need to become a good person. Further, you need to admit to, take responsibility for, apologize for, and make restitution for your wrongdoing.

Reality: Addiction is a medical illness involving structures and functions of the human brain. Before they developed addiction, most people experienced trauma. More than half have a mental illness.

Myth: You have to “hit bottom” before you’re ready to abstain.

Reality: People with untreated medical illnesses are at risk of premature death.

Myth: You can become addicted the first time you use.

Reality: Use ≠ addiction. According to research, 70-80% of people who use substances – in any way, of any kind – do not become addicted to them.

Myth: Pregnant mothers on illegal drugs or on prescribed medications give birth to addicted babies.

Reality: Use ≠ addiction ≠ dependence. Babies may be born dependent upon substances their mothers take, including blood pressure and antidepressant medications, but they are not born addicted. According to NIDA, “Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.” Babies are incapable of knowing what medication is missing, much less how to seek and use it.

Myth: If you’re on medication, you’ve traded one addiction for another.

Reality: Use ≠ addiction ≠ dependence. People on medications may become dependent upon them, meaning they will experience physical symptoms if they stop taking the medications. Taking drugs/medications as prescribed is not “compulsive drug seeking and use” and does not result in behavior that causes harmful consequences.

Myth: If you’re on medication, you’re not really abstinent.

Reality: Laypeople without medical expertise and without knowledge of a particular individual’s particular medical conditions, who mandate whether or not individuals should have medications prescribed to them by medical professionals, put lives in danger.

. . . . .

This post is an online version of one in a series of one-page handouts I am creating for people with addiction who have been mandated to substance abstinence by authorities. I have strong views about this. I have, and will continue to, express those elsewhere. Right here, right now, people with addiction need help and they’re either not getting it, or what they’re getting isn’t working. The handouts are my attempt to strong arm aside belief and theory and present distillations of what research reports helps people abstain.

As I publish them, I will keep track of the handouts here.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Awareness Can Help

I have become aware that I am feeling ______________,   ______________,   and ______________.

I am becoming aware that I am thinking these thoughts:
___________________________________________________,

___________________________________________________,

and
___________________________________________________.

I ask myself, “Am I feeling natural feelings (mad, sad, glad, afraid), or
secondary feelings (shame, blame) resulting from judgmental thoughts?”

If I am feeling natural feelings, I make supportive, reassuring statements to myself. I practice self-kindness and self-care.

If I am feeling secondary, thought-made feelings, I state facts to myself, and make realistic, helpful statements to myself. I try replacing absolute, all-or-nothing thoughts, such as “always, “never,” “all,” every,” “everyone,” with “some,” “many,” “most.”

I monitor the inner volume on the intensity of my feelings and adjust up or down to shift myself to a stable range.

To help myself adjust my inner volume, I first assess the safety of the situation. If it is safe, I shift my attention to my senses. I become aware of what I am seeing, hearing, tasting, touching, smelling, and motions around me.

Without judgment, as thoughts occur, I sort my thoughts by labeling them “helpful” and “unhelpful.” I shift my attention to the “helpful” thoughts.

As a result of adjusting the inner volume on my feelings, sorting my thoughts, and managing my attention, I now have access to my inner wisdom. I can consult my inner wisdom for guidance.

My inner wisdom helps me discern between safe and unsafe situations, know and use my strengths, tell the difference between facts and opinions, handle that opposites can both be true, and do a cost-benefit analysis, with rankings, to decide what I might – or might not – say or do next.

Inner wisdom

If connection is desired or needed, I spend time with kind, supportive people. I use awareness to foster safety, become aware of attunement, listen reflectively, notice and acknowledge others’ thoughts and realities, empathize with (safe) others’ feelings, and intentionally resolve conflicts. Awareness helps me be present for myself and others.

Awareness helps me practice self-kindness and other-kindness.

. . . . .

This awareness-fostering, self-narrative is an evolving attempt to distill the research on personal practices that can help most people, most of the time, better than other methods, and better than nothing, with the symptoms of substance use disorders, anxiety, depression, thought disorders, personality disorders, neurodevelopmental disorders, physical pain, and other challenges. Among other modalities, the skills are informed by cognitive behavior therapy, dialectical behavior therapy – mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness – and cognitive processing therapy. The skills are not a substitute for professional help. Given that many challenges are experienced 24-7, and wait lists for professional care exist in many locales, the skills are offered as an adjunct to professional care, and, perhaps, to help people feel a little better.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Question Criminalizing a Medical Illness

One way I urge us to help all our citizens is to question the legality, effectiveness, and humanity of criminalizing the medical illness of addiction.

Freedom and peace

Here is a summary of my findings:

Many of our citizens with opioid use disorder are arrested, incarcerated, or given the forced choice of drug court or jail. Many receive limited or no treatment, or are denied the first-line, evidence-based treatment for opioid use disorder, methadone and buprenorphine. Some drug courts ban the use of medications for opioid use disorder. At the national level, the Department of Justice’s Civil Rights Division has begun an initiative to remove discriminatory barriers to treatment for those in the criminal justice system. Incarceration does not decrease substance misuse. Treatment is 7 times cheaper than incarceration.

Here are highlights of my literature review of research on opioid use disorder and the criminal justice system:

“A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use.”

– Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, November, 2016, Page 4-1

On-going, long-term maintenance on methadone or buprenorphine are the only two treatments currently known to reduce mortality from opioid addiction by 50 percent or more.

– Pierce et al., Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in EnglandAddiction, 2015

– Sordo et al., Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studiesBritish Medical Journal, 2017

Naltrexone, whether oral or extended release naltrexone, branded as Vivitrol and marketed directly to drug court judges by its manufacturer, does not result in decreased mortality rates for people with opioid use disorder.

