Rural Addiction
Sep27

Rural Addiction

If you haven’t heard, there’s an epidemic of opioid overdose deaths in America. The US Centers for Disease Control (CDC) said of 2013 that 44 Americans died every day that year from overdoses on prescription pain meds. That’s a lot of preventable deaths. In fact, accidental overdose (poisoning in CDC lingo) has become the leading cause of accidental death, outpacing automobile accidents. As is obvious to all, a large percentage of those deaths by opioid overdose are in people who have addiction. There are two approved medical treatment strategies of addiction involving opioids: agonists and antagonists. Antagonists are chemicals that block the opioid receptor making it impossible for a taken opioid to have an effect. Of course, most people with addiction involving opioids don’t see antagonists as a useful strategy and so they did not take off in popularity until the once-a-month injectable form became available a few years ago. Antagonist treatment is freely available with no limits on prescription, but the once-a-month injection is still an expensive route. In addition, there are two types of agonist treatment: full agonists and partial agonists. Full agonists, such as methadone, are available only in special clinics which require daily attendance, and have evidenced a number of social problems that stem from their facility of congregating an ill population in a single location at a particular time. These problems have led some states to ban or severely limit such clinics. Such states, like North Dakota, South Dakota, West Virginia, Vermont, and New Hampshire, are oddly among those most greatly hit by the opioid epidemic. Such states and the rest of the country could turn to partial agonist treatment for the last decade or so, allowing those requiring treatment to be seen in their own doctor’s office and avoiding the “not in my backyard” worries seen with methadone clinics. It was the hope of the federal government, that by allowing buprenorphine partial agonist treatment in doctor’s offices, we would see the expansion of addiction treatment and the integration of it with primary healthcare. That hope has not come to fruition for at least two reasons. First, partial agonist treatment has been  limited by the number of patients that each willing doctor can treat. That would have worked if the expansion into primary care had worked. The idea was that most doctors in the country would be treating addiction the same as they did anything else, so there was no reason why anyone would need to treat more than 100 patients. This has not proved to be the case, as evidenced by the expansion of the opioid overdose epidemic in the same time without a great increase in the capacity for addiction treatment. Not only have the number of doctors seeking...

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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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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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“AA Conflicts with my Religion”
Apr05

“AA Conflicts with my Religion”

“AA conflicts with my religion.” My colleagues and I with hear this often when we suggest to patients that they go to meetings, get a sponsor, and work the steps. It may sound odd to most who were expecting the more common complaint that Alcoholics Anonymous doesn’t work with atheists. In my experience, religion or the lack of it doesn’t matter, so I thought I’d write this to clarify my thinking on the subject. We hear from people without religion that AA is too much like religion, and we hear from people with religion that AA conflicts with their particular brand. On the surface, it would be fair to guess, as a first approximation, that both of these positions are defenses and excuses not to try a 12-step approach. But let’s look a little deeper. AA, as an organization, has no interest in anything but helping others quit drinking. It doesn’t care about the larger issue of addiction; it doesn’t care if you go to church (or temple, mosque, synagogue, etc); it doesn’t care if you’re on medication (that’s another blog); it doesn’t care where you live, what color you are, how many limbs you have or anything else that has nothing to do with stopping drinking using the 12 steps. “But,” exclaim those that don’t believe in a higher power, “AA requires you to have a higher power that they call God. I don’t believe in God, so AA won’t work for me.” Okay, if you just read the words of the 12 steps, you have a point, but what’s more important is to understand what those words mean. Let’s take the words of step 3, “Made a decision to turn our will and our lives over to the care of God as we understood Him.” Well, if you’re an atheist, you’re probably having a problem with that, but please see that the underlying spiritual sentiment is being expressed in the only words the people who wrote this had. Those were words common in America of the 1930s. You don’t have to understand God as they understood him. The step does not say, “Made a decision to turn our will and our lives over to the care of God as you understand him.” What if you understand Him to not be a him at all? No sweat. No one cares. The only qualification for a higher power is not yourself. That’s it. The point of the step is to quit running the show, and by running the show I mean running it into the ground. If our best decisions keep digging the hole deeper and deeper, the thing to do is drop the...

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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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Mardi Gras and Addiction
Feb05

Mardi Gras and Addiction

It happens every year: Mardi Gras rolls around and peoples’ perspective of addiction changes. For those of you who don’t live in the former French colony of La Nouvelle Orleans, a little bit of background is necessary. Carnival isn’t a day; it’s a season. It begins on Twelfth Night (Jan 6) and ends on Mardi Gras Day (47 days before Easter). As a joyful celebration of a spring to come, its origins go back beyond Christianity but the traditions of the Catholic Church rule its incarnation here. During Carnival in New Orleans, one eats king cake and goes to parties. Work is a little lighter, parties are more important, and there’s a general loosening of the social contract. All just practice for the big day. In my line of work, it looks a little different. Admissions to treatment go down between Christmas and Mardi Gras (“Who wants to get sober during Mardi Gras?”), and people leaving recovery and going back to active using goes up. It becomes just a little bit harder to talk to someone about not picking up when they see their social contacts picking up “with impunity.” So what’s an addiction treater to do? It helps to go back to what Mardi Gras really is, not the excuse for a party, but the spiritual holiday season. There are a lot of traditions of Mardi Gras that can actually be used to strengthen recovery rather than risk active addiction. First, there is the day itself. In the old days, servants would dress as kings and rich men as paupers. Hierarchy was abolished except for the make believe king and queen of carnival, and those could go to anybody (in the old days). Abolishing hierarchy is good for recovery. Leveling the playing field is good for us all. No one gets recovery because of what he or she has accomplished professionally or because of how much money they have. We all get the same recovery. So in recovery, every day is Mardi Gras, why make this time any different? Related to this is the masking. I don’t mean that recovering people wear masks like those who celebrate on Mardi Gras do, but rather that we have anonymity. Hopefully, we’re taking off our outside masks at meetings and when we speak about recovery to other recovering people, but whether you’re putting on a mask on to be anonymous or taking one off to be anonymous, the purpose is the same. On Mardi Gras day in New Orleans, everyone is anonymous. Do you use your anonymity to do something you don’t think is right and get away with it, or do you use it to help others?...

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