ABUSE AND ADDICTION
revised 5/2012, 10/2014, minor revisions/editing 8/2015 and 9/2017
[see also posts on abuse-addiction in Blog]
Added 2023. Not adequately considered, important aspects of abuse-addiction and addiction prevention
Preface and introductory remarks; opiate/opioid overdose epidemic
Prevention and Treatment – Counseling Issues, Summary [added 11/2018]
Abuse-Addiction, Related Terms, Definitions and Conceptualization
Abuse: Consideration of Biology of Human Behavior and Ethics
Addiction as Disease or Mental Disorder
Addiction and Psychiatric Disorders – Anorexia Nervosa
TMTA/USAOTP Presentation 8/2015 and opinion article to Austin American Statesman 1/2019
Added 2023 Not adequately considered, important aspects of abuse-addiction and addiction prevention:
Abuse is basically a failure of ethics: abuse means ‘bad use.’ Ethically, we must be compassionate without us-versus-them thinking. Ethical decision-making includes to only take risks when it is very meaningful, because bad outcomes affect many people. It is a major risk to take a drug one does not know exactly, or to drink legal alcohol when one has no clear knowledge how much one is at risk of developing quickly a use disorder (alcohol clouds one’s judgment in small dosages). Young people have difficulties to recognize risks quantitatively, 1:1,000 is generally an unacceptable risk unless the risk-taking is extremely meaningful – however, young people rarely have to deal with the conflict of something very meaningful including major risks. Children should learn early – halt and think when something may be dangerous; don’t play with a car in the garage, put pills into your mouth when not ordered by a parent or medical professional, etc.
Unethical thoughts are dangerous and often acted out under extraneous circumstances, when extremly stressed and tired, intoxicate, in war zones or other law-less environments, and when suicidal. Young people must learn to distract themselves immediately, maybe meditate, when drawn to enjoy unethical thoughts in some morbid ways.
Hopefully, our society will soon do better in dealing with young people’s conflicts, their learning to accept and process abuse experiences and other trauma. They need proper treatment, not be introduced to abuse behaviors when most distraught and vulnerable.
Humans have the ability to hold multiple ‘realities’ and ‘morals,’ accepting what elders and peers do as acceptable, moral, and ‘working’ even when realities have changed and ethics demands that we change course. In the history of medicine, incredible cruelties were perpetrated by professionals as “what is needed and best” and scientific observations were often ignored, with professionals believing whatever they earlier learned. Today, the whole world appears to rapidly move towards disaster because almost everybody thinks “business-as-usual with incentives and some adjustments” is o.k., moral, ‘the best we can do.’ Many civilizations collapsed due to these false ‘realities.’ For some, religion is a false ‘reality’ – prayers do not correct our blunders, halt global warming, etc. Abuse thinking typically becomes a false ‘reality’ – we do not need cigarettes, chocolate, alcohol, etc. to quell frustration, despair, pain, etc. It is a false ‘reality’ that the addict has to, normally and justifiably will, break cultural rules, steal from parents and strangers, etc. because he/she needs the relief – real life is full of discomfort, frustrations and pain; in fact, extreme pain is the most real thing in life.
Also: the worst addictions hardly are substance abuse, they include addictive consumerism, conspiracy theorizing, and the pursuit of wealth and power. They also include pursuing unethical phantasies which people may act out in extraneous circumstances (extremely stressed and tired, intoxicated, in war zones or other law-less places, and when suicidal).
Abuse-behaviors are extremely contagious. Distraught, vulnerable young people may find a new ‘reality’ in the behavior patterns of addicted peers they meet. Treating one addict may save many.
Summary of recent developments in the USA – the dramatic increase in opioid abuse-addiction (added 2017):
Annual overdose death rates (ODdr) in the USA:
Around 1999, ODdr for heroin was about 2,000 and a few thousand for opioid pain medications.
Until 2008, heroin ODdr remained stable, but pain med. ODdr rose to about 8,000.
Since then, heroin ODdr rose to > 15,000 and opioid pain med. ODdr rose to >37,000 (2016).
Disclaimer: There is incredible incongruity between sources reporting drug OD deaths (opioids, benzodiazepines, and other); often there are obvious mathematic mistakes in reports which editors seemed to miss. Most articles understate numbers and particularly the rise in death rates.
Compared with the U.S., the ODdr in the European Union appear to be less than 1/10; it has hardly risen since 2000 even though the worldwide production of heroin multiplied since 2002 (overthrow of Taliban in Afghanistan). The ODdr of Portugal is about 1/30.
Is over-prescribing opioids the main cause? Dentists and doctors ‘over-prescribed’ opioids at least since the 1970s – addicts have long known to look in people’s medicine cabinets for left-over, not used addicting medications.
Around 1990, a ‘right to treatment of paint’ was promoted: Having to frequently ask patients about pain on scale of 1-10 (as additional ‘vital sign’) led health professionals to suggest that patients have major chronic pain – thus doctors and patients expected that more Rx opioids are needed for ‘comfort’ and ‘normal’ life. TV adds for opioid medications added to the problem.
Curbing access to pain medication prescriptions drove pain-addiction patients to heroin.
DEA’s successes led to ever more dangerous drugs being introduced.
Detoxifications in hospital and jails rarely lead to lasting sobriety, cause OD deaths and destroy lives: patients often do worse after detox, often losing family, jobs and hope.
Detox-rehab facilities rarely obtain required informed consent to treatment(explaining prognosis, dangers of treatment, alternative [safer] treatments); medical staff hardy ever informs referring agency or family, or refers patient to structured medication assisted treatment (MAT), i.e. methadone or buprenorphine maintenance.
Non-treatment and ineffective treatments of abusers and addicts is main reason for the continuous contagion.
There has been hardly a positive change in approaches: it is “business as usual” with most patients having no access to MAT, particularly methadone maintenance treatment, the ‘gold standard’. Buprenorphine (Subutex, Suboxone) is too weak for many patients and unstructured prescribing helps only a limited number of patients. MAT providers rarely address psychiatric problems adequately. The introduction of long-acting naltrexone (Vivitrol) is hardly worthwhile – it has been tried before.
Methadone treatment without counseling (as in ‘interim maintnenace’ for patients on waiting list) is comparitively effective as ‘comprehensive’ OTP treatment.
Present prevention efforts have hardly been effective in addressing vulnerability of many people, contagion, etc.
The studies indicating that buprenorphine and methadone have essentially equal effectiveness do not correspond with experience: studies have admissions biases, by who choses to particpate and by exclusion criteria that are used in studies. Different studies show a significantly higher drop-out rate with buprenorphine, including in double-blind studies
There is still little agreement as to what abuse, dependence and addiction mean, much less how they should be prevented and treated. The over 75 years old 12-step approach (AA/NA), a spirituality or religion-based treatment adjunct, dominates the field and is often considered the principal treatment (‘Detox-Rehab’ model). In addition, there has been a trend towards short-term treatments, driven by high costs that are partly due to unreasonable licensing and accreditation requirements (hospital intensity rather than low-cost residential), by insurance companies’ limitations and by the insistence that treatment be ‘least restrictive.’ Treatment cannot be compressed; the human mind needs time to solidify change, even though, in certain circumstances, addiction behaviors may stop abruptly without long-term treatment. Much valuable experience has been gained, utilizing many treatment approaches, but most treatment institutions adhere to an inflexible and expensive treatment model.
This article includes personal experience and relevant anecdotal evidence regarding treatment of addicti.on-multiple diagnosis patients. Physicians have been persuaded that “evidence based” treatments, following what is demonstrated in prospective double-blind studies, is equivalent to good treatment. We tend to forget that many studies are misleading, very limited in scope and/or poorly designed. Rigorous studies are most important in showing what does not work, where placebo does as well as a traditional treatment or a new treatment that looks promising in uncontrolled or retrospective studies. However, most progress in medicine and the psychological treatments result from clinicians’ or researchers’ keen observations and intuition. [compare progress in obstetrics: The New Yorker, 10/9/2006, Annals of Medicine, “The Score – How childbirth went industrial” by Atul Gawande; and observations and work of Peter D. Kramer, MD]
Regarding the opiate/opioid overdose epidemic:
The opioid (pain pill) abuse and overdose epidemic in the USA is a direct consequence of an irresponsible attitude towards pain and pain management and governments’ refusal to properly treat the addicts that pass on the disorder to vulnerable people. Cheap commonsense preventive measures are needed:
– Rather than injectable or nasal short-acting naloxone, CDC, CSAT and state health departments should issue over-the-counter sublingual naltrexone (at least the old Trexan formulation was rapidly absorbed sublingually, a few mg powerfully antagonizes significant levels of opioids (except buprenorphine); naltrexone’s half-life is adequate to treat overdoses of methadone and other long-acting opioids without the need of subsequent dosages every few hours.
– FDA, CDC, CSAT and DEA should order that all pain medications must be dispensed in small dosages; if somebody needs 80mg of Oxycontin or 40mg of methadone, he/she should take 8 tablets.
– FDA, CDC, CSAT and DEA should order that dangerous medication tablets or capsules are individually packaged so that it is not possible to quickly pour large quantities out of a bottle.
– Patients or approved patient representatives who pick up dangerous medications from the pharmacy must carry and store medications in a locked metal box or cash bag, and be informed that these mediations must never be stored in bath rooms or refrigerators.
– Most important drug information must be clear, written in normal seize print in very basic English and Spanish; the information sheet is to be kept in the locked container that contains the medication: the owner of the medication or caretaker of the patient has a responsibility to third persons (compare: a pool owner has a responsibility towards children who are attracted to the water and may drown). Drug information must clearly state if a drug has slow onset of action and is very long-acting, specifically how late drug effect starts, how late overdose symptoms may appear (e.g. highest blood level after several hours), and approximate duration of action, e.g. over 12-24[-48] hours in methadone, time-release opioid preparations and buprenorphine.
– Pain patients must be educated regarding danger of misuse (inappropriate self-medication for minor pain, as muscle relaxant or to relieve anxiety), and abuse-addiction (frequent or regular use ‘to feel better’).
– Patients must be taught that for most forms of discomfort and pain, they should not use any medications. The more frequently over-the-counter medications are used, the less effective they are and the more likel they have toxic effects. Most forms of discomfort should be dealt with by focused activities that distract and/or by specific forms of meditation with self-suggestions or self-hypnotic techniques.
– Patients must also be educated that benefits of opioids in chronic pain are temporary. As the mind learns to ‘tune pain perception down’, opioids become less important and eventually have a paradoxical effect, rather aggravating normal pain sensations. Going for a walk often alleviates headaches, many simple exercises help with most musculo-skeletal pains (e.g. exercises described by Miranda Esmonde-White).
– Patients who cannot responsibly handle pain medications and/or who show early signs of misuse-abuse must be treated at an opioid treatment program (OTP, regulated federally and by states).
– SAMHSA/CSAT, CDC, DEA, state health departments and other involved agencies must respond to the public heath needs:
– A major extension of accessibility of OTPs, including small OTPs (local physicians’ clinics administering and dispensing methadone) accessible in all counties, and a broadening of OTP psychological-psychiatric services is needed and feasible.
– All addicts should have ready access to OTPs: the untreated addicts spread the addiction disorder; opioid addiction is a contagious disorder.
– All addiction professionals, other health care providers, and a people working in human services and legal and law enforcement agencies must be educated that detoxification of opiate addicts is usually contraindicated and dangerous.
– Drug abuse prevention in schools must be improved.
– Ready access to more appropriate treatments for other addictions is needed.
– The lack of treatment of USA’s addicts is the primary reason for the catastrophic violence in Mexico and other Latin-American countries – the USA creates the market and its addicted citizens pay the cartels; the USA, with its insane gun laws, also provides the weapons. The drug-related terrorism in Latin America is much worse than the terrorism we are trying to fight in foreign wars and by federal agencies’ spying and infringing on civil liberties.
– Federal and state agencies’ success in decreasing access to pain mediations through unethical providers (and in 2014 reclassifying hydrocodone products as CII drugs) has been counterproductive; it has driven addicts into the heroin market, particularly because, when pain clinics have been closed, patients were/are not referred to opioid treatment programs. (It would be more helpful to offer U.S. heroin dealers access to morphine tablets to sell in place of heroin that has to be purchased from drug cartels.)
A few general points are relevant when addressing abuse behaviors, abuse disorders and addiction disorders:
– A commonsense approach is needed. However it must rely on a thorough understanding of human nature and it must consider our cultures and scientific insights derived from many fields of research.
– Forms and causes of addictions differ greatly in many regards. Treatments must correspond with the characteristics of addiction-multiple diagnosis patients.
– Factors leading to vulnerability towards addiction may need to be addressed simultaneously or even before treatment of the abuse-addiction disorder, specific psychotherapeutic techniques and medications may be indicated. Examples of predisposing factors: major depression, posttraumatic stress disorder, attention deficit symptoms and generally poor stress management skills with frequent intense anxiety, social isolation and indebtedness.
Being in debt and particularly high interests lead to a discounting of one’s future and depression, and to increased crime rates and suicidality; our economic system, which expanded the money supply largely by extended lending, contributes to the social ills.
– To reduce pathological stress, our culture needs to address people’s acceptance of realities, past, present and anticipated future. People must free themselves from deceiving childhood teachings about supposed opportunities, good things happening to good children and illnesses or abuse being a result of being ‘bad’, expected justice, supposed benefits of positive thinking. Instead people should focus on benefits of meaningful hard work and perseverance without necessarily reaching goals. People should also save, avoiding debt, not seek good credit ratings.
