A Kind, Research-Informed Guide for People Seeking Abstinence from Substances

As a novice group counselor at a social services agency, I earnestly explained curriculum materials from what became a discredited list for what was then termed “substance abuse.” A weary client, court-mandated to treatment, listened respectfully, head tilted towards his hands folded on the table. He would be returned to jail if he used substances again. When I finished talking, he paused, then looked up at me. With earnestness matching my own, he asked, “How do you abstain?”

If he could abstain, he would be free.

I was stunned and chilled by the chasms this realization revealed.  Counselors are advised to “meet clients where they are.” I remain ashamed I was miles away from meeting his true needs. And I didn’t know the answer to his question. That was five years ago. I have devoted myself to answering it since.

In an ideal world, the health condition of addiction/substance use disorder would be managed by health care professionals, not the court system. Rather than ordering up the distress and danger of abstinence, the treatment plan might taper down substance use while tapering in supportive replacements. The criminalization and stigmatization of substance use force health care professionals to try to help the people in their care maintain abstinence to prevent loss: of employment, of custody of their children, of university enrollment, financial aid or scholarships, and of freedom through incarceration for displaying symptoms of an illness. (What an ethical double bind! The primary symptom of addiction is return to use. If clients could abstain, they would be in remission and wouldn’t meet the criteria for the very disorder for which they are in treatment with us.)

For those attempting or mandated to achieve and maintain abstinence from problematic substances, estimates of rates of return to use in year one range from 60% to 80%.

What works to help people overcome the odds of returning to use?

Self-help is not an evidence-based treatment for substance use disorder. Yet, each week holds 168 hours. While people with substance use challenges who follow evidence-based treatment plans may benefit from medications and several hours of medical and voluntary counseling appointments per week, the rest of the time people are on their own.

How do you abstain? During the times when people must help themselves, research offers clear guidance.

With Sanjay Kishore, M.D. and the contributions of countless other individuals with substance use challenges, I have co-authored Help That Helps: A Kind, Research-Informed, Field-Tested Guide for People with Substance Use Concerns. A .pdf of 107 pages, Help that Helps is a self-guided program – tested and refined by real people with real substance use issues – for people with substance use challenges who need or want to abstain.  Again, the caveat: Any self-help guide is to be used in tandem with medical care. (For those who are allowed to practice harm reduction, this workbook may be helpful.)

My theory is that interspersing an hour per day of remission-focused work with research-informed materials during each of the 7 days of those 168 hours per week can increase the chances of remaining abstinent. Help That Helps offers those materials. To push past one-year return to use stats, I’ve devised a year-and-a-day notebook project to assist. For 52 + 1 = 53 weeks, individuals are invited to do engaging exercises with reference to Help That Helps. I add new ideas and materials on the For Clients page. On the For Clients page, I also offer suggestions for further reading.

My client was returned to jail for return to use soon after he asked, “How do you abstain?” I regret beyond words my inability to answer at the time.

Today, I know that, after medical care, the research suggests that self-care is the primary method people can use to help themselves abstain. A self-care checklist is on pages 28-29 in Help That Helps. An example of a day spent practicing self-care is here. Second, they can begin to identify the needs and wants met by substances and ponder alternatives. Assistance with that process is on pages 13-27 in Help That Helps.

I have been in remission from alcohol use disorder since the end of 2012. I had the luck of choosing to attempt abstinence from the substance that had become problematic for me rather than being mandated to it. Regardless, the first years were spent in anguish, easing up only once I was able to follow the guidance of research, primarily through reading Maia Szalavitz’s Unbroken Brain: A Revolutionary New Way of Understanding Addiction and  Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, both published in 2016.

As a person in remission who is also a counselor, I see my work as three-fold. One, I protest the war on people who use drugs. Two, I advocate for addiction policy reform to allow free access to evidence-based treatment. Three, I get evidence-based treatment to the people who have what I have.

I am only person and can only do so much. But in my sections of Help That Helps, I tried to write words that would have reassured, informed, and guided me. I hope they offer comfort and guidance – even freedom – to people who have what I have.

If I can be of any service in any way, please do not hesitate to contact me.

