Just What Is Resistance?
May31

Just What Is Resistance?

People in the mental health world use the word “resistance” a lot. In fact, they use it so much, and in so many different ways, that it’s hard to know what it means anymore. But there are places where the word is used in a precise manner, and that tells us something about what resistance is and how to use it. The places I’m speaking of aren’t in the mental health or addiction fields, but in the business world, specifically the world of Constraint Theory. I’ve written before about Goldratt’s Theory of Constraints and how it applies to addiction treatment, but here I want to focus on a more global perspective. I am going to focus on how people change and what makes them resist change. But first, I need to add a bit of a preface. I work every day with people who treat addiction and have trouble with their patients. In my discussions with counselors and doctors I use a question that seems counterintuitive to them at first. “Why would someone in their right minds act like that?” As you’ve probably guessed the most common answer is, “They aren’t in their right minds, that’s my point!” It’s the only answer I won’t allow. I have my reasons, but here are Goldratt’s. TOC says that everyone wants to do a good job, that people who have the same goal don’t disagree because they don’t want to work together, but because they have different assumptions about how to meet the goal. Just knowing that alone gives us a leg up. First we need to know do we have the same goal as the patient? If we do but they don’t agree on the plan, we know it isn’t because they want to live in misery or don’t like us; it’s because of a difference between our and their assumptions. So our first task is to get our goals aligned with the patient’s, and after that, to understand what the assumptions are on both our parts that explain why we don’t come up with the same plan. In TOC speak, this comes down to three questions: 1. What to change 2. What to change to 3. How to change In short, what TOC, and other logical systems, give us is a method of understanding disagreement and conflict as well as a method of resolving that conflict. So far, most of the addiction treatment field resolves conflict by saying, “We’re right; you’re wrong. Do it our way,” and wonder why things aren’t working out. So they see a lot of resistance. So would anyone with that attitude. So let’s consider the...

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The Real Question About Buprenorphine – Part II
May27

The Real Question About Buprenorphine – Part II

In Part I, I gave you the background on buprenorphine. You know why we ask each patient if their first opioid gave them energy. The question now is, “how does that help us know whom to give buprenorphine to?” So first, the data. We looked at the records of 1512 patients who we had data on for the question about their first opioid. We looked at their retention in treatment, the number of sessions attended and their discharge DAS score which I explain elsewhere. The 905 patients who got energy from their first opioid 644 (71%) took buprenorphine and 261 (29%) did not. They differed in the number of sessions they attended based on whether or not they received buprenorphine in their treatment. In fact they attended about 25% more sessions (24 vs 19; p<.0001) if they received buprenorphine during their treatment than if they didn’t. It’s no surprise then that they were 18% more likely to complete the program (p=0.0078). The question often comes up in conversations about buprenorphine that opponents feel that people don’t make as much psychosocial progress in treatment when on the medication. The idea here is that maybe the medication helps retain people but there isn’t much treatment going on. In measures of our DAS at discharge there was little difference between those who took buprenorphine and those who didn’t (p=NS), but if you want to push the point, the buprenorphine patients have a higher average DAS score than those who chose not to take the medication. But what about the 607 patients that said they did not get energy from their first opioid? Of the 607 patients who did not get energy from their first opioid 463 (76%) did not get buprenorphine during their treatment and 144 (24%) did. Remember opioid dependence is not defined by energy from first opioid, so some patients who didn’t get energy from their first opioid still met criteria for opioid dependence where buprenorphine is indicated. In these 607 patients there was no difference in completion, number of sessions retained or DAS score between those who got buprenorphine and those who didn’t. So it didn’t seem to hurt them, even though these are the patient who will likely be able to taper off the easiest. So it helped a lot in those patients who were different before their first opioid and didn’t have long range benefits in those who weren’t. If you’ve been doing this for a while, you’re probably angry right now that I published this, because now patients will read it and tell you they got energy from their first opioid just to get buprenorphine. Don’t worry. First, the...