People should practice healthy lifestyles; people may combine cognitive stress management approaches with meditation and self-suggestive techniques, etc. People may need to develop resilience, strengthen interpersonal bonds, find meaningful pursuits, practice approaches derived from happiness research, etc. Abuse-addiction disorder patients may need to develop a personal culture that is more developed than their family culture and/or culture at large.
– Abuse, by definition, is unethical. Patients must learn: abuse ‘cheats’ the emotions-behavioral system; frequently feeling good for no good reason greatly delays emotional development (“permanent adolescence”). Our culture needs to address ethics, particularly avoiding us-versus-them thinking, broadening empathy with a forgiving attitude, avoiding unethical thoughts and fantasies, and resisting the natural fascination with suffering, cruelties and all forms of violence. Grossly unethical behaviors and abuse behaviors should become ‘taboo,’ meaning too shame and guilt inducing or disgusting for thoughts to be enjoyable. An early focus on ethics and meaning in life is likely to greatly decrease young people’s propensity to addiction.
– Treatment professionals and our culture at large must reevaluate our attitude and approaches to pain.
– Widespread addiction must be recognized as a failure of our culture.
– In treatment and in prevention efforts, ethics is most important: young people and addiction patients must learn about the importance of developing a personal culture that is based on ethics [3.4 Natural Ethics]
Summary: Paradigms used in the study of substance abuse are problematic.
Abuse-addiction disorders, including substance use disorders, should be conceptualized as psychological disorders defined by a [learned] pattern of self-reinforcing unethical, harmful behaviors, with powerful associated feelings, thoughts and behaviors, and distorted priorities; they are usually associated with other psychiatric disorders. A simple description or definition of addiction is an abuse pattern that has become a first priority that continuously competes with priorities such as being a good worker, a good parent, a good person within one’s society, etc. There are biological correlates and predispositions, but these do not constitute the disorder.
For political reasons, when writing the Diagnostic Statistical Manual III and IV, the DSM committee called “addictions” “dependence”, which led to much confusion. The term dependence usually refers to the physiological adaptation to certain substances, many of which are not addicting. The DSM 5 moved to gradual severity criteria of substance use disorders rather ran recognizing that there are steps where the pathology changes with few people remaining in an ‘in-between’ stage. The ‘impaired control’ or ‘using more than planned’ criteria miss that patient usually misjudged a drug’s effects, e.g. for pain control, to deal with frustration or to get ‘high,’ and that many patients falsely assume that their problems will soon resolve. ‘Risky use’ criteria miss that, if something is emotionally important, animals and people always accept major risks, often staying in ‘denial.’ Tolerance applies to almost everything since biological responses always adapt (an exception is severe toxicity). Withdrawal symptoms are not good criteria and may be largely psychological (missing something good and expecting to feel bad) or physiological problems adjusting; placebo effects are very powerful in creating or suppressing withdrawal symptoms.
There are major problems in how abuse behaviors, abuse disorders and ‘substance dependence’ have been defined and conceptualized. Health professionals, politicians and lawyers broadly misunderstand substance use disorders and other addictions. Clinical implications of misconceptions are pertinent for both treatment and prevention approaches.
Abuse-addiction disorders are not ‘genetic,’ however some protective and vulnerability factors are (vulnerability factors include a propensity to severe depression, male-type risk taking and ‘lost sheep syndrome’). Addiction is not a disease with damage to brain tissues, it is, as many psychiatric disorders, the result of pathological learning. Addiction behaviors are generally not ‘compulsive’ (e.g. responding to fears of contamination, having sinned or having forgotten something important); abuse behaviors are mostly driven by a visceral sense that the behavior is ‘right’ and expectation of good feelings.
Different drugs have different effects, and correspondingly, self-medication of psychological-psychiatric symptoms is often associated with specific drug abuse patterns.
Drug abuse behaviors mimic following instincts, they may be understood as artificial instincts.
As in instincts, after the abuse behavior, there is a gradually increasing but inhibited internal readiness to repeat the behavior. First only highly specific and later less defined triggers in the environment lower the inhibition and lead to the execution of the abuse behavior. Appetence behavior, seemingly aimless looking for triggers, may, depending on environmental triggers, lead to one or another instinctive or substance abuse behavior, e.g. a bored person may think about chocolate but find cigarettes instead, or vice versa.
The drugs “cheat” the emotional-behavioral system, rewarding the drug use in a way similar or identical to the fulfillment of specific instincts: benzodiazepine give pleasant feeling as if having solved conflicts; opioids give warm feelings as if unexpectedly finding self loved and nurtured; psychostimulants mimic anticipatory excitement and surge of strength when imminently expecting something great. Like instincts, enjoying abuse behaviors, actual or vicariously in fantasies and memories, strengthens them; frustrating any thoughts and impulses towards the behaviors weakens them.
Abuse-addiction disorders are contagious. In people with psychological-psychiatric and/or inherent vulnerabilities, the propensity only becomes a disorder if certain environmental factors coincide. In a propensity towards substance abuse disorders, the critical influence is contact with untreated abuse-addiction patients. Anxious teenagers may be vulnerable to alcohol, nicotine, marijuana and medication abuse but they would hardly invent the substance use behavior. Addicts teach vulnerable people self-injecting. Ready access to effective treatment of abuse-addiction disorders is the best prevention. In addition, cultures must improve environments and institutions: young people should always be meaningfully engaged, learning and developing a personal culture; and many need access to psychotherapy and psychiatric treatment addressing mood and anxiety disorders.
Structured, regular use of addicting drugs, as in heroin maintenance treatment (Switzerland and other European countries), hardly leads to unethical behaviors and allows reasonably good functioning. A most problematic aspect of abuse behaviors is the irregular use, using when feeling bored or otherwise bad, thus rewarding both, bad feelings and abuse behavior.
Addicting substances vary greatly in their adverse effects, and different addictions need different treatment approaches. AA (Alcoholics Anonymous) is based on a model of addiction that has limited validity but often gives patients valuable support and a social network. AA works fairly well for many alcoholics, particularly males who are in denial regarding their loss of control; but NA (Narcotics Anonymous) generally has very limited benefits for most opioid and other drug addicts. Opioid/opiate addiction treatment should usually include structured methadone or buprenorphine maintenance for at least 1 1/2 years. Methadone maintenance treatment is not a continuation of the addiction and, in proper dosage, allows normal functioning with decreased craving for opioids, alcohol and other drugs. Opiate detoxification has a poor prognosis, and it is expensive and dangerous (high risk of relapse and overdose and/or psychiatric decompensation). Many addicts would benefit from highly structured, low-cost, long-term residential treatment, which is rarely available.
Drugs do not directly lead to unethical behaviors, but unethical people tend to use alcohol and/or illicit drugs. Unethical behaviors, committed while under the influence of a drug, were previously thought about and vicariously enjoyed. Alcohol then makes it easier to act out unethical fantasies. Psychostimulants may worsen risk taking and violent impulses. Most problematic are distortions of priorities, often leading to unethical decisions, particularly crimes of negligence, and distorted thinking (rationalizing drug use) may aggravate weaknesses in ethical values (examples: confusion regarding sex in a drug user’s personal culture may lead to prostitution and exploitative or otherwise unethical sex, or lax values concerning property may lead to theft). Some drugs may lead to erratic and even psychotic thought processes, perceptual disturbances and consequently to accidents; others (e.g. opioids) may decrease propensity to psychotic reactions.
Abuse prevention and treatment should emphasize ethics because
1. Abuse is, by definition, unethical; trying to rationalize abuse means seeking to justify unethical behaviors.
2. Abuse is self-rewarding and it rewards and reinforces what led to the abuse, including discomfort, incompetence and/or unethical thoughts, feelings and behaviors (the abuse reinforces everything closely associated with it).
3. Abuse-addiction patterns slow or prevent emotional growth.
4. If patients vicariously enjoy unethical acts, the enjoyment of such fantasies may become a psychological addiction; if lapsing into substance abuse, particularly alcohol, patients may act out the unethical fantasies.
5. Humans inherently want to be ‘good’ or ‘right’ and there are also instinctive inclinations towards ethical thinking; however, there are often major conflicts regarding individuals’ priorities (there are always conflicts between any two individuals), and there are instincts and cultural principles that encourage unethical behaviors. Abuse prevention must be within the context of education directing people to seek meaning in ethical inclinations while overcoming unethical propensities,
Addiction behaviors are in many ways immature with characteristics of adolescence. Drug addicts, as adolescents often vacillate between being self-centered versus caring and idealistic, inappropriately self-assured versus feeling very insecure, wanting to rebel against all aspects of culture and guidance (wanting to reinvent everything) versus wanting to learn from, even emulate, some idealized older person (sometimes also follow a foreign ancient culture’s wisdoms). Maturity reinforces the human propensity of wanting to be good and right, to avoid what is likely to be later regretted, to grow emotionally as a person, and to find meaning in one’s life’s pursuits.
Prevention and Treatment – Counseling Issues, Summary: Primary prevention: before abuse occurs; secondary prevention: preventing abuse from becoming an addiction; tertiary prevention: relapse prevention starting during MAT or residential treatment:
– Evaluate and treat psychiatric disorders, particularly trauma-related anxiety and mood disorders
– Psychosocial problems, particularly loneliness/isolation, existential crisis, lack of meaning in life
– Cognitive stress and pain management techniques
– Meditation (awareness, Autogenic Training), self-hypnotic techniques
Discussion issues – grouups and individual counseling:
Learning about human nature, the inherent human dilemmas and the importance of global and science-based ethics as they relate to addiction prevention and treatment:
– Very culture-bound (culture at large, family or group culture), always tending to return to old ways, and instinctively believe past was better (cultural ways and mandates are based on instincts that are modified and/or sublimated)
– Fearful, suspicion of novelty.
– Very docile, easily enslaved by culture and authority figures (unlike most animals, comparable to the domesticated animals we exploit – few animals respond to punishment)
Exception, people readily accept novelty that is imminently rewarding, enticing, addicting. Technological progress is largely addiction-driven (wealth and power, etc.); most real improvements are ‘spin-off’ or by-products.
[This is why progress of Homo sapiens and its ancestor humans/hominids was extremely slow; and since developments accelerated in the last few centuries, developments were largely misdirected.]
– Humans are extremely social primates, always oriented towards relationships within hierarchies and networks of attachments. Indirectly, meaning in life is always relating to others.
– In humans, social bonds within impersonal, larger groups are based on and strengthened by myths and legends concerning their origin, ancestors, spirit-like beings, ghosts, and gods. Humans appear predisposed to quasi-religious beliefs that seem to explain phenomena that are beyond the capacity of human understanding.
Humans are not rational. Decisions are emotion driven. The rational mind may recognize what is ‘bad’ but can only stop behaviors if able to mobilize more powerful emotions. Emotions are basically instincts and instinct-derived cultural directives; drugs may imitate instinct fulfillment. Propensities and cravings are also driven by what is associated with instinct or cultural fulfillments and/or by instinct-fulfillment-imitating drugs. Humans often perceive dopamine driven propensities derived from what was associated with reward feelings but may be unaware why they are driven towards them.
Dopamine driven emotions overvalue expected reward; sometimes it is not clear what reward will be. Fulfilling cultural mandates is very much like pursuing instincts, and many mandates unethical, cruel and/or very damaging.
Abuse is the paradoxical action of doing something one knows to be bad (at the moment this awareness may be suppressed). Abuse is carried out because it is expected to be in some way rewarding. Addiction is a pattern of abuse behaviors that continuously interferes with the person’s first priorities (family, vocational, ethics, etc.).
Instincts are strengthened by use, even thoughts of instinct-fulfillment, etc.; they are weakened by non-use, avoiding virtual or otherwise imagined instinct-fulfillment; same applies to cultural (indirect) ways of instinct fulfillment and drug-use.
Some instincts support goals of global ethics versus instincts that counter them; positive instincts include
– wanting to be ‘right’ – in the end ethical (rationalizing is illogical way of justifying actions as ‘right’)
– compassionate empathy (people need to learn to apply it across all lines/boundaries)
– supportive, loving and generous attitude (people naturally like doing what others wish and helping),
– fairness (reciprocity); people may have to learn to expand fairness, e.g. being honest and responsible as one wishes other to be.
Particularly destructive instincts we have to fight, allow to weaken by non-use (‘let expire’):
– Us-versus-them thinking (erases compassion, encourages violence; in groups people do much worse things than they would do as individuals)
– Vindictiveness (negative aspect of fairness – in global ethics, people want vindication but broadly prefer mediation, arbitration and peace to violence)
– Fascination with suffering and violence
Examples of instinct-culture related addictions:
– Addiction to wealth and power (greed, materialism, enjoyment when able to exploit others and when getting away with cheating and fraudulent acts, etc.)
– Unhealthy comfort, comfort food and other ways of getting temporary good feelings
– Unethical thoughts: sexual, exploitative, violent, etc.
We have to evaluate what instincts and cultural directives serve global ethical goals and what emotions – propensities we have to distract from, avoid, even avoiding the enjoyment of thoughts. To evaluate ethics of a considered decision, we may ask ourselves “would I recommend this to my twin brother or loved peer? What would, of the people I know well, the wisest, loving friend or teacher recommend? If there were a panel of many very different people (culture, gender, socioeconomic), would they likely reach consensus that it is o.k.?
