The Anatomy of Addiction (10 page)

I
have a chronic disease called diabetes. There's no cure for my chronic disease, but I maintain a fairly normal and, some would say, highly successful life. How do I do it? I follow a strict regimen of medications formulated to address my particular disease. I also modify my lifestyle to minimize the risks associated with my disease.

Now as a diabetic, not to mention a physician, I would no more think that I could treat my disease by sitting around in a room with other diabetics and commiserating about our problems than thinking I could cure it by eating a diet of only chocolate cake. These are but ridiculous propositions—yet, that is, in effect, the expectation we have for those who suffer from the chronic disease of alcohol and drug addiction.

In western Europe, drug policies differ from country to country but focus first and foremost on providing evidence-based treatment to addicts rather than criminalization of substance abuse. Portugal has decriminalized drug possession in small amounts
altogether. Germany, too, focuses on treatment, but still aggressively pursues drug trafficking. While still criminalizing possession, German prosecutors have moved away from pressing charges to emphasizing treatment. The Netherlands, famous for its legalized cannabis bars, nevertheless has taken new steps to crack down on the smuggling of so-called hard drugs, such as opium and heroin. The result of these harm-reduction programs has been a massive decrease in new drugs users, with Portugal decreasing by 38 percent, the Netherlands by 24 percent, and Germany by 17 percent.

The standard for addiction treatment in the United States—unlike all other Western nations—is a program based on a seventy-five-year-old philosophy in which sharing stories is the focus. The organization that offers this philosophy, Alcoholics Anonymous, makes no claims to having helped the majority of people with substance addiction or even the majority of people who come to it for help. By its own estimates, it is probably effective in treating addiction over the long-term for only 5 percent of those who have attended one of their group meetings.

Now, you may say that no one forces anyone to seek help for addiction treatment from AA, but that's not true. For the most part, drug courts in the United States assign mandatory treatment for those convicted of minor drug-related criminal activity (mostly possession of small amounts of illicit drugs) to so-called rehab clinics whose treatment consists mostly or exclusively of AA treatment protocols. That's a fancy way of saying that their patients sit in a room and talk about their drug problems. If they're lucky, the discussion might be led by a drug counselor, but more often than not, it's lead by someone who doesn't even have a college degree
much less any medical training and whose only qualification frequently is that they, too, are recovering from an alcohol or drug addiction.

It's incredible, but that is the sorry state in this country of the treatment of alcohol and drug addiction, the third most widespread chronic disease in America.

A recent nationwide study on alcohol and drug addiction by the National Center on Addiction and Substance Abuse at Columbia University concluded, “Unlike other diseases . . . the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.” It goes on to say that the consequences of this failure are “profound,” resulting in “an enormous array of health and social problems such as accidents, homicides and suicide, child neglect and abuse, family dysfunction and unplanned pregnancies.”

Here's the greatest irony: This chronic disease, unlike Alzheimer's, arthritis, or asthma, for example, is largely preventable. We also know how to effectively treat it with evidence-based medicine.

Addiction Treatment in the Twenty-First Century

I mentioned earlier how the U.S. standard of addiction treatment has nothing to do with medicine. In western Europe, Japan, and most other industrialized nations, treatment of alcohol and drug dependency is grounded in science and research. Now, here in the United States, we offer that same kind of treatment, too, but the difference is that evidence-based treatment is not the standard here.

What is evidence-based treatment of addiction? Evidence-based medicine is simply the application of the scientific method
into healthcare. It's the standard for the treatment of every chronic disease in America except substance addiction.

There is absolutely no denying that addiction is a chronic medical illness that must be controlled with proper treatment, including medications—just like my disease of diabetes and other complex and chronic medical conditions.

As a psychiatrist specializing in addiction medicine and who has been treating addicts for the last two decades, I can tell you the answer lies in integrating mental health and addiction treatment into a single, comprehensive program designed to meet the individual needs of each specific patient.

Effective, evidence-based treatment of addiction has three parts that work together:

•
Biomedical
, which focuses on improved detoxification regimens, followed by the use of medicines to reduce cravings and manage addiction over a lifetime and, when appropriate, the application of psychiatric medications.

•
Psychological
, which includes addiction counseling, cognitive behavioral treatment psychotherapy, aversion therapy, and behavioral self-control training.

•
Sociocultural
, which uses the community reinforcement approach, family therapy, therapeutic communities, vocational rehabilitation, various motivational techniques, culturally specific interventions, and contingency management.

All three of these modalities have more than one dimension in common, such as social skills training, relapse prevention
techniques, self- and mutual-help programs, support groups, and chemical aversion therapy.

Addiction is a chronic medical condition, a brain disorder. Just as hypertension and asthma have biological, psychological, and social components, so do alcoholism and drug addiction. An evidence-based addiction treatment must include all three components.

Equally important, each program must be individualized for each patient. It's not that the current AA/12-step protocol that characterizes treatment at most rehab clinics is inherently bad. It's just incomplete. Fundamentally, it lacks two of three essential components—biomedical and psychological—needed for a successful treatment of the disease of addiction over the short and long term. It also has a one-size-fits-all mentality in which any deviation from its main tenet—abstinence—is considered heresy. In a disease as complex as substance addiction, that simply does not work for most people.

Here's the good news: Just as the diabetic can live a normal life with certain adjustments (monitoring blood sugar levels, regular medicals exams, taking insulin, modifying diet, and so on), so can the recovering alcoholics or addicts can live normal lives with their own life adjustments.

Assessment

Before evidence-based addiction treatment begins, all patients need a full medical and psychiatric diagnosis and evaluation, plus evaluation of their individual psychological and social situation.