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Now For Something Completely Different
May17

Now For Something Completely Different

I’ve been reading Eliyahu Goldratt’s The Goal, and you may be wondering why an addiction medicine doctor would read a book about manufacturing processes and constraint theory. Well, the answer is that it isn’t really a book about manufacturing and Goldratt really isn’t a trained manufacturing process expert. He’s a physicist, and it’s a book about how the universe works. If Goldratt has it right about manufacturing, we’d have a lot to learn about how to treat addiction. “But what could anything that applied to an assembly line have to do with something as personal and experiential as addiction treatment,” you ask? Well, I’ll tell you. It’s not that different. Manufacturers have a goal, to make money; we have a goal, to make recovering people. They have inputs to the process, raw materials; we have inputs to the process, people with addiction who are not yet in recovery. They have demand for a product, whatever it is they make; we have demand for a product, recovery. They have a linear set of steps, an assembly line; we have a linear set of steps, moving a patient from active addiction to recovery one cognition at a time. And right there is where I’ll probably lose you. “No way is my treatment as linear as an assembly line. There’s no way what I do can be reduced to a manufacturing process. What I do is experiential; the person changes. And it’s not linear.” Okay, that’s how we experience it. And probably how the patient experiences it also, but let’s take a closer look. Let’s say you have a patient who comes to treatment because someone has forced him to come. He doesn’t believe he has any problems much less a problem with his using. His problems are all other people: his wife, his boss, the judge, you. I’m sure you’ve heard this story. Now, consider something you sometimes say to patients at some point in treatment. It might be something like, “People in recovery find that helping others feels good.” Or it might be something like, “Many people find they enjoy an enhanced spiritual life once sober and open to the change.” I have no idea what you say, but there will be some statement somewhere like that, that you would obviously not say to this guy. It would sail right over his head, and be a waste of breath. Worse, he might get bored or offended and see treatment as useless and leave. The problem is that this guy isn’t today who he needs to be to profit from some statement you have that you usually use on someone later in treatment. So...

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The Truth About Cutting Drug Use Rates
Feb22

The Truth About Cutting Drug Use Rates

A recent article on truth-out.org has an interesting title, “Portugal Cut Addiction Rates in Half by Connecting Drug Addicts With Communities Instead of Jailing Them.” It’s a good read, and has some enlightening points to make, but there are some things I’d like to comment on as well. First, let me hit the positive parts. The article makes a strong case against the efficacy of the “war on drugs,” and the underlying concept that drugs are the pure cause of addiction. Also the article unknowingly points out, the increase in dopamine receptors that comes with social connection and the consequent increase in dopamine tone and decrease in symptoms. In fact, what the article points out is that fully half of the drug users in the Portugal experience stopped showing signs of addiction as defined in an academic study based on DSM criteria. That’s better than any social or legal policy action we’ve had in America. But there are some problems with the article as well. First is the false dichotomization of addiction as either a moral problem or an “illness” caused by drugs. While it is possible for someone to get the requisite damage to cause addiction from using drugs, it is far more likely that it is addiction that causes someone to use. Addiction as a disease is primary; that is, it requires no cause. You can have it when you are born. The symptoms are there, the attachment to rewarding stimulation is there, the rest of the pathology is there before the first drug. What happens first is that we get pathologically attached to various environmental sources of increased dopamine tone and over the years as they no longer work anymore we find bigger sources and get pathologically attached to those. So the idea of addiction as a drug problem is like looking at the part of the iceberg above the water and thinking you understand the whole. It’s not even the biggest part of the problem. What the article leaves out is that people can have addiction before their first drug as a true illness, not something that results from voluntary behavior. That leads me to the part about opioids. First, your doctor and hospital do not give you heroin for pain. It is true that Bayer pharmaceuticals created heroin as a pain medication, but after practicing medicine for 30 years, I have yet to see a single physician write a single order for heroin. In fact, it’s impossible to see one because the DEA schedules heroin as a schedule one substance, meaning that there is no acceptable medical use. The other problem with this article in understanding...

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Abstinent From What?
Feb15

Abstinent From What?