We must learn to, whenever feeling a strong propensity or urge, whenever a significant-appearing decision is to be made, to halt, review what is ethical and in accordance with personal culture and goals, then find emotions that counter destructive impulses and find alternative, rewarding activities.
3 ways of feeling good: nature (instincts), culture (directly derived from culture, modified and sublimated instinct expression), drugs that imitate feelings of instinct fulfillment. Other 3 ways of feeling good in ethical, mixed-neutral or unethical way.
Distinction: guidelines-recommendations (convenient), family and legal laws (much of what is illegal secretly desired), taboos (too shame, guilt and disgust inducing to be enjoyable even in thoughts). People learn to change what is taboo, concerning eating culture, fecal contacts, etc. Abuse behavior must become taboo.
Patients need to find meaning in life, growth towards maturity with ethical personal culture and values higher than culture at large and subcultures of past; get away from adolescent thinking; hopefully develop interests, artistic skills, some hobbies. Often thinking of what one wants to be in future – e.g. eight months, five years, eulogy, also how one wants to perceive self and be seen on death bed. Making multiple changes at once easier than one change at the time, like conventional marriage for women who have to leave home, move to in-laws place and start reproductive cycle, or joining Peace Corps.
Willpower is derived from positive goals being strongly associated with emotions, usually involving social instincts. Discipline may be practiced: making plan for small step with determination to follow plan with no further thoughts (unless there is major news) ‘like in military’; no distractions, procrastination.
We may also need to address shortcomings of 12-step groups/12-step oriented treatments:
– A ‘higher power’ must be core of being, ethical-social instincts (not external God)
– Having to do it for oneself? No, for loved ones, even people one wants to love in future (potential partner, children not yet born, etc.)
– Counselors are often not clear about what abuse is, having a very narrow view, may (inadvertently) encourage abuse behaviors.
– Relapse – Distinction impulsive ‘lapsing behavior’ (most of mind does not go along and steers back to healthy goals) versus mind starts going along, ‘giving in’ or ‘giving up – “once an addict, always an addict”‘ leading to relapse.
AA is basically religious, not ‘spiritual’ in a non-religious sense. Religion may be helpful as a tool in very religious subcultures. Today most people many people are trying to be religious but much of the time ignore core teachings of their religion. Trying to become religious for purpose of recovery is not likely to last. Generally, religiosity is always fragile since religious teachings of different groups contradict each other (they are, by definition, not tolerant since there are no alternate truths), there are also contradictions within holy texts of religions, and there are conflicts with sciences ad even global ethical goals (in their developments, religions usually incorporated unethical mandates). And the human mind does not have the capacity to grasp concepts of eternity, a God, etc.
Counselors should not have history of same problem: all but impossible to be objective/neutral/unbiased/open-minded towards many ways to find motivation for change. Former addicts keep themselves in danger of relapse/do not get distance from their old behaviors (AA is more valuable than NA since alcohol is ubiquitous; in healthy relationships, people do not talk about illegal and other unethical abuse behaviors, present and past).
Counselors/therapists/addiction professionals lack a good understanding of human nature:
we need models to work with patients, explain addiction and, most importantly, what leads to progress.
Counselors/therapists must understand: humans are not rational beings, humans are driven by emotions (instincts, raw and culturally adapted), and we are not afraid of or try to avoid deprivation and suffering when pursuing goals that are emotionally charged and/or appear meaningful. Cognitive therapy is limited. Therapists have to help patients mobilize social instinct- and ethics-based emotions. Positive, emotion-supported goals, more than insights, may pull patients away from abuse-addiction and lead to growth.
Brain disease, and ‘the brain is changed by the drugs’ are not particularly helpful models. All learning, significant experiences (positive or negative), hormones, etc. change the brain. Apparently, many addicts evolve out of addiction without AA/NA or formal treatment. Addiction may be interrupted or permanently cease because of positive emotion-driven motivation, for instance when a women becomes pregnant; strong unethical but emotionally charged motivators may also ‘cure’ addictions.
12-step approaches have limited value.
Regarding positive motivation, ethics (in broadest sense of the term) appears particularly important: ‘abuse’ means unethical use. People inherently want to be ‘right’ and ‘right’ should mean ‘ethical’ (rather than following some cultural mandates, loyalty, etc.). Humans are extremely social, however, opioids often replace patients’ need for loving contact (with opioids it is easy to be isolated without feeling lonely and abandoned; this is why PTSD patients often become opioid or alcohol addicted). People generally enjoy ethical acts but are also able to follow unethical instincts and behave extremely cruel; and it is human nature that much of decision-making is influenced by abuse thinking (addiction to wealth and power; consumerism/acquiring and accumulating luxury products; pursuit of unethical sex; extreme competitiveness with neglect of loved ones, risk-taking, etc.; sugar and comfort addiction; competing for or maintaining untenable social position; unethical fantasies; etc.).
Abuse-Addiction and Related Terms: New Working Definitions and Conceptualization: Abuse is a behavior that feels good but at some level, the person knows that it is ‘bad’. “Feeling good” may mean experiencing joy, thrill, ‘high’, or rapid relief of anxiety, anguish or boredom. Relief from pain may include feeling rapidly slightly better than simply pain free, e.g. having additional anxiety relief – this feeling may make the medication abusable. ‘Bad’ means unethical and/or benefits do not outweigh likely direct and indirect negative consequences to others and/or self. Abuse behaviors are positively motivated and self-reinforcing; consequently, in addition to the behaviors themselves, associated thoughts, feelings, behaviors and experienced environments are remembered, perceived as positive and later sought. Generally, the patient feels in control and may consider abuse behaviors a calculated risk worth taking.
The large majority of people who start abusing alcohol and/or illicit addicting drugs do not progress to abuse-addiction disorders.
Misuse may be defined as inappropriate or illegal self-medication. The person has usually little or no concerns about potential dangers or illegality.
Abuse disordermeans the abuse behavior dose not only occur occasionally, and there is a pattern of abuse and associated behaviors with significant negative consequences. Abuse disorders are a major ethical issue: by definition, abuse is itself unethical; it ‘cheats’ the emotional system and culture; in addition abuse usually reinforces many unethical thoughts and behaviors. These associated unethical behaviors, which are also enjoyed, are often more problematic than the substance use itself – thoughts and behaviors related to the abuse may spread into more and more aspects of life comparable to a “mental cancer”. In abuse disorder, the patient still has a sense of being in control; he/she goes through periods where there is virtually no abuse and the behaviors can be stopped or interrupted when there is a good reasonto do so. Abuse primarily competes with secondary priorities such as hobbies; sometimes it competes with first priorities but the patient is likely to be in denial. The behaviors are usually planned and the significance of risks is considered low. Abuse disorder patients may sometimes feel addicted and if there is an acute vulnerability factor at such times, they may lose a sense of control.
Addiction disorder is a pattern in which the abuse behavior became one of the patient’s first priorities, along with priorities such as being a good parent, spouse and employee or student, living essentially within the laws of one’s culture, being essentially safe, etc. The abuse behavior is clearly more important to secondary priorities, such as becoming a better artist, getting additional education, saving for emergencies and vacations or doing some volunteer work.
The mind always seeks patterns that lead to rewards or reinforcement and ways to follow drives. There is a sense of excitement, however the excitement is often perceived as mixed, not clearly positive. In gambling, intermittent small rewards maintain the search for non-existing patterns; the continued gambling may feel compulsive, and particularly when taking dopaminergice drugs (e.g. to treat Parkinsonism), gambling becomes even more addicting.
As in other positively motivated pursuits, addicts strong motivation to follow their ‘drive’ may include major risk taking; as for instance in ski races, risks and fear may become rewarding associated factors.
“Bad addiction” may lead patient to start ignoring all other priorities: rather than the abuse behavior being one of the first priorities, it is the first priority, putting work, children, etc. to the rank of second priorities.
Abuse-addiction usually means that there is irregular use, determined by the person’s perceived needs and desires, access and availability, etc. Poor coping skills usually contribute to increasing abuse behaviors.
Healthy habits are sometimes considered addictions. Running to stay healthy is not a disorder; running regularly may result form a fear of getting out of the healthy habit, becoming anxious and/or depressed and having later difficulties restarting. Running away from family may be an abuse behavior, as working late to avoid spouse and children is abusive. Enjoying and looking forward to a good meal with family in a structured way is healthy. Eating calorie-rich food at night when anxious or angry is abuse. Sex in a casual relationship is generally abuse, often two people using each other. (Sex, with or without precautions, has a powerful function in creating a bond between parents and lovers [there is release of the hormone oxytocin in females and vasopressin in males]; sex should always be the last step in becoming closer to a person one is attracted to, likes, knows and loves. Particularly the women’s emotional-behavioral system or instincts do not ‘know’ if there is contraception.)
Compulsions and obsessions are different from abuse-addiction in that they are negatively motivated. Obsessive and compulsive behaviors attempt to undo or alleviate what was done against one’s culture: sins, accidental defiling actions, forms of contamination, or victimizations that affront culture and/or religion. Examples, such as ritualistic praying and washing do not feel good, are egodystonic, and have at best a temporary minor effect. In addiction, exaggerated and/or irrational fear of withdrawal may lead to compulsion-like behaviors (objectively, patients know that small amounts of a related drug alleviate withdrawal).
Impulsive refers to behaviors that usually feel good and may be instinctive, cultural, habitual or part of abuse patterns, but they are spontaneous, unplanned, often interfering with what one wants to do at the time, and usually regretted shortly after the behavior. Impulsive behaviors often occur when person is tired, inattentive, distratcted, etc. Children – people must learn to avoid or at least minimize impulsive behaviors.
Habit generally refers to behaviors that are frequently done in functional meaningful ways but later become automatic, sometimes done out-of-place but without special feeling of relief or other benefit. Examples: without conscious decision making driving on an old, dangerous road when knowing of a new, safer and faster way; going daily to a market even if no grocery needed at the time.
Over-grooming behaviors such as hair pulling, scab picking and fingernail biting often has a habitual quality and may be continued when there is no actual trigger, e.g. picking smooth skin, pulling hair that is not bothersome or seen as ugly, biting or picking fingernails that are already too short. These behaviors seem sometimes hard to resist but are hardly enjoyed; rather the patient may feel as if the skin, hair or fingernails are not o.k. no matter in what shape they are.
Lapse [versus relapse] means that key stimuli (triggers), with or without craving, lead to abuse behavior (impulsive substance use or attempt to find drug); however, the patient almost immediately regrets having fallen victim to old habituation and patterns he/she tries to avoid and perceive as shameful.
Relapse refers to not only moving towards abuse-addiction behaviors, but also mentally consenting to it, readily giving up efforts to stop it. The patients may rationalize that they now deserve exceptional use and can handle it or that the situation is hopeless – “once an addict, always an addict, why try to stop” (giving in or giving up). A belief that every use or ‘lapse’ is a ‘relapse’ often becomes a self-fulfilling prophecy. Relapsing may be compared with Pierre Abelard’s concept of sin (French Medieval theologian-philosopher around 1000 c.e.): he maintained that the sin of (sexual) wrongdoing consists not in the illicit desire for it, nor even the act, but in mentally consenting to the desire. Craving and lapsing is not the sin, mentally consenting to desire, plans to act and action are.
Abuse-addiction disorders may be understood to be a moral weakness, a lack of emotional strength to follow own ethics and values. Abuse behaviors result when the emotional appeal of a drug’s false good feelings is more powerful than the emotional strength to pursue healthy, moral goals. A patient may drift into addiction when lacking strong goals and direction, and/or when feeling worthless and hopeless, but ceases to be an abuser-addict when finding a powerful positive, by emotions supported goal, e.g. expecting a child, being greatly inspired by new learning and new relationships that create meaning, or by finding a religion and spiritual community. While positively motivated, stimuli that are associated with abuse-addiction behaviors weaken, and in following years, the danger of return to abuse behaviors becomes minor unless vicarious and actual lapsing behaviors and abuse thinking and memories, including identifying with abusers maintain the drive. Unfortunately, many strongly positive motivators are too short-lived for the patient to solidify a life without intermittent craving, e.g. many new mothers relapse when stressed with a newborn, dealing with CPS, etc. and the motivating power of religious community is usually also rather short-lived. The readiness for abuse and associated behaviors may also be maintained by sometimes acting them out vicariously, by enjoying and elaborating abuse thoughts and memories, identifying with abusers in movies or games, etc. To avoid relapse temporary effective motivation may be transferred to a more powerful on ethics based personal culture.
Abuse-addiction behaviors are primarily positively motivated, even though fear of withdrawal often contributes to the chronicity of the disorder and/or add a component of negative motivation (fear of discomfort). However, withdrawal symptoms are not the reason patients stay addicted. Patients usually know that, if they decrease the amount of the abused drug and later taper it further, they would have craving but hardly withdrawal. In addition, if suffering withdrawal pain would be a cure, many addicts would accept it, as many accept as meaningful perceived pain from tattooing, plastic surgeries, etc. Many substances lead to physiological dependence without being addicting and many addicting drugs and behaviors do not lead to physiological dependence: there is overlap between addiction and dependence but they are not the same.