Image: iStock

Last updated 9/14/19

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia.

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.

Health Care Professionals Must Take Back What Happens to People with Addiction from the Criminal Justice System

The health care gold standard of achieving remission from addiction or substance use disorder is not the absence of substance use, but the absence or presence of substance use such that substance use does not result in notable harm to self, others, or society. Nine out of ten Americans use substances without noticeable harm.

In contrast, the gold standard of the criminal justice system is abstinence as evidenced by negative urine drug screen. As with most health conditions, during the time that treatment is attempting to help the person achieve remission, an individual is likely to display symptoms of the condition. With substance use disorder, that defining symptom is continuing to use substances despite adverse consequences.

Unite to help people with addiction

This disconnect harms our outcomes. For health care professionals who treat people with substance use disorders, time after time, we and our patients and clients see clinical stabilization, patients and clients display the symptom of the illness for which we are treating them – use – and they’re incarcerating again, re-traumatizing and destabilizing them.

The arguments for “sanctions,” i.e. re-incarcerating drug court participants and people on probation or parole who test positive for illegal or banned substances are: 1) Using illegal substances is breaking the law and they should go to jail for that. 2) They committed crimes while using substances and they should go to jail for that. 3) They should be grateful to be in drug court or on probation/parole rather than in jail.

We, health care professionals who treat people with addiction, need to continue to educate the criminal justice system that our patients and clients are not yet cleared for medical release. Addiction is a medical illness for which people may need emergency, then urgent, then long-term care. Even wounded armed robbery suspects are taken to the hospital first. Only when they are medically cleared for release are they taken to jail. Then due process begins. In contrast, people with substance use disorder are a uniquely persecuted population, particularly when they participate in drug court. They are presumed guilty of crimes and incarcerated over and over again – without due process – for having wounds.

Our current system overrules medical and public health best practices in favor of criminal justice mandates. In terms of dollars and cents, the criminal justice system is robbing health care professionals of our outcomes which are increasingly required by payers for reimbursement. If not for humanitarian reasons, then for economic reasons, health care professionals must take back what happens to people with substance use disorders from the criminal justice system.

If we must have drug courts – although the data overwhelmingly denies their effectiveness – they need to be transformed into aftercare treatment courts capable of receiving patients and clients who are still weakened and vulnerable as they attempt to recover from this potentially life-threatening medical illness.

For further reading

Image: iStockphoto

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia.

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, 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.

Drug Courts Could Improve Their Stats If They Allowed Evidence-Based Policies

The drug court judges I have listened to seem to believe that the people standing before them are making willful choices to engage in self-pleasure, either by over-indulging in alcohol or using illegal substances. They can’t imagine doing this themselves and are outraged that others do. They believe the people possess depravity so pervasive that people “like that” will steal and assault others to get what they want, breaking laws and committing criminal acts.

Drug court judges’ policies seem based on the belief that “bad people” doing wrong can be made to become better and do right through publicly humiliating scoldings, sanctions, punishments, and incarceration. For substance use disorders, that logic doesn’t hold up.

Drug court

Substance use disorders and addiction are considered a medical illness of the organ of the brain because of the very presence of what drug court judges use to try to “heal” them: adverse consequences.

If people don’t have substance use disorder, the brain is wired for punishment to work. Most people who try substances – up to 80% – don’t like their experiences (consequences) with substance use and quit or only use occasionally after they try them. The 10% of Americans with substance use disorders who don’t quit – literally and medically – have something going wrong with their brains.

Persistence in use despite negative consequences is the defining symptom of the illness. That the criminal justice system attempts to use the symptom of the illness to treat the illness is nonsensical. And results in tragic harm.

If drug court judges understood and acted upon these three facts, I believe the the whole system would be transformed:

1. Substance use disorder/addiction is a medical illness. We’re all out of our league in helping people with it unless we’re medical professionals or are adding adjunctive services to medical treatment plans.