As a part of a comprehensive medical evaluation, an EKG and a complete blood chemical analysis should be performed. A blood metabolic panel is a group of chemical tests that measure the amount of vitamins, minerals, cholesterol, protein, blood sugar, electrolytes, and other bodily requirements and functions.

An EEG, CT, MRI, or PET scan may also be conducted before treatment to ascertain the severity of brain structural or functional damage, or other brain-related concerns. After all, alcoholism and substance misuse are diseases of the brain.

From this information, a physician, preferably one trained in addiction medicine, can determine the severity of the patient's addiction. The American Society of Addiction Medicine, a professional society representing more than 3,200 physicians and associated professionals dedicated to increasing access and improving the quality of addiction treatment, defines six dimensions to addiction severity: (1) potential for acute intoxication and/or withdrawal, (2) biomedical conditions and complications, (3) emotional/behavioral conditions or complications, (4) treatment acceptance/resistance, (5) relapse potential, and (6) recovery environment. The goal is to match the patient's needs to the appropriate treatment service by assessing the severity of the addiction as well as verification of the medical diagnosis.

Key to Effective Treatment

There are very few diseases that are purely biological in nature. The causes of most diseases, including alcohol and drug addiction, are multifaceted, with biomedical, psychological, and sociocultural
factors. Effective treatment is achieved when all of these factors are integrated into a comprehensive program.

Let's be clear: The effective treatment of substance addiction is highly individualistic, requiring a trained physician to assess both the patient's physical and psychological condition. For some patients, no psychological treatment is required; for others, it becomes a primary focus. Sometimes counseling that includes a patient's family is absolutely necessary (and this is especially true with teen addicts), but in other cases it's not necessary and is even counterproductive. Rehab clinics that offer a standard treatment for all patients are engaging in the worst kind of breach of medical ethics. They either know better or should know better.

Despite the individualistic approach required in effective addiction treatment, this I know for certain: The successful treatment of alcohol and drug addiction
must first
address the biological component and correct the brain's chemistry imbalance in the process.

Let's dig a little deeper into each of three parts of an evidence-based treatment.

BIOMEDICAL THERAPY

If we accept the scientifically proven theory that addiction is a medical condition, then we have to recognize that medications can compensate or even reverse the pathology of the disease. When medications work, no matter what the target illness, they have a relatively quick and dramatic effect.

Of the medications that have proven to treat the disease of
addiction, Suboxone, which is the combination of buprenorphine and naloxone (the drug used by first responders to reverse the effect of an overdose), is the most successful. Suboxone mimics the effects of opioids like heroin, in effect, by occupying the receptors that opioids affect. If someone on Suboxone injects heroin, he feels little effect. And because the medication mimics an opioid, there's little craving. Unlike methadone, which has a similar if not albeit more crude effect, Suboxone doesn't have to be administered via a daily visit to a clinic. Suboxone is a pill of a sublingual (under the tongue) form that can be prescribed to the patient by an authorized doctor.

Several other drugs for treating addictions have been approved in recent years, adding to the portfolio already in use. Clonidine is used for heroin and opiate addiction and naltrexone, acamprosate, gabapentin, and topiramate for alcoholism (we will delve deeper into each of these medications further in the book).

It's important to emphasize again that each individual patient will respond differently to different medications and different dosages. That's why it is essential that biomedical therapy only be administered under the supervision of trained medical professionals.

PSYCHOLOGICAL THERAPY

Most chemically dependent people and those with mental disorders feel overwhelmed and helpless. They yearn for hope and a sense of empowerment in the face of debilitating disease. An important aspect of effective treatment includes empowering patients to
see themselves in partnership with their physician, strengthening their physical, emotional, and mental health.

As the disease of addiction impacts the thought processes, another important aspect of effective treatment is individualized cognitive behavioral therapy (CBT). This therapy is a form of psychotherapy that emphasizes the important role of thinking how we feel and what we do.

There are several approaches to cognitive behavioral therapy, including rational emotive behavior therapy, rational behavior therapy, rational living therapy, cognitive therapy, and dialectic behavior therapy. All of these cognitive behavioral therapies are based on the idea that our thoughts cause our feelings and behaviors, not external things like people, situations, or events. Even if a situation remains unchanged, how we respond to that situation can change. We can choose our response, making a conscious decision to respond in ways that are in the best interest of our health and happiness.

In conjunction with CBT, there is another therapy valuable in treating addicts. Motivation enhancement therapy (MET) has been thoroughly researched in the field of substance misuse and has proven to be exceptionally effective at enhancing an individual's motivation to make positive changes in behavior. Also, with many patients, family therapy is also helpful and even essential. Depending on the patient's family dynamic, involving the family in the recovery process can mean the difference between success and failure.

An effective treatment must help patients address, identify, and describe the personal meaning of their addiction. Are they
self-medicating, filling up an inner emptiness, numbing feelings related to a trauma, or all of the above? Unless clients understand what they are actually doing on a deep conscious and subconscious level, they will chronically relapse. A responsible, comprehensive treatment program takes all aspects into consideration for the ongoing health and well-being of the patient.

When it works properly, psychological therapy empowers the patient to be her own gatekeeper so she doesn't have to be told (or scolded or shamed) into avoiding behavior that can trigger relapse. Let me give an example.

Motivational Therapy at Work

Maureen was a middle-aged woman who had been referred to me by her primary-care doctor for depression (about 50 percent of all addicts have a mental disorder, and depression is the most common). While interviewing her, it quickly became clear that she had a dual disorder, both clinically depressed and an alcoholic. She drank two to three bottles of wine daily, which was not only making her more depressed but also ruining her physical health. Keep in mind that she had come to visit me only for her depression. Like many addicts, because of their impaired brain function, she didn't think she had a serious addiction.