Generally abuse behaviors are planned, not impulsive, and to some degree habitual (i.e. following conditioned responses without much awareness), but generally not compulsive. Lapsing behaviors are by and large impulsive but usually do not lead to relapse, at least at times when they are unhappy and not engaged in meaningful pursuits.
The question why people become addicted appears less relevant than the question why people do not become addicted if they found a very rewarding abuse behavior that they tried and considered an acceptable risk. Most people probably do not move from abuse to addiction because humans (in contrast to other animals) have a sense of an anticipated future and they want to be ‘right’, ‘good’ or ethical. Insight is a major factor in people stopping abuse behaviors before they become an ingrained pattern. Sometimes people express that the good feeling of a drug felt dangerous.
Abuse-addiction behaviors appear to be symbolically dealt with in fairy tales describing a contract with the devil or Satan: the poor peasant or miller is blinded by the promise of gold and inadvertently promises to give his daughter or first-born to the devil. His wife immediately recognizes the disastrous situation; the protagonist that agreed to the deal suffers last and least.
Abuse disorders tend to become addictions, if patients have no powerful emotional reason to check or stop the abuse pattern, e.g. if patients are confused and lacking goals (particularly adolescent and young adult males “drifting” [“lost sheep syndrome”] and/or thinking that this is an age to enjoy in whatever way possible), if they are very depressed and unable to think positively about their future, if they try to self-medicate psychiatric symptoms, or if they live in a culture/subculture that encourages or at least condones the abuse. There are other predisposing or protective factors, such as being short-term oriented (attention deficit symptoms) versus a long-term planner and/or a person who wants to be always in control. Fearful or overly cautious children are less likely to try abusable drugs as adolescents than outgoing risk takers. The state of mind while trying a drug influences whether a specific drug feels ‘good’ and ‘right’, seems neutral or makes person feel worse.
While many psychiatric conditions may predispose to addiction, the addiction later becomes its separate psychiatric disorder, interacting with the primary psychiatric condition in a two-sided way. When one becomes worse, the other is likely to become worse as well and vice versa. Sometimes the addiction becomes the predisposing factor e.g. making a to depression predisposed person acutely depressed. Marijuana is known to increase the probability that to schizophrenia predisposed persons become acutely psychotic.
Abuse: Consideration of the Biology of Human Behaviors and Ethics:
Basically, humans feel good from
1. instinct fulfillments (perceived as following emotions); and, closely related,
2. cultural fulfillment (instinct fulfillment through culturally adapted behaviors and/or artistic sublimation); or
3. abusable/addicting psychotropic drugs.
Drugs, bypassing any thoughts or actions, feel good as if fulfilling an instincts; “the person feels good for no good reason”. While abuse pattern develops, drug use stars feeling instinctive, the drug use and associated behaviors feel ‘right’ and ‘needed’. Terms used referring to instincts are readily used when talking about drug abuse.
The good feeling is almost immediate or very soon follows drug consumption; if delayed, as in nicotine patches, the drug is not perceived as addicting even if people may use them like antidepressants or vitamins, expecting to later feel better.
Drug abuse may be understood as ‘artificial instinct’ that is fulfilled in cultural ways.
Some natural instincts, particularly eating, are only fulfilled in cultural ways: modern humans do not perceive squirrels and crabapples as triggers to eat even when hungry; when hungry or having appetite related to boredom, we think of refrigerators with processed foods in them, stores, restaurants, etc. As with instincts, more and more associated perceptions, thoughts and behaviors may become attractive and desirable, spreading like a ‘mental cancer’; however, in most people there is no progression to addiction.
Drug abuse behaviors “cheat” nature and culture. Tranquilizers and alcohol make person feel good as if conflicts were resolved, feeling clam, believing to deserve rest. Psychostimulants imitate the (immediate) anticipation of something positively exciting and/or big. Opiates seem to feel nurturing, as if surrounded and held by loved ones, family and close friends. All three types of drugs usually raise sense of well-being and pain tolerance, particularly opioids.
Patterns of drug abuse (substance abuse) have much in common with instincts – they are like ‘false’ or ‘artificial’ instincts, but often more powerful than natural instincts. Mind and body respond to triggers for substance use very similarly as to opportunities to eat, drink, find mate, etc. There is a readiness or appetite for the behavior, the appetite being triggered by more or les specific stimuli, and often there is seeking of stimuli (appetence behavior). There is temporary satisfaction and satiety after the instinctive or drug use behavior. As instincts, drug use patterns are strengthened by any form of mentally activating pathways towards the behavior and what is associated with them (memories, plans, images, initiating steps, etc.). And as with instincts, regular, systematic distraction from and frustration of drug abuse related mental activities weakens the patterns. Even instincts such as sexuality, eating and need for caring contacts are sometimes essentially erased. Examples: renouncing sex when dedicating life to religion and charitable work, when ‘addicted’ to a career, after having had very bad experience with partners or when there appears to be no other form of contraception than avoiding sexual contacts; during severe starvation or if unable to swallow and fed by gastric tube, people may lose their appetite and instead focus on other pursuits and activities; after severe disappointments with humans, particularly in severe posttraumatic stress disorder, a person may seek isolation, ignoring possibilities of loving interactions and follow pursuits that may include suicide or homicides.
Abuse patterns are also habitual. Animals and humans learn behaviors, practice them frequently and then may execute them without any thought or screening of environment, e.g. behaving in a habitual way when circumstances have changed and the behavior is not efficient and/or appropriate. Behaving in a habitual way may feel reasonably comfortable but it is not directly rewarding.
Abuse feels good or is at least expected to most likely lead to good feelings in the very near future, and consequently, the abuse behaviors are self-reinforcing. Preceding and concomitant feelings, perceptions, thoughts and actions are also reinforced and start feeling ‘right’, beautiful and/or good. These often include uncomfortable, dangerous and unethical behaviors that are directly or indirectly related to the abuse (e.g. lying to self, family and/or health care professionals; property crimes and dealing drugs; trading uncomfortable sex for drugs and other dangerous interactions when acquiring drugs; painful self-injecting often with unclean needles). Abuse-addiction and related behavior are learned patterns that soon feel natural or like part of one’s culture. Most people restrain or stop abuse behaviors and do not develop abuse-addiction disorders because of insight, including ethical considerations, and because of positive goals that exclude the abuse behavior. For some, as the reward feelings weaken, much of their addiction behavior pattern becomes distressing and they eventually find the emotional strength to stop the habitual behaviors without formal help.
Abusers perceive on some level that there are ethics violations. Typically, they
– would not recommend the abuse behavior to a close relative, friend, or peer, and particularly not to a loved child.
– would feel embarrassment, shame and/or guilt discussing the behavior with a true peer who does not display same or similar behaviors and pathology.
– recognize that no wise, benevolent friend or counselor would advise them to continue the behavior (if another person is involved, they would recognize that friends and relatives would disapprove for good reasons)
– have a sense that they will sooner or later regret the behavior.
Abuse often starts as a means of dealing with frustrated instincts, severe conflicts and/or psychopathology. People who have difficulties accepting reality, suffer much conflict, and have poor stress management skills have a propensity to use alcohol and tranquilizers (benzodiazepine, barbiturate). They may perceive the drug use as treating an abnormality of their mind rather than being abuse, and they may rationalize it accordingly. Being frequently anxious is normal in puberty and adolescence; teenagers then may perceive being drunk as feeling ‘normal’, at least if they do not have significant cardio-vascular side effects (until reaching some tolerance, alcohol usually leads to feeling dizzy and lightheaded). Some people do not have this inherent reaction (genetic) and thus may be more likely to immediately move towards regular use and addiction. Low self-image is temporarily alleviated by nicotine, making cigarettes particularly addicting to adolescent girls. However, nicotine’s effect is subtle and the smoker may hardly recognize its reinforcing effect. (In most civilizations, adolescence and young adulthood is very difficult for girls, however, the high rate of anxiety and depressive disorders is due to cultural factors and varies significantly between societies and groups; e.g. girls in Amish communities and female college students seem to have similar rates of depression as their male peers.)
Humans have also an instinctive propensity toward seemingly irrational behaviors. Particularly males’ competing for rank order and for female attention includes an instinctive urge to show off with outlandish behaviors and risk taking; the intention is to show that the male has courage and is able to do much more than fulfill his personal needs. This instinct, a lack of drive and a lack of structure in many young men’s lives may be the reason why many male addicts show little other psychopathology and why young men are about twice as likely to become addicted than young women although, starting in teen years, females in the USA have about twice the rate of anxiety and mood disorders than same age males (there have been shifts with more teenage girls imitating male patterns and overstepping cultural norms; in the past smoking and drinking were culturally much less acceptable for women than men).
Women generally take much less meaningless risks, except when complying with males. Women typically start drug use to self-medicate mood disorders and/or when going along with male partners. Girls often recognize that a boyfriend has drug related and other problems and, particularly if they have emotional issue themselves, they believe they can help them (they often can, but not enough); eventually they may get pulled into the addiction behaviors. Feeling abandoned, cheated and isolated puts people at high risk for opioid addiction and alcoholism. Abuse experiences along with cultural, genetic and other factors may also lead to anorexia nervosa which has an addicting quality that is liked to endorphin activity.
These are probably the reason why, in our clinic for opioid dependence-multiple diagnosis patients, we see many PTSD patients, and much less twins than statistically expected (anecdotal data and retrospective research). It also explains why anorexia nervosa responds well to opioid maintenance treatment. (At our clinic we gathered strong anecdotal evidence that methadone, even in low dosage [and possibly buprenorphine], is very effective in the treatment of anorexia nervosa.)
Major psychiatric disorders, particularly if there is a history of anorexia nervosa and/or PTSD, are major contraindications to attempt detoxification-‘rehab’ of opioid addicts (“rehab”) and/or early withdrawal from opioid maintenance treatment.
In modern humans the endorphin system is extremely weak. When suffering severe pain, few people feel an endorphin response comparable to the effect of medicinal or abused opioids. According to anecdotal data [personal experience with patients with PTSD and dissociative disorder], the endorphin system may be ‘primed’ or activated by early abuse or neglect; patients may later like significant pain stimuli from self-injurious behaviors or tattooing (even fall asleep while getting tattoos), and/or report that pain of childbirth was minor. It is not clear how much endorphins contribute to dissociation, spontaneously or with meditation, (self-)hypnosis and possibly acupuncture. Some patients with multiple personality disorder (MPD) and/or PTSD patients with flashback experiences appear to actually benefit from the endorphin antagonist naltrexone, having less dissociation (personal experience when naltrxone used with MPD patients) and/or less flash backs.
There is no information why endorphin responses are largely lacking in humans. A possible explanation is that prehistoric cultures frequently used mutilating practices as ‘fads’ and to distinguish themselves from other ‘inferior’ cultures. The mutilations caused many deaths due to infections, and increased pain due to a lack of endorphin response, with more resistance to extreme practices, may have been evolutionarily an advantage. An additional factor may be that the system needs to be initiated or ‘primed ‘with forms of early physiological and/or psychological stress.
Abuse includes a wide range of behaviors, including inappropriate instinct fulfillment, e.g. eating for relief of anxiety or inappropriate sex, and abuse of cultural enjoyments, e.g. casino gambling and dangerous races. When wanting to immediately repair a malfunctioning device, a person may feel better but then abuse and break an inappropriate tool. Immature persons who do poorly may make themselves feel better by picking physical fights and bullying, physically abusing a partner, sexually abusing children, etc. Abuse-addiction patterns may include addictive (“compulsive”) shopping, watching games (with strong leaning towards one team), surfing Internet, overeating, continuously seeking physical comfort and restful positions (avoiding any exercise), etc.
We may distinguish ways of feeling good primarily from the perspective of meaning, judging value and ethical considerations:
– Feeling good from positive, constructive and loving activities, including learning, practicing valuable skills; giving, helping, nurturing children and people in need; developing broad empathy and compassion; developing ties with friends, family, children, and a partner, including enjoying sex within a loving relationship; preparing and eating healthy family meals; exploring nature and art.
– Enjoying activities that are neutral or mixed, partly positive, partly wasteful or negative, e.g. activities that may be partly challenging mind or distracting self from anxieties but in a broader sense wasting time. Misuse of drugs and medications may prevent suffering but include dangers where benefits may not outweigh risks.
– Abusing instinct fulfillment and cultural fulfillment in inappropriate, unhealthy and/or destructive ways; taking medications and other substances in an abusive way, benefits do not outweigh risks.
In case of pain, medications may help a person to be more functional, better able to work and be nurturing, etc. but generally, people should use medications for symptom relief sparingly and largely rely on natural approaches, always first focusing on functioning rather than symptom relief. Naturally, meaningless pain sensations are soon ‘tuned down’ and can be much of the time ignored.
Virtually all people show some abuse behaviors but most do not progress to abuse disorders and addictions. Often, people become addicted because they have psychiatric disorders that decrease insights and motivation to pursue healthy goals. Much drug abuse starts as attempt to self-medicate. A legal and/or reasonable pain medication may soon be used to alleviate loneliness and/or psychiatric symptoms. Particularly young people often want to rebel and may choose abuse behaviors to distinguish themselves from the previous generation.