2. Punishment not only doesn’t work and doesn’t help, it hurts. Punishment doesn’t treat medical illnesses. More than 2/3 of people with substance use disorders have experienced punishing trauma already, particularly in early childhood – including the chronic trauma of poverty and economic hardship. Punishment, particularly sanctions and jail time, decreases the likelihood of any desired outcomes by further traumatizing, stressing, and destabilizing an individual’s already stressed and unstable system.

3. Positive urine drug screens a) have a high incidence of being false positive – for some substances, 20% – and b) indicate nothing more than the presence of the defining symptom of the illness: persistence in use despite adverse consequences. Evidence of using substances may indicate an acute phase of the illness or a negligible flare-up. Determining this, and subsequent treatment, support, and/or monitoring, would belong in the realm of medical/clinical expertise, not legal opinion.

“Drug courts, which coerce people into treatment under threat of criminal punishment, continue to expand nationally. But three decades of evidence clearly shows that most drug courts do not reduce imprisonment, do not save money, do not improve public safety and ultimately fail to help people struggling with drug problems.”

Katharine Celantano

My understanding is that drug court judges compete among themselves for low dropout and recidivism rates.

Drug court judges would improve their stats if they:

1) Quit jailing people for positive urine drug screens. (See New bill could prevent jail time for relapse in Massachusetts, The Daily Free Press, 2/7/19.)

2) Let people have the meds prescribed to them to treat their diagnosed medical illnesses. (See Setting Precedent, A Federal Court Rules Jail Must Give Inmate Addiction Treatment, NPR, 5/4/19.)

3) Use evidence-based treatment for meth misuse and addiction, particularly contingency management. (Please contact me for a copy of my literature review on evidence-based treatment for methamphetamine use disorder.)

Drug courts are increasingly under attack for medical, legal, and constitutional violations. Perhaps tantalizing drug court judges with the power of evidence-based treatment to improve their outcomes might tempt them to allow it.

For further reading

Image: iStockphoto

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia.

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, 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.

A Typical Day in the Life of a Person Practicing Evidence-Based Treatment for Addiction

Morning

I get up at a time that is healthful for me, either by natural awakening or by setting an alarm clock. Sleep disorders can precede, co-occur with, or result from substance use, so I give my sleep-wake cycle tender, loving care.

I take substances used as medications as directed that have been prescribed to me by health care professionals.

Sun of Self-KindnessI take substances that are legal using harm reductionFor me, that means preparing one pot of strong English Breakfast tea in the morning. Tea, coffee, and other beverages can contain the stimulant caffeine, a legal, mood-enhancing drug. I find the comfort of a hot beverage and the rousing effects of the drug pleasurable and rewarding as I write each morning. I limit my intake, avoid caffeine intoxication, and consciously use caffeine in moderation.

If I used the legal stimulant nicotine, I would do the same. If cannabis were legal in my locale, I would consult a health care provider. I protect my sleep-wake cycle as if it were a small child, precious and essential.

I track my food and feelings. I eat breakfast. I keep a notepad or food log in the kitchen, write down what I eat, when I eat it, and how I feel afterwards. Some foods seem to trigger a greater longing for substances than others. Timing of eating may matter. For me, a salty steak and a rich chocolate dessert at dinner make wine a must-have. That’s a no-go since my current treatment plan includes abstinence from alcohol. By carefully tracking my food and feelings, I’ve learned what foods to have when. For me, I can still have steak at lunch and a bit of dark chocolate after dinner. These are times and flavors my brain has not associated with wine.

Unfortunately, substance use can result in malnourishment. Early recovery from addiction can be associated with weight gain.  Like most Americans, I have trouble limiting my intake of that most problematic of substances, food. I have Harvard’s Healthy Eating Plate in mind as I plan my meals for the day, but I have to customize for my particular case of substance use disorder, plus for my age, height, weight, activity level, other factors, and personal goals.

I exercise. I’m trying to stack the odds of maintaining my health in my favor. For people who can’t exercise, it is motion that is correlated with a sense of well-being and improved outcomes.

I mentally check off that I have completed the “big three” to help myself with a sense of well-being: 1) sleep, 2) nutrition, 3) exercise.