– Degenhardt et al., Excess mortality among opioid-using patients treated with oral naltrexone in Australia, Drug and Alcohol Review, 2014

– Jarvis et al., Extended-release injectable naltrexone for opioid use disorder: A systematic review, Addiction, 2018

“[H]ealthcare providers, criminal justice officials, and the media should consider the potential for overdose when prescribing or promoting Vivitrol treatment.”
– Saucier et al., Review of Case Narratives from Fatal Overdoses Associated with Injectable Naltrexone for Opioid Dependence, Drug Safety, 3/20/18

Persons recovering from, or receiving supervised treatment for addiction to alcohol or drugs, are often qualified as disabled individuals according to the American with Disabilities Act. Courts, drug courts, probation departments and prisons may not treat individuals with opioid use disorder differently from other individuals who are allowed to take medications as prescribed.

Letter to the New York State Office of the Attorney General from the U.S. Department of Justice, October 3, 2017

80% of people with opioid use disorder who attempt abstinence-based behavioral treatment or detoxification relapse.

– Gavin Bart, M.D., Maintenance Medication for Opiate Addiction: The Foundation of RecoveryJournal of Addictive Diseases, 2012

“The majority of patients who discontinued BMT [buprenorphine maintenance therapy] did so involuntarily, often due to failure to follow strict program requirements, and 1 month following discontinuation, rates of relapse to illicit opioid use exceeded 50% in every study reviewed.”

– Bentzley et al., Discontinuation of buprenorphine maintenance therapy: perspectives and outcomes, Journal of Substance Abuse Treatment, 2015

People are more likely to fatally overdose prior to beginning maintenance medication and upon ceasing it than are those with continuous treatment. Cornish et al. caution, “Clinicians and patients should be aware of the increased mortality risk at the start of opiate substitution treatment and immediately after stopping treatment.”

– Sordo et al., Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studiesBritish Medical Journal, 2017

– Anders Ledberg, Mortality related to methadone maintenance treatment in Stockholm, Sweden, during 2006–2013, Journal of Substance Abuse Treatment, 2017

– Cornish et al., Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK General Practice Research Database, British Medical Journal, 2010

Individuals with opioid use disorder who are newly released from prison are at high risk of overdose death.

– Binswager et al., Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009, Annals of Internal Medicine, 2013

Incarcerated individuals with opioid use disorder should be treated with methadone and buprenorphine while they are incarcerated. “[R]esults suggest that comprehensive MAT [medication-assisted therapy] treatment in jails and prisons, with linkage to treatment in the community after release, is a promising strategy for rapidly addressing the opioid epidemic nationwide.”

– Green et al., Postincarceration Fatal Overdoses After Implementing Medications for Addiction Treatment in a Statewide Correctional System, JAMA Psychiatry, 2018

For those with opioid addiction in the criminal justice population, maintenance medication can reduce rates of re-incarceration by 20% or more.

– Larney et al., Effect of prison-based opioid substitution treatment and post-release retention in treatment on risk of re-incarcerationAddiction, 2011

To stay in remission from opioid use disorder, people must remain on methadone or buprenorphine for extended periods of time, sometimes life-long. According to SAMHSA’s guide, “Medication-assisted treatment should continue as long as the patient desires and derives benefit from treatment. There should be no fixed length of time in treatment. For some patients, indefinite medication-assisted treatment may be clinically indicated.”

– Federal Guidelines for Opioid Treatment Programs, SAMHSA, 2015

“Medication-Assisted Treatment (MAT) is an evidence-based substance use disorder treatment protocol, and BJA [Bureau of Justice Assistance, U.S. Department of Justice] supports the right of individuals to have access to appropriate MAT under the care and prescription of a physician. BJA recognizes that not all communities may have access to MAT due to a lack of physicians who are able to prescribe and oversee clients using antialcohol and anti-opioid medications. This will not preclude the applicant from applying, but where and when available, BJA supports the client’s right to access MAT. This right extends to participation as a client in a BJA-funded drug court.”

Adult Drug Court Discretionary Grant Program FY 2017 Competitive Grant Announcement, U.S. Department of Justice, 2016

“Examining any two-year post-program recidivism (defined as an arrest, conviction, or incarceration), over one third (37.6%) of graduates and almost all program terminators (95.3%) had two-year post-program recidivism ( p < .001). [my emphasis]. For the overall sample, age, outpatient treatment, marital status, number of times treated for a psychiatric problem in a hospital, substance use (i.e., past-30-day cocaine use and intravenous opiate use), number of positive drug tests, and receiving any sanction/therapeutic response were associated with two-year post-program recidivism.”

– Shannon, et al., Examining Individual Characteristics and Program Performance to Understand Two-Year Recidivism Rates Among Drug Court Participants: Comparing Graduates and Terminators, International Journal of Offender Therapy and Comparative Criminology, 4/1/18

“The analysis found no statistically significant relationship between state drug imprisonment rates and three indicators of state drug problems: self-reported drug use, drug overdose deaths, and drug arrests.”

– More Imprisonment Does Not Reduce State Drug Problems, The Pew Charitable Trusts, 3/8/18

Treatment is up to 7 times less expensive than incarceration.

– NIDA, “Is drug addiction treatment worth its costs?”, 2018

Watercolor painting by Jesi Pace-Berkeley

The above includes data I used for a talk I gave on the opioid crisis on Tuesday, March 13, 2018. I reviewed common beliefs about opioid use in the U.S., and compare those beliefs to what research reports. I published highlights from my background research for the talk as Opioid Crisis: What People Say vs. What the Research Says.

Last updated 5/15/18

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.