There is a widespread belief that enjoying thoughts of unethical behaviors is not immoral, as long as one does not act on the thoughts. Ethically, enjoying unethical thoughts and vicariously acting them out is not acceptable. Vicarious acting out unethical instinctive propensities and abuse behaviors, identifying with persons in novels, movies, etc. who behave unethically, enjoying memories or elaborating imagined future unethical acts strengthens the propensities. Unethical thoughts tend to be acted out in extraneous circumstances: in war zones, in strange lands where one does not agree with local culture, when severely sleep deprived and overwhelmed with conflicts, when drunk, etc. Extremely poor people who feel excluded from civilized society and very wealthy people who feel they are above the law are more likely to act out unethical fantasies. Some drugs (particularly alcohol) lower the ability to judge, and they make it easier to act out unethical thoughts that were previously enjoyed. Alcohol then may be doubly rewarding: the patient may enjoy the alcohol effect as well as acting out violently and/or sexually; later he may blame the alcohol for the unethical actions and enters “rehab.”
Addiction as a Medical Disease or Mental Disorder : The notion that addiction disorders are diseases marked by changes in brain structure and functioning (as confirmed in imaging studies), is not helpful. Addictions may be conceptualized as pathological learning “patients learned something they should never have learned.” However, virtually any learning that involves new information, emotions and motor skills leads to significant changes in the central nervous system. Learning to ski, play the piano or boxing, going through law school, becoming sexually active, experiencing pregnancy and childbirth, etc. undoubtedly change the person’s brain, and areas that are vital in a learning process may expand in size.
If comparing the human mind with a computer, we may consider addictions as being mostly a ‘soft ware problem,’ the healthy functions are pushed aside and many perceptions and memories immediately lead to abuse thinking. A disturbance in the reward system is probably not unique to certain drug addictions (such as amphetamine addiction) but it may be relevant in therapy. More important is the toxic effect of some drugs, particularly organic solvents. Alcohol is globally toxic to tissues and leads to gradual damage of the nervous system. Chronic marijuana use may also lead to brain damage.
A propensity to addiction was also considered to result from a natural deficit of endorphin or other specific receptors. Opiates and tetrahydrocannabinol (THC) imitate neurotransmitters and match receptors, however, these receptors are usually not important in humans’ emotional-behavioral system. Natural endorphin release is usually very weak, e.g. in response to skin injuries, loving relationships, calorie dense sweet foods, acupuncture and possibly meditation. The action of the powerful endorphin antagonist naltrexone is not directly felt; it is not perceived as a psychotropic drug; it hardly decreases the quality of life, even though it may decrease the addictive qualities of sweets and possibly the effectiveness of acupuncture. Studies indicate that endocannabinoid lead to the so-called ‘runners’ high’ but most people may not perceive a ‘high’ from aerobic exercise other than a sense of accomplishment and with regular practice an anti-depressant effect. Dissociation with extreme stress, when a wounded person in a war zone or accident cannot feel his/her body, is probably not related to endorphins; the person usually has signs of very high adrenalin/noradrenalin, which actually resembles opioid withdrawal. Nicotine, low dosage psychotimulants and opioids have little or no effect on thinking and judgment other than disturbing priorities due to the self-reinforcing properties. Side effects of opioids may be beneficial, particularly its hormone-like effects lead to patients feeling less aggressive and sexual and decreased craving for more dangerous drugs; particularly methadone has been shown to have antidepressant effects. Sometimes people feel more able to think and work while using drugs due to a decrease in intrusive, disturbing thoughts, which should be addresssed in other ways. Low dose psychostimulants help people focus on given tasks, even if they do not have attention deficit disorder symptoms.
The recent Diagnostic Statistical Manuals’ (DSM III, IV and V) concepts and criteria for abuse, dependence and impulse disorders appear inadequate and in places inappropriate. The implied close association of substance use disorders and physiological tolerance and dependence is inaccurate1 and suggests inept treatment2. Increasing dosage, using more and longer than planned is typical in many or most human endeavors including non-abuse behaviors: after introducing them, people typically increase amounts of flavoring agents in their food (e.g. sweetness or spiciness), quality and/or size and power of their instruments, etc.; when starting a pursuit or succession of activities, pleasurable or meaningful, art, hobby or pastime, people usually stay with it longer and need more resources and time then intended in order to feel satisfied, and they often increase the time they spend in the new pursuit.
The in 2014 released DSM V no longer distinguishes abuse disorder and dependence (addiction) disorder. While there is not a sharp division between abuse, abuse disorder and addiction disorder, as there is no sharp division between the colors of the visual spectrum (or rainbow), there is hardly a smooth continuum. As with colors, which we perceive as red, orange, yellow, green, blue and purple (violet), we perceive demarcations between first and second priorities, between second priorities and coincidental pastime activities, and between acceptable entertaining pass times and unethical or criminal pleasures. Expressed in plain language, observers intuitively distinguish between
– abuse as an unusual calculated risk or a rare impulsive unethical act,
– abuse disorder with an established intermittent pattern of abuse behaviors that causes damage,
– addictions with essentially continuous abuse thinking but with significant aspects of healthy functioning maintained (even if often compromised), and
– “bad” addiction in which the patient ‘lets everything go,’ where virtually all aspects of healthy functioning became second or third priorities.
Addiction is commonly considered progressive and often lethal, essentially a malignant disease. Because of the huge differences between humans’ characteristics and temperaments, their individual experiences, and their varied insights, actual courses of addiction disorders vary greatly; treatment may be crucial but many addicts improve and recover without professional or other interventions3. Significant learning and life experiences with emotional impact may lead to healing. Thus addiction treatment probably should emphasize broad learning and maturation.
It is also problematic to consider addictions genetically transmitted. Psychiatric disorders are not inherited, though predispositions often are. In the case of propensity to addictions, there are primarily less protective factors, such as personality traits of a planner who wants to feel in control, being sensitive to drug side effects, etc. Many psychiatric conditions may predispose to addiction disorders, e.g. patients with attention deficit symptoms, mood disorders, PTSD, borderline personality disorder, and to a lesser degree antisocial personality disorder. Generally, humans have adequate insight to avoid moving from abuse to addictions, but everybody may, in unfavorable circumstances, develop a serious substance use disorder. It is easy to get laboratory animals addicted to many types of drugs. In principle, humans are similarly susceptible, except that our forebrains help anticipate possible future scenarios leading the rational mind to mobilize countering emotions that support other healthy emotion in halting catastrophic developments. Regarding antisocial behaviors: opiate addicts sometimes learn to behave in antisocial ways while becoming addicted. With methadone treatment, most improve rapidly and think more ethically. That methadone (and other opioids) lower testosterone and aggression is also beneficial. People with major antisocial traits may readily abuse drugs but are probably less likely to become addicted to drugs as they usually have a high tolerance for discomfort and mostly seek other forms of ‘highs’ and excitements.
Concerns over medicalizing unethical behaviors have been raised with the fear that psychiatric diagnosis may be used to excuse behaviors. We never need a mental disorder diagnosis to excuse behaviors: scientifically, we must be essentially determinists. [If having free will is part of a person’s religious and/or moral thinking, he/she may believe that there is a minute “unclaimed” space – science cannot fully explain how animals (and humans) make decisions.] Basically, our behaviors are determined by genetic predispositions, by previous helpful, neutral and pathological learning, and by the present environment (learning includes play, folklore, what people hear and observe, the ‘mind changing’ aspects of experiences including abuse experiences, etc.). We should never fool ourselves, believing that a person who lived in a world were violence has been considered normal can always maintain a present separate reality as a law-abiding citizen, that people could voluntarily commit crimes that go against their upbringing and personal culture, or that we ourselves could have acted differently in the past without the in the meantime changed state of mind and added knowledge.
Naturally, “by design,” humans are always in conflict with fellow beings, and humans suffer much “normal” physical and mental pain, particularly women. Many factors may lead to severe dysfunction, mental disorders and addictions. That we consider a suffering human being’s condition to merit therapeutic help is a matter of pragmatic compassion, not based on a judgment as to whether the patient’s pain is voluntarily self-inflicted and/or the result of crimes versus due to a disease or accident.
Addiction and Psychiatric Disorders, Anorexia Nervosa: According to our experiences, retrospective studies and anecdotal data, psychiatric disorders are frequent in patients with abuse-addiction disorders, usually preceding severe addiction, particularly in women.
Women seeking treatment for opiate addiction often relate major abuse histories and bad experiences with intimate partners. Psychiatrically, we see much depression, anxiety, PTSD, self-injurious behaviors and anorexia nervosa. (Bipolar disorder may be over-diagnosed and borderline features are often expected but are rarely the primary problem.) Generally, times of extreme loneliness, as typically experienced by PTSD patients, appear to cause vulnerability to developing opioid addiction.
An interesting observation has been that we admit and treat far less twins than statistically expected. It appears that having a twin, fraternal or identical, decreases the vulnerability towards opioid addiction, probably because phases of extreme loneliness are less likely4.
In our observations, first sex is often the point when adolescent girls loose a sense of control and self-respect; experimenting with abusable substances and emotional problems often lead rapidly to major pathology and substance use disorder. Depression often leads to self-injurious, parasuicidal and/or acute suicidal behaviors, eating disorders and/or a first addiction. The problems may wax and wane but usually last many years to decade.
Media, peer groups and pre-adolescent/adolescent subcultures lead girls in our culture to feel insecure and conflicted; their self-esteem often plummets. Nicotine, which temporarily lifts the self-image, often becomes the gateway drug. Depression and anxiety are much more frequent in adolescent girls than boys. Many factors contribute to these problems. For girls, a mother’s job as same-sex parent includes to teach and often criticize her; an opposite-sex parental figure should give unconditional love, admire the child’s inherent value and beauty and thus contribute to a lasting sense of self-worth, but for girls more than boys, such opposite sex parental figures are largely missing. Sexual attraction and curiosity while lacking an understanding of psychological aspects of sex lead young people to very dysfunctional sexual behaviors; and boys often exploit girls’ insecurities. “Sexual freedom” with the introduction of contraceptives and “women’s liberation” has lead to the false belief that girls/women can and should “enjoy” acting like boys/men (in sports, in careers, sexually, etc.), take pleasure in males’ freedoms, while ignoring the great inherent differences between the sexes5. For boys sexual experimenting does not seem important; for girls, sex is always important and emotionally multifaceted – a girl’s emotional systems does not take contraceptive measures into account. Additional examples: many male sports are much more dangerous for girls; girls feel less aggressive and are more concerned about the feelings of losers in team sports; girls may not want to compete with (be better than) boys they like, etc. For girls, sex outside a stable loving relationship often causes a succession of negative emotional consequences.
Anorexia nervosa (AN) is related to abuse disorders. Vulnerability factors to AN are similar to those often leading to opioid and other substance use disorders; societal and family culture are important. The young person experiences a sense of internal reward from fasting, first as an accomplishment, later also consequent to physiological changes influencing thinking and emotions, including elevated endorphin levels.
Opioid maintenance gives addiction patients structure and an environment where treatment of all aspects of pathology is possible. Opioids make the emotional loneliness more tolerable and patients may learn to become more socially connected.
Both males and females may benefit from maintaining the reduced sex drive they experienced when abusing opioids. Particularly males’ lower testosterone level helps them control aggressive impulses.
In a few patients, we noticed antipsychotic effects of methadone: when slowly tapering methadone, paranoia appears. This effect appears dose related.
We believe to have strong anecdotal evidence that methadone even in low dosage, and probably also buprenorphine, rapidly and significantly decreases most symptoms of anorexia nervosa. Symptoms may not return when, after extended time of maintenance treatment, when methadone (or buprenorphine) is slowly tapered and withdrawn. I believe that methadone or buprenorphine maintenance should be considered a safe and well tolerated treatment of anorexia nervosa if not the treatment of choice. However, further studies are needed.
1. Many nonaddicting substances lead to physical dependence, including seizure, hypertension and nonprescription pain medications, some antidepressants, and high dosage salt intake. People may be dependent on insulin because of food addiction and/or addiction to a physically lazy lifestyle, but they are not addicted to the insulin.
2 The focus on physiological dependence supports the assumption that discontinuation of the drug constitutes successful treatment.
3 The DSM III research summary on course of opioid dependence stated (page 172): ” Among those who survive, increased abstinence is found with the passage of years, with final cessation of dependence an average of about nine years after its onset.” (I do not know what studies this was based on but it is hardly accurate for most U.S. opiate addicted patients.) It also mentions the excellent prognosis of heroin addicts returning from Viet Nam. We tapered many patients off methadone and we know of some that they did very well for at least 10 years.
CDC statistics of incidence of use of alcohol, tobacco and street drugs, based on age, show a steady decline with age (maturity). Valiant described the natural course of alcohol addiction: many alcoholics stop drinking or even return to social drinking without specific treatments. Many smokers stop without professional help or peer/support meetings.
4 We did a larger survey of our patients with opioid dependence. Our experience has been that much less than one in 30 to 40 of last few hundred admissions, as statistically expected, are twins, and the last few twins have been in many ways atypical, usually developing their addiction disorder in their twenties rather than teen years. In addition, we found a very high rate of PTSD in this population.