I check a schedule I have created for myself with input from my treatment team. I have a health condition identified by the Surgeon General’s Report as a medical illness. Specifically, NIDA identifies addiction as a brain disorder, and a chronic one at that. Although I profoundly wish I did not have anything with the term “disorder” in it, I have accepted that my schedule needs to prioritize evidence-based treatment for addiction.

Since addiction is a 24-7 condition, I actually am my own 24-7 treatment provider. I have customized my schedule to accommodate my strengths, preferences, and quirks.

Since medical care is the top recommended treatment for addictionI check my schedule for medical appointments. I make sure I’ve had a physical exam and lab work.  I make new and follow-up appointments and attend the appointments I’ve scheduled.

Since counseling can assist with medical care and conditions that can co-occur with addiction, I check my schedule for counseling appointments. Counseling personally helps me thrive, both in giving as a counselor and receiving as a client. I attend weekly individual counseling sessions.

Since, in addition to medical care and counseling, people with addiction can benefit from social support and social connection, I check to make sure I have scheduled contact with an individual who supports my recovery, or have scheduled attendance at an event with a group of people with whom I feel safe and engaged. I consciously become acquainted with new people to increase the possibilities that they can be in my support network and I can be in theirs.

Since people with addiction can benefit from support with accessing resources, I acknowledge these opposites are both true: I need to feel independent AND I can’t do everything for myself. I reassure myself that sometimes asking for help is self-care. I schedule reaching out to my support network for guidance, or for suggestions on whom to contact about concerns I have.

Afternoon

I nourish myself with lunch. I track what I eat and note how I feel afterwards.

I may feel tired by mid-afternoon. I use a legal stimulant to help me with focus and energy. I continue to moderate use of the drug caffeine by having one cup of caffeinated coffee, and one cup of decaffeinated coffee no later than 5 hours before bedtime. If I used nicotine, I would have my last cigarette or vape 4 hours before bedtime. With regard to cannabis use before bed, I would consult a health care provider.

All day, every day

I become aware of, and name, my feelings. This is data for being my full, human self. I may need to practice accessing my feelings.

I engage in emotion regulation. I feel feelings intensely and quickly. My feelings can spike and plummet instantaneously. In extreme states, both high and low, I can do and say things I don’t intend. If I imagine an inner volume dial on my emotions, I can mentally adjust the volume up or down a tad, just enough to return myself to a stable range. My feelings aren’t good or bad, right or wrong. Although intense joy, anger, and sorrow are normal, for me, a person with substance use disorder, I just need to be able to return my emotions to a stable range.

I engage in “thought-sorting.” My brain is a thought-making machine. Some of my thoughts enchant me. Some of my thoughts appall me. Judging them as neither good nor bad, neither right nor wrong, I simply become aware of my thoughts, identify them as “helpful” or “unhelpful” as if were sorting laundry, and shift my attention to the “helpful” pile.

I become aware of physical sensations. I’m not that great at becoming aware of my breath, heart rate, or presence of perspiration, but I have become adept at noticing a swelled feeling of upset in my chest. With others, I can become aware of whether I’m leaning too far in, or too far back for physical comfort. I use data from physical sensations to ease my body.

I engage in attention management. I become aware of to what I am giving my attention. I use “helpful” and “unhelpful” labels again – “Is it helpful or unhelpful for me to stare at a bottle of sauvignon blanc in the grocery store aisle?” – and imagine my hand reaching forward and manually picking up my attention and shifting it to something else. I ask the same questions about the next object or subject of my attention, constantly and consciously deciding what’s helpful for me.

I use interpersonal effectiveness skills. As a result of being aware of my feelings, thoughts, physical sensations, and attention, I can also become aware of how I’m doing in my interactions with others, and how they’re doing, too. As a result of counseling, I know some of my issues and patterns that can automate my interaction style. I can manage those and let myself be present for that person, in that moment, for authentic possibilities.

I co-travel with longing. These opposites remain true: I want to use AND I don’t want to use. I’ve tried everything I, and my treatment team, can think of to make the longing for wine and beer go away. Given the brain science of love and addiction, and of bonding and attachment, that it’s as firmly there as my ache to see my long-gone mother again and to have had my own child makes sense. In the film, “A Beautiful Mind,” the main character learns that, due to his mental illness, the entities in his mind will always be with him, but he no longer speaks with them. I’ve ended up with a similar strategy, but one that requires less energy. Not takes effort. I become aware I am longing for a drink, acknowledge it, comfort myself with self-kindness, and shift my attention to a beloved preference.

