Archive for July, 2013

When we acknowledge that addiction is a brain disease it becomes easier to understand that there is a battle going on inside the addict’s head.  They hear the “voice of the disease” saying that they need drugs and alcohol to cope with life, or they really don’t have a serious problem, or what they do is no one’s business. And then there is the “voice of recovery,” reminding them of the consequences that have come from their use of drugs and alcohol, their inability to make wise choices, and the knowledge that “just one” will never be enough.

This battle inside an addict’s head intensifies at the beginning of treatment.  Addiction uses manipulation, dishonesty and denial to protect itself, and when the use of drugs and alcohol stops, the addiction fights back.  There are unpleasant physiological symptoms, increasingly strong cravings, and intense thoughts and dreams about using.  It is at this stage that tough love is often necessary to keep someone on the path to recovery.

All too often we see addicts wanting to leave rehab within the first week of treatment. Many think “I can do this on my own,” even when the individual’s past experiences prove otherwise.  Staying in treatment for those first few weeks and learning how to begin a strong recovery are not easy. Quitting crosses the mind of most.

Consequences Help Overcome AddictionIn these times, it is crucial for family and friends to stand strong as well.  If they want the person they care about to stay in treatment and change his or her life, they must resist the temptation to believe the manipulation and lies.  A great way to do so is to create consequences for quitting, such as revoking financial support, housing or even friendship. Failing to do so is like abandoning the fight against addiction before it has really begun.

Joe provides a good example:

After five days in detox he was feeling better than he had in years, his family could hear a new person on the phone, and excitement for a new life began to grow.  Joe said all the right things about how “this time will be different” and how he was ready to be a new man.  He argued that he did not need to stay in treatment; he was ready to start his new life now. So he left.

Two weeks later Joe relapsed.  It wasn’t that he had been intentionally insincere, but he was nowhere near ready to begin recovery on his own.  He had not learned the necessary skills to think in new ways, nor had he established a support network to help him manage the challenges of recovery.  A month later, Joe admitted defeat, and began addiction treatment for a second time.

Marie’s story does not have a happy ending:

Ten days into her treatment for a heroin addiction, she begged her mother to come and get her. She missed being at home, she would never use drugs again, and it would be different this time. During each phone call she used tears and pleading. Even though Marie’s counselor explained to her mother the pattern of manipulation, and how Marie needed to push harder to get beyond her cravings, she did not want her daughter to be sad.  Two weeks after Marie’s mother picked her up she died from a drug overdose.

Recovery should not be a negotiation.  For many people it is a life or death decision to fight a disease that destroys families, careers, relationships and lives.  Everyone who cares about someone trying to break free from addiction must be ready to stand strong.  There must be consequences for abandoning the fight – because they motivate the addict to win.

Try these: “If you leave treatment early you cannot come home.”  “Our relationship will end if you are not prepared to stop using drugs and get help.”  “Don’t expect me to pick you up or offer support if you don’t make a sincere effort to stop.”

These are the resolutions that help people overcome times of weakness and stay strong in recovery.  Without consequences, the addict will often choose the easy way out.

Before your loved one goes into treatment, decided what the consequences of quitting will be. Don’t be afraid to be tough – because you are fighting the addiction as well – and draw a very hard line.  By standing firm, you are showing your true love, and you may end up saving someone’s life.

I spend a lot of time talking to families determined to find help for a loved one who is addicted to drugs.  Inevitably the conversation includes the questions: “Aren’t there some medications that will make them stop?” “I’ve heard about Suboxone, is that the answer?” “Will Vivitrol cure my son’s addiction?”

How wonderful it would be if there was a medication that would stop all cravings, or change the brain in ways that reversed the patterns of addiction.  However, these “silver bullet” ideas are largely based on a false understanding of the disease of addiction, what triggers the use of drugs, and what is necessary to achieve lasting recovery.

Medication-assisted Addiction TreatmentThe two most common medications for opioid addiction are the “agonist” treatments: Methadone and Buprenorphine (brand name is Suboxone). These oral medications contain an opioid that suppresses withdrawal symptoms, weakens cravings, and blocks the effects of heroin, Oxycontin and other drugs that are generally referred to as Opiates. The theory is that if you take these drugs you will lose the desire to use illegal drugs.