5 Compare: Why Gender Matters, Boys Adrift, and Girls on the Edge, by Leonard Sax, MD, PhD
TMTA/USAOTP Presentation August 2015, Heinz Aeschbach, MD
Expanded summary of material – Info based on sciences (ethology, anthropology, psychology, neurosciences – broad understanding of human nature: human thinking and behaviors)
Because of the severe discrimination against OTPs and the support for dangerous and poorly working, expensive approaches, we encourage people to write to officials: SAMHSA/CSAT: Robert.Lubran@samhsa.hhs.gov Westley.Clark@samhsa.hhs.gov
SAMHSA: dirtector: Pamela Hyde; Dr. Melinda Campopiano,MD firstname.lastname@example.org
President Obama, Michael Botticelli, Director, Office of National Drug Control Policy The White House, 1600 Pennsylvania Avenue NW, Washington, DC 20500 https://www.whitehouse.gov/contact/submit-questions-and-comments
FDA: Margaret A. Hamburg, MD, Commissioner of Food and Drugs
CDC: Tom Frieden, MD, MPH, Director, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333
– “Knowing”, “knowledge”, “scientifically proven”: models valuable to explain and predict, not “truth” in an absolute sense. Models are based on observations, they are tested by more observations in which observer predicts likely outcome and scientists may lead experiments that test the model. Experiments must then be reproducible (generally in many different settings).
– “Opinion”: attempt to interpret scientific data that is not conclusive or interpretation where there is not broad agreement on how data is to be interpreted, what models can be deduced from data. Philosophy.
– “Belief”: not substantiated scientifically, e.g. folklore, biases. Beliefs and superstitions develop due to instinctive expecatation of cause and effect and misjudgment of randomness; when someting good or bad happens, people assume what hapend before caused it.
– Religious belief = that what people cannot agree on but consider very important and often fought/fight wars over.
Sense of a god may be included in spirituality; believing a god communicated/communicates how we should live is religion. Praying to a god and finding insights when praying (recovering material from own mind that is otherwise hard to elicit) may be helpful; believing a god talks back is hallucinating. “If there is a God that wants us to live a certain way, She is not communicating clearly”; it is hard to find two people who agree on details of any religion. Edward O. Wilson proposed that humans have an instinctive need to create religions. Religions probably based on desire to understand nature, instinctive perception of causality, hallucinating communication with dead people during acute grief and remembering more when wishes [prayers to ancestors, etc.] fulfilled than if not fulfilled. Religions, even though never substantiated, flourished because they fulfill multiple functions within groups and cultures.
[Example of bad model: pressure pot model of aggression – need to express aggression, let steam off; such behavior makes person more aggressive.]
Basic understanding of mind, animal/human behavior:
– Animals/humans are positively motivated, governed primarily by emotions (which are essentially instincts – emotion means what leads to motion), not rational mind, going from pursuing instinct fulfillment to pursuing instinct fulfillment; suffering before, before and after sought event not perceived as very important.
– Instincts (emotions): feelings that include urge to express itself physically in body posture, movements, etc. Instincts basically are raw inborn action patterns: there is internal readiness but also inhibition that has to be decreased/overcome by key stimuli (or triggers) in environment (occasionally stimulus is imagined); play and experiences refine environment specific triggers and ways of fulfilling instincts; cultures modify, strengthen, weaken or pervert instincts; everything associated with triggers and seeking and reaching instinct fulfillment becomes “normal” or positive and may acquire trigger function.
– Humans/primates have few predispositions to fear, examples: snake- and spider-like animals, fire, deep water; most “modern” dangers do not impress people.
– Humans are opportunistic; throughout the evolution of humans and their cultures, individuals have followed social instincts within groups but otherwise often deceived, exploited, etc. Groups and individuals usually have been very violent, raiding neighbors (stealing women, animals and transportable goods) and killing as revenge in cowardly manner (i.e. when attackers had advantage in numbers and/or when attacking while enemy slept); if humans appeared courageous, it was mostly to defend immediate family or group and sometimes in impulsive revenge.
– The rational mind cannot directly guide actions though it thinks ahead and sometimes tries to stop behaviors if seemingly moving towards catastrophe – the rational mind then tries to find and mobilize more powerful countering emotions. Usually, external and internal triggers move body towards action, the body’s response is largely responsible for feelings, thoughts supporting or rationalizing actions are usually last step.
– In the process of attempting to be ‘right’ and ‘important’, people devised cultures, cultural ways of doing things, specifying what is ‘good’ or ‘bad’ and for what reasons, explaining natural phenomena, etc.
– Progress of cultures: often attempts to strengthen human’s ethical propensities and to introduce by religion supported forms of morality, usually including rewards and threat of punishment in an afterlife. However, most ethical teachings of spiritual leaders were quickly perverted; in addition, adolescent males want to compete with and reject “fatherly” gods and religious leaders. Families and different formation of groups usually develop own subculture and, while contemplating life, individuals have to create own culture, find ethics and meaning in life.
Characteristics and aspects of instincts: inner readiness, inhibited, triggers decrease inhibition, after fulfillment or satiation very powerful trigger needed for response and if long no fulfillment, very unspecific triggers leading to response; often appetence behavior, i.e. looking for triggers (any trigger or trigger for long not fulfilled instinct); triggers, seeking and accomplishing instinct fulfillment perceived as positive, beautiful, etc.; formation of secondary and indirect triggers. Instincts strengthened by use, exposure to triggers, imagined and vicarious use and enjoying memories, non use, avoiding triggers and memories, etc. eventually weakens instinct until it is irrelevant, but it may be revived.
– compassionate empathy, efforts to understand others’ memories and understanding of the present, emotions, fears, aspirations, etc.
– common sense
– understanding human nature [Ethological research: Eric von Holst, Konrad Lorenz, Irenäus Eibl-Eibesfeldt, primate research, research and observations of all types of societies, broad range of psychological research]
– understanding natural ethics [not primarily professional ethics], and developing ethical personal culture that excludes any abuse
– specific knowledge about disorders
Patient autonomy nonsensical, patients always in social system and highly influenced by environment, they want to know opinion of experts. Motivation for treatment: not wanting to do well for oneself, motivation mostly based on social instinct, doing better for loved ones, present and future.
Definitions and models explaining abuse-addiction
– Definitions of misuse, abuse, abuse disorder, addiction and “bad addiction” according to three levels of priorities.
– “Psychological abuse/addiction”: misuse/inappropriate use of reinforcements from directly or indirectly fulfilled instincts.
– Disease versus disorder: disease usually thought of in terms of tissue damage, poison, microbe or parasite in body, disregulation of important physiological function e.g. minor blood vessel changes leading to high blood pressure.
Psychiatric disorder usually consists in bad use of brain with possible minor changes that are not clearly abnormal and usually changes when person starts thinking and feeling differently. Example: when depression with PTSD symptoms improves with exercise, better interpersonal relationships, psychotherapies, “life changing” experience, etc., some brain nuclei becoming bigger. With regard to changes in functional brain imaging, what area “lights up” depends on previous experiences: many things change brain, including major learning (e.g. Buddhist teachings and practices; attending law school, starting extreme sports); dramatic changes with hormonally influenced developments; major experiences including accidents, abuse experience, child birth or first love and intimacy, success in studies and career.
Regarding ‘messing’ with reward system, psychostimulant abuse may be compared with extreme thrill seeking, extreme sports, psychological abuse like severe gambling addiction where brain seeks and fails to find patterns of how to achieve rewards [brain assumes cause and effect relationships and quickly makes predictions to reach goal – this is exciting but always fails in true gambling where winning is random. Still, gambler craves excitement before likely disappointment.]
– Abuse disorder: something learned that one never should have learned and leading to dysfunction, distracting from healthy thinking. [Positively reinforced (rewarded) behaviors, associated actions and perceptions reinforced; habitual elements; usually not compulsive (except with irrational fears) or impulsive; usually considerable planning.]
– Abuse as crime
– Abuse due to lack of will power
Probably best model of abuse-addiction:
Drug abuse is a contagious psychiatric disorder (patients do not invent abuse behaviors, they learn from untreated patients); they learn what they should never have learned. Brain is used in ‘bad’ way but not damaged
Drug abuse becomes “artificial, in cultural ways fulfilled, instinct” – rewards same, same language used, learning and unlearning same. Same characteristics: always readiness but usually inhibited, satiation with high level of inhibition after fulfillment, triggers and lapsing time weaken inhibitions (shortly after instinct fulfillment only most specific and powerful triggers work, later weak triggers adequate, eventually triggers imagined), everything associated with instinct triggers and fulfillment become reinforcers and perceived as positive, leading to forming indirect triggers.
Abuse-addiction behaviors other than drug abuse: pursuit of abusive, unethical instinctive-cultural fulfillments that people may learn, usually influenced by a subculture and/or peer environments. Examples: abusive eating, gambling and computer games that are addicting and may contain gambling, materialistic pursuits and consumerism, pursuit of unethical fantasies (vicariously engaging in unethical sexual, violent, vindictive behaviors), conspiracy theory – theorizing, pursuit of wealth and power, etc. Also enjoying memories or fantasies about substance abuse.
AA/NA: problem issues:
– idea of permanent “disease”, not phase in life (self-fulfilling prophecy?);
– no distinction lapse – relapse [lapse impulsive, relapse starts with mind consenting, giving into temptation and rationalizing why it may be o.k., or giving up (too hard for me, or “once and addict – always an addict”)
– ‘Higher Power’ often seen as ‘external’; religious formulation (God’s actions invoked), and no change in >70 yrs. (AA book treated like a religious scripture).
Treatment and prevention – principles and applications:
– To stop abuse that is self-reinforcing, something that is emotionally more powerful must counter it – patient must finding motivating factors, usually based on social instincts
[Myth: having to do it for oneself, no for loved ones, including future partner and future children (nieces, nephews)]
– Instincts/drug abuse reinforced by use, real or vicariously, memories and fantasies enjoyed “relished” and pursued, etc.
– Instinct weakened/”killed” by continuous avoid of triggers, non-use, real and vicariously, not romanticizing memories and fantasies, etc. Later changing meaning/effect of triggers, no longer inciting instinctive behavior, rather shameful, guilt inducing and/or disgusting (not just ‘forbidden,’ taboo).
– Broad learning (finding meaning in sciences, observing and/or studying nature, literature and arts, healthy lifestyle with exercise and meditation [possibly yoga, marshal arts], improving social connectedness, helping activities, etc.)
– With choices what to do: always ways of feeling good that are 1.a and b constructive [for résumé or eulogy, 2. neutral or mixed, 3. negative, damaging to self and/or others, benefits do not outweigh possible negative consequences;
– Understanding priorities: rocks, pebbles, sand (first put rocks into jar, then pebbles, last sand).
– Guiding principles: guidelines and recommendations [usually convenient to follow], family rules and laws [people wish to overstep them if not caught], taboos [too shameful or disgusting to enjoy thoughts]
– Ethics and establishing personal culture most relevant in drug abuse prevention. Adolescence is not about enjoying time before life becomes serious, adolescence time of most relevant psychosocial and vocational development/learning. Ethics is equally relevant in secondary (abuse not developing into addiction) and tertiary prevention (work during maintenance treatment, or after detox).
Ethics: most relevant principles
Ethics is about what is instinctively doable while positive for others, future of world and, directly or indirectly, for self:
– Supporting/strengthening ethical social instincts, wanting to nurture, help and please, etc.
– Generous reciprocity with compassionate empathy (not strict “tat of tat”; no exploitative or sadistic empathy)
– Avoiding us-versus-them (group) thinking, which dehumanizes others and suppresses sympathy, compassion and empathy.
– Avoiding (attempts to overcome) other unethical propensities (instincts), including vindictiveness, physical aggression, compassionless opportunism, promiscuity, fascination with painful situations or procedures and with cruelties (wanting to be participant).
– Avoiding or weakening problematic instincts, such as competitiveness (fighting for rank, territory and managerial powers), expectations for children to practice to where healthy balance is lost, minimizing competitive games (gathering-hunting tribes’ children rarely play competitive games or keep scores of successes), expectations of other being satisfactory and ‘right’ by own expectations and standards.
– Broad compassionate empathy that oversteps us-versus-them (group) thinking
– Generously giving excess resources (material, time, care) in natural order: developmental stage, previous investment and reciprocal feelings; close and distant; considering animals, particularly animals we are involved with; future generations (environmental concerns); etc.; but attempting to include some giving for all groups.
– Avoiding unethical thoughts: they are dangerous and damage human relationships
– Intuitive ethics checks (broadening perspective: imagined talk with peers, wise people, panel of very different people; imagining advising own planned actions to same sex older child, twin or loved peer, etc.)
[To have/strengthen willpower, we need emotional reasons for change. Discipline can be practiced, planning steps that are followed without any further thinking, like in military – no excuses, no procrastination (unless there is major new information that demands reconsideration of plans).]
Stress and pain management, psychiatric problems:
– Meditation/Autogenic Training (AT); Meditation = narrow mental focus, no judgment; frequent short meditation; sometime longer always returning to focus, e.g. breathing; awareness mediation e.g. walking with good posture and observing self and natural environment without judging. Self-suggestions: ‘nothing is important’, ‘I expect nothing’, ‘the past does not define me”, etc. Continuous self-talk (mantra, short prayer, repeated self-suggestion) distracts from thoughts. Focus on essence/serenity of clam scene (e.g. ‘sinking into’ warm sand, body shaded, sun on stomach, cool breeze over forehead: essentially includes suggestions of AT: heaviness of right hand, then spreading, warmth [comfortable indifference temperature], observing heart beat, observing breathing [passively], warmth to upper abdomen [above body temperature, to calm abdominal organs], coolness to forehead [alertness]). With meditation, often uncovering of superficially ‘buried’ memories and emotions, seemingly paradoxical reactions (e.g. important event almost forgotten, anniversary of good or bad things, anger about something one tried to forget, feeling need to move).