I shine the sun of self-kindness on the whole process. The only way I have found to thrive – in spite of the hardships, meticulousness, and endurance required to manage this challenging health condition, plus battling the persecution and incarceration of people with substance use disorders – is to be so very kind to myself. This is all very hard, very unfortunate, and so unwished for. I am very sorry I have this and have to do all this. I appreciate myself for how hard I have worked to figure out what might be most helpful to me, and how hard I work to get it done for myself.

Most of all, I appreciate that my efforts to use what science reports is helpful have produced results. I no longer use substances in a way that causes adverse consequences for myself or others. I understand that this health condition is chronic for many people and I may experience a flare-up and return to use. I anticipate that the awareness skills I use will shorten and lighten such an occurrence.

Further, I appreciate an unexpected side effect of practicing self-care and awareness skills: occasional opulence. For example, this particular moment is quite rich. I’m aware of my feelings, thoughts, physical sensations, attention, preferences, issues and options, right here, right now. Rarely, but frequently enough to be memorable, I am aware of my own consciousness and am filled with wonder at its shimmering splendor.

Let’s see. What else? I work, do chores, play with my cats, see people, do stuff.

Evening

I check my schedule to make sure I’ve done what I’ve deemed helpful for me today.

I eat a light dinner to help myself sleep well. As a child, dinners were a family feast so this has been a difficult change to make.

I practice individualized sleep hygiene before going to bed at a time that is healthful for me. To stack the odds in favor of restful sleep, research suggests, for example, that I don’t use my mobile phone before bed. I would prefer to take one last look at my email inbox, but if it’s kind to me not to? I abstain from my phone.

I haven’t had to become a better person, a more moral person, or a different or changed person. I just do what science says helps people who have what I have so I no longer seek and use substances in problematic ways.

I am myself. I live my life as myself.

. . . . .

The above is an individualized example of an evidence-informed treatment plan for substance use disorder and for alcohol use disorder. The links above are to primary research articles, or to research syntheses I have done, or to syntheses by research-citing health care professionals and journalists. The text uses person-first, accurate, non-stigmatizing language.

The self-care checklist on which my day is based is on pages 28-29 in Help That Helps: A Kind, Research-Informed, Field-Tested Guide for People with Substance Use Concerns, by Anne Giles, M.A., M.S., L.P.C. and Sanjay Kishore, M.D. The guide currently consists of 107 pages in .pdf format.

“Sun of Self-Kindness” is a coloring page by Nichol Brown and is available as a printable .pdf here.

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia.

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, 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.

Facts Overwhelmingly Demand the Elimination – Not Proliferation – of Drug Courts

I was interviewed about the myths and realities of drug courts with Changing the Narrative Webcast host and journalist Zachary Siegel (@ZachWritesStuff ) on Thursday, July 11, 2019.

Here is a link to Changing the Narrative’s Event page. The interview can be found at “July 11: Drug Court Webinar.”

Changing the NarrativeBelow is a summary of my introductory and concluding remarks, a link to references, and other follow-up information.

. . . . .

I really appreciate being asking to be a guest on Changing the Narrative’s webcast. It was an honor to meet you, Zach, Leo Beletsky, Sarah Wakeman, Maia Szalavitz, and over sixty other advocates to found this effort to use words about addiction that are supported by facts.

Before we start talking specifically about drug courts, I would like to provide some context.

In the United States, substance use is generally perceived, at best, to be an immoral act of self-pleasuring. At worst, it is perceived as a crime.

These are beliefs, not facts. The fact is that humans have used substances for over 12,000 years. According to research done by the National Institute of Alcohol and Drug Abuse – an unfortunate, stigmatizing agency title, by the way – people use substances for reasons that are meaningful to them. To paraphrase NIDA’s research findings, people use substances to feel better, to do better, to not feel bad, to not feel worse, and to connect.