A newer, different, non-addictive medication is gaining popularity. Naltrexone (brand name Vivitrol) is an “antagonist” treatment because it blocks the opioid receptors in the brain and prevents an individual from feeling the effects of drugs such as heroin or Vicodin. Available as a pill or a monthly injection, this medication is designed to remove the incentive to use.   In time, it is argued, with counseling and other forms of treatment and recovery support, the addicted person will learn how to avoid drugs in the future.

Suboxone, Methadone, Naltrexone are intended to keep someone from using drugs and enable them to establish recovery.  However, this is not what happens in far too many cases.

Overcoming addiction, and establishing a strong recovery, requires learning how to live life differently.  The addicted person has continually turned to their drug of choice to manage their emotions and control their response to life’s events. The addict’s actions are predictable: when you are stressed you use; when you are sad or angry you use; when you want to feel better and celebrate you use.  Rather than dealing with life as it comes, drugs are used to manage and change feelings.

Successful, Proactive Recovery from AddictionLasting recovery requires a combination of two actions: first, creating a life where it is easier not to use (e.g. less stress, less conflict) and secondly, effectively managing the emotions (e.g. anger, sadness, low self-esteem) that motivate the desire to use.  Change has to happen inside and outside.  One of the popular slogans for recovery is that “nothing changes if nothing changes.”

The greatest problem with Medication-Assisted Treatment (MAT) using Methadone, Suboxone, and Naltrexone, is that they become substitutes for the work of recovery.  While an individual is taking the medication they may not be abusing other drugs, but their commitment to the actions necessary for recovery is seldom more than luke-warm. Intensive counseling, attending meetings, getting a sponsor, building a support network – any of the steps that may be necessary to change one’s life and live it better – can be set aside.

All of the major organizations that advocate for drug and alcohol addiction (ASAM, SAMHSA, NIDA) emphasize the importance of counseling and other support services for lasting recovery.  In fact, when the FDA first approved Suboxone in 2002, it was suggested that it should be used for only a short time to reduce cravings while the individual participated in intensive outpatient activities.  What we see today, however, is people being on Suboxone and Methadone for years, with minimal or no recovery treatment.

Research does not provide encouraging results for people who seek lasting recovery through the use of medications.  Studies show that a large majority (70% – 90%) of the people using Suboxone and Methadone relapse very quickly after discontinuing the medication1. While the FDA has always advocated psychosocial treatment for those using these medications, most programs are weak, and fall far short of the intensive treatment that has proven successful in addiction recovery2.

Several government sponsored studies suggest that the use of medications to treat addiction should be seen as resignation that recovery is not possible, and the medications should be taken for the remainder of a person’s life3. This judgment implies that recovery is too hard, too much work, or the individual too damaged – and the effort to learn how to live life differently should be abandoned.  I concede that there are chronic relapsers, with little motivation, who may find a lifetime of medication as the only way to stay alive.  But surely this approach to treatment must be the last resort for the addicted person, when all other efforts have failed.

Every day I hear from graduates of our program who are living clean, happy lives, free from the bondage of addiction.  I believe they show us the preferred path forward.  We need to help people break free of dependence on drugs and discover all that life has to offer.  There are no medications that provide an effective substitute.

 

Notes:

1.Weiss, R.D., Potter, J.S., Fiellin, D.A., Byrne, M., Connery, H.S., Dickinson, W., Gardin, J., Griffin, M.L., Gourevitch, M.N., Haller, D.L., Hasson, A.L., Huang, Z., Jacobs, P., Kosinski, A.S., Lindblad, R., McCance-Katz, E.F., Provost, S.E., Selzer, .J, Somoza, E.C., Sonne, S.C., Ling, W. (2011). Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Arch Gen Psychiatry, Dec;68(12):1238-46.

2. The use of Naltrexone and Vivitrol in addiction treatment is relatively new and the available research is limited.  Vivitrol was approved for use in opiate treatment in 2012 and the high cost — $800 – $1200 per injection – has restricted trial.

3 – a.  Calsyn, D.A., Malcy, J.A., & Saxon, A.J. (2006). Slow tapering from methadone maintenance in a program encouraging indefinite maintenance [Electronic Version]. Journal of Substance Abuse Treatment. 30 (2), 159-163.

3-b.  Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 43.) Available at http://www.ncbi.nlm.nih.gov/books/NBK64164