– Self-hypnotic techniques to raise stress and pain tolerance, changing pain perception with self-suggestions (pregnancy, childbirth preparation)
– Cognitive stress management, looking at issues from many angles and accepting reality, forgiveness (Christian) and decreasing expectations (Buddhist); going back and forth between meditative and cognitive approaches. Meaningful to live ‘as if’ safe, protected, trusted, etc. while knowing that nothing safe or predictable
– Addressing psychiatric issues: going back and forth between cognitive and meditative approaches, stress management techniques, approaches of happiness research, exercise and healthy diet, improving interpersonal interactions and social network (pets helpful), Eye Movement Desensitization and Reprocessing (EMDR) often indicated for PTSD related disorders
– Addressing, learning to understand chronic pain (body should adjust, decrease pain perception that becomes meaningless; meditative attitude accepts pain impulses without automatic judgment “that must stop/change”). People must learn to find meaning in life in spite of imperfect or ‘bad’ body [treat what safely treatable, accept what is not].
– Emotionally supported positive motivation gives will power. Change then easy, one must expect lapses; avoiding relapses most problematic and relevant.
– Negative goals, e.g. stopping bad habit or drug abuse doable if not easy but necessary to work on multiple levels (multiple changes at once, negative and positive, easier than working on one gal at the time).
– Visualizing positive results that are possible with work, and luck an enjoying image of goal (but in many situations not expected or mainly hoped for); work towards goal meaningful and in some ways enjoyed even if stressful, e.g. for weight loss, ‘enjoying’ and pride handling hunger feeling.
– Self-monitoring to avoid habitual aspects of behavior; structuring/decreasing behavior; finding many alternative behaviors.
– Planning change in steps, e.g. scheduling next day, following through without thinking more and reconsidering unless there is major new information.
– Lapse versus relapse: expecting lapsing thoughts and behaviors, always returning to plan, never giving up or giving in.
– Making multiple changes at once much better prognosis than one at the time; important to learn new things; work on psychiatric issues.
Myths: Patient must do it for themselves – motivation usually from social instincts for loved ones, potential future partner, future children, etc.)
Why is methadone not an addiction: reward too indirect for spontaneous self-reinforcement. Nobody acquires a taste for methadone or buprenorphine. Methadone medication taken to decrease craving to manageable level, feel “normal”, etc.
Improving treatment at OTPs:
Patients should see abuse-addiction as phase in life.
Opioid maintenance should also be phase in life (usually years), rarely be lifelong
During maintenance treatment,
– abuse-addiction must become distant past (immature or adolescent phase in life, mote between present and past with thoughts about abuse becoming taboo (meaning even thoughts feel bad, guilt/shame-inducing, disgusting) rather than “forbidden” enjoyable or romanticized memories (forbidden is what people secretly wish), and triggers must change in meaning;
– all abuse behaviors addressed (not increasing food abuse, not continuing smoking or vapor nicotine, etc.);
– broad learning necessary: non-pharmacological stress and pain management, ethics, helping activities and refreshing healthy relationships, hobbies, artistic and scientific learning, learning about other cultures (bicultural people do better than Anglo-focused Americans)
– addressing pain management and stress management (negative anxiety), mood disturbances, loneliness, PTSD related symptoms and disorders including panic disorder
Meditation and pain/stress management (AT and self-hypnotic techniques) most important in pregnant opioid maintenance patients – in our experience greatly reduces likelihood of Neonatal Abstincne Syndrome (NAS).
Addressing the USA opioid addiction epidemic: Failures and Possible Solutions
As a psychiatrist who has worked with opioid disorder-multiple diagnosis patients since 1975, I am astounded by the failed and negligent responses to this epidemic, the worst health crisis in 100 years. Lacking relevant education, physicians and agency representatives keep referring patients to dangerous, obsolete and experimental treatments.
Methadone has saved lives and families for decades. Detox-rehab, erroneously broadly considered ‘the standard of care,’ has an expected relapse rate of about 90%, with many patents consequently overdosing, some fatally. Vivitrol (naltrexone), which blocks the effect of opioids, is new, very expensive, and similarly dangerous. The patients lose their tolerance to opioids, but their addiction thinking remains. Later they usually relapse with a high risk of overdosing. Some “successful” patients become alcoholics or amphetamine abusers.
Methadone maintenance, a safe treatment with better results than any other approach, is still broadly misunderstood and maligned; it is not widely available and rarely covered by insurances; government agencies interfere with its use. Methadone has a very slow onset and long duration of action; there is no “high,” no intuitive connection between taking the medication and feeling better, as in addicting drugs. Craving becomes manageable and daily functioning returns to normal without impairment of judgment. Dysfunctional addiction behaviors cease. Buprenorphine (Suboxone) is similar to methadone but weaker and for many patients inferior. It has a significantly higher drop-out rate compared with methadone treatment. While methadone programs must offer some counseling, Suboxone is usually prescribed without structure and counseling support.
There is hardly another psychiatric treatment that leads to similarly rapid, dramatic improvements. Methadone and buprenorphine also have antidepressant effects; they decreasing alcohol craving, aggression and sex drive, and, in our experience, also symptoms of anorexia nervosa. Solidifying changes in emotional-behavioral patterns takes time: most patients need the medication for years, along with psychotherapeutic approaches.
So far, Texas has had some successes concerning availability of buprenorphine and decreasing opioid prescriptions. However, many patients have been driven from pain pills to heroin, more dangerous opioids, alcohol or amphetamine.
From a societal perspective, our civilization largely fails to address vulnerabilities to abuse-addiction in young people and even in patients who are in treatment. Factors include:
– Previous/continued abuse behaviors (nicotine, alcohol, gambling, etc.): having learned to rationalize overstepping cultural, ethical and other limits.
– Depression, anxiety and posttraumatic disorders, social isolation, aimlessness, spiritual-existential crises, etc.
– Local cultures: family, friends, and media strongly influence how vulnerable, struggling people respond; they may cut, burn or starve themselves, withdraw, become suicidal, abuse alcohol and other drugs, join extremist groups, callously pursue wealth and power, etc.
– Additionally, young people often lack guidance in their task to develop a personal culture, values and meaningful goals; our culture does not adequately teach ethical principles, such as a loving, forgiving attitude, avoiding us-against-them thinking, accepting discomfort and deprivation while working towards meaningful goals, avoiding unethical thoughts, respecting boundaries, self-sufficiency as feasible and being an asset to others, etc.
Learned abuse behaviors soon feel natural. Anything associated with the abuse starts feeling normal, good and desirable. In addiction the pattern of abuse behaviors continuously competes with the patients’ highest priorities. Patients may switch from one to other dysfunctional behaviors. They rarely have the will power to stop because they lack lasting positive emotions that are powerful enough to override the appeal of abuse behaviors. The behaviors become habitual. With traumatic or very exciting events and significant learning, the brain changes, this applies to opioid abuse. While unable to erase previous learning, we can learn more mature ways of responding. Long-term medical treatment must include psychological-psychiatric therapy that addresses the patients’ vulnerabilities, psychosocial development and growth.
Heinz Aeschbach, MD
= = = = =
added 9/2015, minor revisions 5/2016
– Adults must teach young people about ethics in a broad sense, particularly that generosity feels good and is necessary in relationships, that they must develop broad compassionate empathy, avoiding “us-against-them” thinking, and that they must learn about ethical and psychosocial aspects of intimacy.
– Young people should hardly ever be given complete privacy, e.g. no closed doors when with other person(s); particularly groups of males should always have some adult supervision. (Groups, young males more than females and more mature people, often amplify biases and unethical inclination in each other, sometimes devising highly unethical plans.)
– When with young people, adults may emphasize the importance of adolescence; tasks include general broad learning, ‘finding self’ and developing personal culture and values.
– Young people, while ambivalent towards adults, benefit much form adult attention, interaction, support and limits.
– While young people can think in mature ways, the critical parts of their brains work slower (frontal lobe neural pathways not yet myelinated). Already in childhood, people should learn to always pause before making any significant decision (doing something or avoiding what could be done), and ask self questions concerning ethics: “Will I probably regret what I want to do?” and “Could I recommend such an action to peers?” “Would the wisest, most trusted older friend of mine probably agree with my decision?” etc.
– Young people should focus on rebelling intelligently and meaningfully, evaluating what parts of family culture and culture at large is good, and what they can improve on without reinventing everything.
– Young people should learn about “three ways of feeling good”: with 1. constructive, 2. neutral or mixed,3. destructive activities. Or alternately. 1. direct instinct fulfillment, 2. indirect instinct fulfillment, through cultural activities, 3. by using drugs that directly reach reward system and cheat the emotional-behavioral system. Abuse is, by definition, bad, unethical. Drug abuse “cheats” the emotional-behavioral system. Abuse-addiction derails normal developments and keeps person psychosocially and emotionally in an immature state.
– Young people should fill their days meaningfully with activities that include academic and artistic learning; meditating, yoga and/or marital arts; learning cognitive stress management skills; practicing sports and games for enjoyment and health rather than competition; etc.
– Young people should learn to feel part of groups that are defined by meaningful principles and goals, avoiding visible symbols of group identification (tattoos, piercings, brand-name identity, apparent gang membership).
– In young people, addressing poor handling of stress and mood disorders is particularly important. If the structure of residential treatment is indicated, we must avoid seeking “least restrictive” treatment options. Most psychiatric disorders need long-term treatment with caring structure being very important. Healthy lifestyle and learning forms of meditation and self-suggestive techniques is usually beneficial; religious teachings should be avoided.
– Drug related messages and education about dangers are hardly helpful, except within comprehensive health teaching and while learning about ethological research and neurosciences. People of all ages need positive goals that counter abuse thinking and that are supported by powerful emotions.
Abuse feels like a short-cut to the reward of instinct fulfillment. However, one gets close to instinct/cultural fulfillment but enjoys only false anticipatory reward feelings. There is an unbridgeable gap between where the drug leads to and what the goal is. While feeling like conflicts are resolved, the relaxed, intoxicated person is further removed from a resolution. While feeling the warmth of human bonding, physiologically, in light-eyed persons visibly tiny pupils of the opiate user create an even greater distance between drug user and loved ones: the “window to the soul” appears closed, it seems like “there is nobody there.” When positively excited with psychostimulants, the user does not have an accomplishment in mind that he anticipates.
The feeling from an abusable drug should be perceived as “too good” and young people should have an intuition that something is not right as when somebody suddenly acts very generously – people will ask “what does he want?” Abuse-addiction is like a contract with Satan, as in many fairy tails [e.g. tails by the brothers Grimm]; the abuser feels good not recognizing that he promised the first born or his daughter to Satan; the loved ones suffer first, eventually the negative consequences also reach the abuser-addict (these stories probably symbolized gambling and beer drinking).
In many cultures, adolescents are well supervised and kept (or keeping themselves) busy working, studying and/or in artistic pursuits. Sometimes adult university students act more like adolescents, not yet experienced and mature enough to handle their freedom, even though having mature brains.
‘Anxiety’ is a major factor leading to new abuse behaviors or to relapse. As children face less adversity and adults seem overly concerned about children’s self-image, many children fail to develop strong resilience. Humans generally like and seek anxiety or stress, including danger and anticipated pain, if meaninfgul; but humans do not like conflicts. Anxiety is not “overestimasting dangers and underestimating coping skills,” it is overvaluing (overly focusing on) dangers and losing sight of the need to learn coping skills, particularly when difficult situations are unavoidable and/or meaningful. ‘Being/feeling overwhelmed’ includes the thought of temporarily giving up, not trusting in own resilence.
General uncertainty is normal but no longer well tolerated. People are generally much safer and know much more about loved ones than in past. However, uncertainly due to debts appears particularly toxic, depressing, often leading to abuse-addiction and suicide.
The natural male propensity is to rebel against authority figures, to take major risks to prove his strengths and skills, and to compete with, fight and drive away other males, the winner then wanting multiple females. Showing off often includes abuse behaviors. Obviously, following these instinctive propensities is unethical and leads to disaster.
Young people’s clothing and tattoos do not express who they are; instead they show messages to others that are likely to be misinterpreted. The young person cannot foresee how they will be judged based on their appearance nor how they themselves will feel about their tattoos in the future.
Young people often benfit from cultural experiences with spiritual feelings. However, religions should not offer specific teachings concerning good and bad behaviors, life after death, etc. By definition, religious beliefs cannot be substantiated, religious teachings among leaders of a religion contradict each other, and teachings often contradict natural ethics, and religions divide people.
Factors pertaining to mental health and primary drug abuse prevention:
For a healthy development within their society, children need stable attachments and opportunities to learn and practice social skills, including broad empathy and an understanding of cultural values and traditions. Children have inherent temperaments, talents and predispositions, and they may have some lasting problems from early childhood traumas and under- or over-stimulation in critical periods of development. A major task for children is to practice/strengthen areas of weakness, to compensate for shortcomings and to develop potentials that are beneficial within their societies.