A recent conversation with colleagues has raised the issue for me of what we mean when we say a person is abstinent. What are we saying they are abstinent from? One colleague said that a person on a regularly taken medication that acts at the opioid receptor couldn’t be considered abstinent because he/she is “using an opioid.” Given that buprenorphine, the medication in question, causes the tonic release of dopamine from the Ventral Tegmental Area the same way as the medicine varenicline, a partial nicotine receptor agonist, does made me wonder. Is person with addiction who used to use opioids and is now taking varenicline abstinent? They aren’t taking something active at their opioid receptor, but they are taking something that acts the same way as if they were. What about someone who used to use cocaine? If they are taking bupropion which blocks the dopamine re-uptake pump, are they abstinent? Cocaine blocks the dopamine re-uptake pump, so the chemicals work the same way, but one’s considered a drug and one’s considered an anti-depressant. Can we really tell if a person is abstinent or not from what medication he’s taking, or does it have more to do with how he’s taking it? Let’s take nicotine for instance. I know lots of people with addiction who consider themselves abstinent but who smoke. They say they are abstinent because they no longer use the drug that got them in trouble. Not only do they use nicotine, but also they use it when they want it, how they want it, as much as they want it, as opposed to a routine medication that they’d take when they were told to. Is someone abstinent who uses a drug that releases spikes of dopamine at the Nucleus Accumbens? Are they more abstinent than a person who is taking, as directed, a long acting medication that raises dopamine in a tonic fashion? I just can’t see it. Let’s take a lesson from a 12-step program that has nothing to do with drugs, Overeaters Anonymous. In OA, “abstinence is the action of refraining from compulsive overeating.” That’s really interesting. Abstinence is an action, not inaction. Abstinence is a decision to refrain from compulsive eating, not all eating. Abstinence is an act of surrender that is part of a larger recovery based on accepting the world the way it is and growing from there. In OA, abstinence is not “just not overeating.” I think we all have a lot to learn from that. So if we open up the question, what do we ask people to be abstinent from in addiction recovery? It could be the drug that got them in trouble....

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Just Sharing
Jan27

Just Sharing

A patient of ours recently wrote a letter to her treatment team. I wanted to share with you what she wrote to her doctor: “Dr. X – Thank you so much for allowing me to be honest. The first experience with a doctor where I didn’t have to lie/cover up my illness lest I be judged and written off. I am grateful for your knowledge and experience in helping people like me. I know it can’t be easy, but please know how grateful I am that you chose to help ‘us.'” This particular patient had her first substance use at age 13. Before that she already had some symptoms of primary low dopamine tone: relative anhedonia, irritability, and trouble forming attachments to others. Also before the patient’s first drug use, she engaged in the following dopamine raising behaviors in order to feel better: manipulating others to like her, showing off, getting involved in relationships, making others feel good, dangerous behaviors, getting a hard job done, academic achievement, and power over others. Before she came to us she saw a general psychiatrist and made several attempts to stay off drugs without medication, which were never successful. This patient had told her psychiatrist that the only thing that works for her to feel normal is “pain medicine.” Rather than see that as a biological finding and diagnosing addiction, the doctor said she had depression, anxiety and ADHD and placed her on an SSRI, a benzodiazepine and an amphetamine. Now before you think I’m bashing general psychiatrists, I am one, and so is the doctor she wrote this letter to. The difference is that we have learned what addiction is from our patients and from scientists. We’re willing to accept that addiction is an illness. We’re not ashamed of people that have addiction; it’s just an illness. We understand that addiction isn’t wanting or using drugs, but rather addiction is the neurobiology that causes the symptoms that make the patient want to use drugs. Dr X was able to derive from her history how she could best be helped and got her on medication to suppress her symptoms. She’s several months out from her 7 weeks in intensive outpatient treatment and doing well, with full adherence to the care plan. She’s going to 5 meetings a week, has a sponsor, and is working step 9. I write a lot here about data and groups and outcomes, but every once in a while, it’s good to write about an individual patient to remind us why we’re...

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