So, substance use, and possession of substances to use, would be human. Not immoral. And not criminal.

However, beliefs about substance use, and about the people who use them, have generated an increasing number of laws about substance use and possession. Courtrooms and jails couldn’t hold all the people arrested. Many of those incarcerated for drug-related charges were rearrested. To address the high number of people in the legal system and high recidivism rates, an intermediate state was derived. Termed “drug treatment courts,” people arrested on drug-related charges would not be incarcerated but would be mandated to treatment.

The logic makes sense on some level. Requiring people who use substances to receive treatment would certainly seem likely to decrease the number of people in jails and prisons. And it should “fix those addicts” so they won’t be rearrested.

The logic, however, is based on beliefs, not facts, about substance use.

This is important. The people I have talked with who have been involved in founding drug courts actually had the best of intentions. They were trying to keep people with substance use issues out of jail. And they were trying to get them treatment, including medications.

Supporting drug courts, however, is based on a false, belief-based narrative.

One belief is that substance use is bad, period. The reality is that the vast majority of substance use is non-problematic, historic, normal, and human. However, we have established social norms that don’t jibe with human history.

Further, we have these tut-tut norms about some substances and not others. The data is clear but we wouldn’t know this from media coverage: alcohol kills more than twice the number of Americans as opioids.* But we don’t seem alarmed about deaths from the beloved substances we consume openly and plentifully in public.

Nearly 99% of Americans use some combination of the legal, experience-altering substances alcoholnicotine, and caffeine. If we count food as a substance, over-consumption of food kills many times more than that.* We are arresting and incarcerating some people and not others, for using some substances and not others.

Another myth is that all people choose to use substances. The reality is that when people use substances, experience adverse consequences, then use the substances again and again, that means the brain is malfunctioning. Put your hand on a hot stove burner, your brain tells you to remove it. Put your hand on a hot stove burner, and you don’t remove it? That’s something up with the brain.

Indeed, that is what researchers have discovered. When substance use is repeated again and again despite the person experiencing negative consequences, that is defined as a medical illness involving the organ of the brain. This brain condition currently affects 1 in 10.

We have widespread access to this knowledge now thanks to the release in November, 2016, of Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health.** In this 400-plus page report, the Surgeon General and panels of experts describe the medical condition of addiction and prescribe a three-prong approach to treatment: medical care first, beginning with a visit to one’s primary care physician. Then individual counseling if needed. Medical care and medications may be sufficient. And, finally, again if needed, we can add what the report terms “recovery support services” which includes access to community social services agencies.

The myth that kills is that punishment treats addiction. The reality is that punishment does not treat any medical illness.

In sum, drug courts were founded on beliefs unsupported by science. The facts overwhelmingly demand the elimination of drug courts, not their proliferation.

In mid-2016, before the release of the Surgeon General’s report, Maia Szalavitz wrote in a letter to the editor of The New York Times, “Shame and stigma are the exact opposite of what fights addiction.” I used Twitter to ask her the equivalent of “Well, what does fight addiction?” She replied, “Love, evidence & respect.”

Those three criteria are useful for evaluating any conversation about substances and addiction. Let’s start with drug courts. Does the existence of drug courts, and do drug court policies, embody “love, evidence & respect”?

. . . . .

*Sources

  • Opioid-related deaths: 35,000 (2015: Source)
  • Gun-related deaths: 35,000 (2014: Source)
  • Alcohol-related deaths: 88,000 (2015: Source)
  • Obesity-related deaths: 300,000 (Source)
  • Tobacco-related deaths: 480,000 (Source)

**The Surgeon General’s Report, published in November, 2016, needs these updates:

  • In terms of treatment effectiveness, research data does not support inclusion of 12-step approaches or rehab.
  • Research does not support inclusion of naltrexone, or extended release naltrexone, as a primary treatment for opioid use disorder, equivalent to methadone and buprenorphine. Further, naltrexone may be contraindicated for those with liver disease and can be associated with depression. According to Buchel et al., November, 2018, “blocking opioid receptors decreases the pleasure of rewards in humans.”

#ChangingTheNarrative

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia.

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, 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.