Children may need at least one stable parental figure, and children benefit from parental figures of both sexes, close relationships with relatives and friends of a wide age range, and access to natural environments. These components in the young child’s environment are today less available with yet unknown consequences (it is not clear how the frequent, very early placement in commercial day care affects their development). Children’s natural propensity to exercise their bodies, express themselves artistically and to meditate and contemplate are often suppressed.
Major problems in early childhood include folklore that raises false expectations, e.g. good things happen to good children, bad things happen to bad children; if working hard or visualizing and believing in your goals, having hope, you will reach them and live happily ever after. Children hardly ever hear stories written from the perspective of a victim, somebody who suffers and dies prematurely. Western folklore also reinforces black and white thinking, rather than recognizing shades of good and bad, yin and yang, male and female traits in virtually everything.
Accepting and dealing with realities is important from an early age on. Fate is random (no god or guardian angel intervenes personally on a person’s behalf); we can only influence, never control or predict, our environment and future. Accepting reality includes accepting emotions, feelings and thoughts as they come up, while being aware that the self can keep some distance: judgmental, ugly thoughts that intrude into awareness are not who he is or what he believes. A girl may observe and accept a fear as natural, it then is likely to become an apprehension she does not often think about. She may observe a pain sensation but continues to focus on what is meaningful to her at that moment. A child may deal with issues in more or less solitary play and in social interactions; however, some children need help to handle stresses. It is reasonable for children of certain temperaments to rely more on leader figures. Some children benefit from a very structured environment. Probably most traumatic is abuse that clashes with cultural expectations, leading to shame, guilt, disgust and horror, a sense of dread, unpredictability of people and fate, and extreme loneliness; traumas may be personal or sympathetically experienced. Dissociation and/or wishing strongly that reality can be changed, should at most be a temporary response to extreme situations.
Inability to adjust to micro- and macro-environment, and/or a mismatch between temperament, individual shortcomings and environment, leads to psychiatric disturbances. Most psychiatric problems considerably increase the probability of young people slipping into abuse-addiction patterns. Early and effective psychotherapeutic approaches (EMDR should often be considered) and/or other treatments are likely to make a significant difference.
The question whether drug abuse-addiction or another psychiatric disorder, such as major depression, is primary is in most cases irrelevant. Both develop side-by-side influencing each other, and treating one successfully does not necessarily help with the other disorder. However, leaving a major psychiatric disorderuntreated usually interferes with the successful treatment of an addiction disorder. Substance abuse prevention and treatment programs often fail because there is no staff to properly address PTSD or other major psychiatric disorders.
Some psychological propensities and symptoms make addiction disorders more likely, e.g. attention deficit or posttraumatic symptoms, including anxiety, panic attacks, depression and borderline personality traits. Other propensities may be somewhat protective, e.g. obsessive-compulsive symptoms, always wanting to be in control .
In the USA multiple social-cultural issues contribute to the crisis of many or most adolescents. Kindergarten should focus on imagination, social play and social learning, observing and working with nature (‘Kindergarten’ means a garden for children); helping and cooperating more than competing, hopefully learning tolerance and learning to accept, trying to understand people who are different, etc. Language, including listening when read to, should be fostered, hopefully in two (or three) languages and including material from multiple cultures. Materials used in teaching languages should foster empathetic understanding of very different people (culture, age, socioeconomic, sex, etc.). Children should observe and practice artistic forms of expression (singing and/or musical instruments, dance, drawing. etc.). Academic learning, writing and mathematics, should generally start in grade school, even though some children learn such skills before kindergarten. In grade school years, children must primarily learn to enjoy and appreciate the meaning of learning, becoming engaged, not passing some tests.The differences between boys and girls are not adequately taken into consideration and at least partly sex-segregated education has significant advantages. In high school, many children are given too many choices; some overspecialize early, develop in a one-sided way and become overly competitive; many are left unengaged, bored, ‘lost’ and unhappy; some seek an identity through superficial symbols or by joining gangs. Late grade, middle and high school years is a time when children should learn much, broadly and in depth, creating the basis for complex thoughts, and the basis of a self, an identity with personal culture and values, and also friendships that last lifelong.
The most relevant factor in abuse-addiction prevention is treating the active abusers and addicts. People do not invent abusing specific substances when they perceive life as meaningless, are bored, lonely and/or emotionally disturbed; they learn abuse behaviors from the active users.
There are three stages of drug abuse prevention:
– Primary drug abuse prevention includes preventing abuse behaviors, decreasing vulnerabilities and strengthening protective factors.
– Secondary abuse prevention seeks to avert the development form minor abuse to abuse and addiction disorders.
– Tertiary abuse prevention is relapse prevention during and following treatment for addiction; it may include preventing or treating secondary addictions, such as food and nicotine addiction while in treatment for alcoholism or opiate addiction.
In all three stages, vulnerability factors must be addressed. When a child feels he/she hardly can tolerate a situation and would like to become invisible, the child may need help, otherwise observing others’ drug use may soon become irresistible when trying to soothe anxiety and seeking ways to self-medicate. Many addicts have mood disorders, psychosocial problems and/or post-traumatic symptoms that need to be addressed.
If adults smoke, drink and/or use “recreational drugs,” they must do so only in adult company. As people may not know of a neighbor’s substance abuse problem, children should know very little about substances their parents, relatives, teachers and older friends use. Children may observe if somebody has mood swings and functions poorly, but they do not need to know why. Instead education should help them conclude that they can, most likely, do better than their parents, when they grow up.
Children learning respect and caution is another prevention issue. In the past, young children were taught very early that only what the child knows to be safe may be considered safe; if he does not understand an instrument and does not know exactly how to use it, he must not manipulate any lever or button, pick it up, etc. And only if specifically given permission may he take, play with or eat what he can see. Today children often believe that what he physically can do must be o.k. and safe, and adults often reinforce that belief; if a machine has a moving part, it must be safe to move it. What is visible may be touched and picked up, eaten if looking edible, etc. Many children believe that pills that are not hidden and locked up must be safe and good for anybody.
Abuse prevention, starting in school age and in later stages, must focus on ethics, positive motivation that is supported by emotions, and dealing with negative stress, i.e. negative anxiety and depression. Generally people want anxiety – most anxiety and stress is mixed or positive; however people do not want conflict and may need to learn dealing with conflicts, cognitively and utilizing meditation, artistic expression, exercise, etc. to regain resilience and adaptability of the mind. Patients need to develop a personal culture that precludes abuse behaviors [see below: Abuse-Addiction Treatment].
Particularly in secondary and tertiary prevention, developing a personal culture is most relevant. People need values and long-term goals that have emotional meaning, such as not wanting to be hypocritical, wanting to be self-sufficient, wanting to be the best parent possible (for most mothers a main goal is that her children do better than she and her siblings did), helping to move society towards positive developments, practicing highest ethical standards, etc. Patients may re-evaluate values they had before their adolescent turmoil and drug abuse. The emotional power of values must be greater than the attraction of the drug and other abuse behaviors. Replacing alcohol with other abuse behaviors, such as loveless sex or sweet binges, is not recovering.
Primary adjustments to life include accepting our feelings, including anxiety, anger, fear and pain. Heathy responses to life situations follow the principle “function first, comfort second”, e.g. first taking care of children, animals, household or relevant work without pondering aches and worries (not “I cannot do this until I am pain-free, feel less anxious, etc.). In case of a new form of pain, we should think “is this a symptom of a new disorder that needs evaluation and treatment?” rather than “what ‘pain killer’ or drug will make it go away?”
Approaches in stress management include cognitive approaches – mainly overcoming conflict, transforming fear of pain during meaningful pursuits into apprehension while focusing on (looking forward to) probable good outcomes; overcoming or consciously challenging ‘automatic thoughts’ that may have been created by authority figures in early childhood; recognizing own role in difficult situation (sometimes taking on a very limited task, sometimes leading and taking charge, sometimes simply being ready to be supportive and positively influencing situations as feasible). In ill-defined anxiety (afraid to look at what one fears) and conscious extreme fears, the patient should evaluate ‘worst case’ scenarios, confront them and imagine how one would courageously suffer and accept extreme challenges. Also important are healthy lifestyle, interpersonal approaches that fosters good human relationships (relationships with animals are also helpful), relaxation-meditation techniques (particularly Autogenic Training), awareness meditation and contemplation (practicing nonjudgmental attitude), and self-hypnotic techniques. Under stressful conditions, the person may have to go back and forth between cognitively evaluating, being meditative and contemplating without judging. Antidepressant and mood stabilizing medications (and/or omega3 fatty acids, l-tryptophan) may be indicated.
Ethics teaching should focus on humans’ inherent desire to be “right” and “good” (right may refer to adhering to rules or rmisguided religious teachings rather than ethics). Particularly adolescents are ambivalent, not realizing how self-centered they often are while, at other times, being highly idealistic. Abuse is, by definition, unethical. Abuse-addiction not only “cheats” nature and culture, it reinforces incompetence, unethical behaviors, pain, etc. Teaching may stress how abuse-addiction “work against nature”, derails healthy developments, reinforces young person’s feeling bad, keeping him/her “stuck” in immature state. (Ethics teaching is very important, compare 3.4.1)
Medications such as antidepressants and mood stabilizers may help increase mental flexibility and sense of resilience; tranquilizer-type medications, to handle stress and to sleep, should be reserved for emergencies such as after a heart attack, while treating an acute ulcer or possibly in a defined stressful time such as while waiting for crucial laboratory results.
Regarding stress: stress is defined by animals using their mental and physical resources when dealing with heat, cold and dangers, and while seeking forms of direct or indirect instinct fulfillment. Animals, including humans, are positively oriented, guided by instinctive (and cultural or drug use related) goals that feel ‘fulfilling’ or rewarding. Humans are not primarily thinking of avoiding pain and frustration. If there is no stress, if everything is static and safe, people seek pain and stress: in fights for rank order, exploration and reproduction; in extreme sports; in tattooing, piercings and unnecessary plastic surgeries; etc. People only complain about stress when there are conflicts: the person feels the stress should not occur and goals are confusing with contradictory expectations by influential people, conflicts between instincts and culture, etc. In drug abuse, goals are pursued like instincts; fear of withdrawal is less of a motivating factor than the frustration of no longer having access to the addiction behaviors (withdrawal is perceived as particularly negative because it is meaningless, the person will use again as soon as feasible).
It imay be more hlepful to divide thoughts and images into what is or is not helpful, than what is closest to the ‘truth’, whether there is good reason to be angy, etc. The core of our selves is separate from thoughts, perceptions and impulses; we may pursue meaningful goals while accepting negative perceptions; our minds can move away from negative thoughts such as doing something unethical to alleviate pain or anger. Particularly in girls, confusion about sex and poor self-image leads to vulnerability towards drug abuse and addiction. (Our anecdotal data indicates that most women patients reported a significant deterioration shortly after first intercourse, often rapidly moving from substance misuse or abuse to addiction.2)
For adolescent and young adult males, drugs are often part of male risk taking and rebellious acting out against cultural values of parents, teachers and culture. Usually, there is a sense of being in control, able to stop at any time, however, often there are no adequately powerful motivators to stop patterns of abuse. Men need positive goals and their ambitions should be directed. If there are no good role models in their families and schools, school counselors and mental health workers may find mentors and helpful organizations.
In young people, role models may be persons they know about and even fictitious people. Counselors and parental figures that the young person appreciates may direct the adolescent towards role models that were highly ethical, rather than glamorous.
Example of cigarette smoking (usually a ‘gateway drug’): raising positive motivation is most important. Teaching addresses immediate effects and the ugliness of smoke versus clean breath, clean and natural smelling clothes and hair, etc. To explain intermediate and long-term health effects: while smoking: the decline of body systems (lungs, blood vessels, heart, taste sense organs, etc.) is more rapid than normal; smoking cessation leads first to a partial recovery of damaged organs, then the normal decline is slow as in a nonsmoker with healthy habits. [Fore women, smoking, as drinking, is more damaging and dangerous than for men.] Considering ethics, smokers may be reminded that buying cigarettes pays for the advertising of cigarettes: advertisements targeting children and the most vulnerable people, young Third World women.
Laws and research appear largely misguided. Making specific drugs illegal may be futile since laws are hardly enforceable and entrepreneurs develop more dangerous replacement drugs that are not [yet] illegal. To curb drug developments, health officials may focus on the marketing of any substance that is not researched, has no known medical or nutritional benefits but is sold for “human experimentation”, i.e. seeking some sort of “high”. Similarly, medications/drugs from other cultures that are not proven to be effective and possibly contain toxic minerals and other substances should be limited in sales with clear warnings; they may be outlawed for use in minors.
Similarly, focusing research on specific drugs may be meaningless. Long-acting opioid antagonists miss the problem of abuse-addiction disorders, and immunizations that leads to inactivation of cocaine molecules is likely to lead patients to different, most likely much more dangerous drugs.
1 Some instinctive inclinations are problematic in modern societies; they often lead to unethical behavior and to distorted thinking; they must be addressed in cultural institutions (education, entertainment, literature, etc.) and by individuals while developing a personal culture. Particularly detrimental are:
– ‘Us-versus-them’ or group thinking: Social instincts, sense of fairness and compassion generally exclude people perceived as ‘them,’ ‘others’ or ‘outsiders.’ In groups, people often encourage biased, extreme positions in each other. Particularly young males are more likely to commit dangerous and unethical acts while with peers than when acting alone.
– Competing for rank and territory which may include aggression, greed, intense competitiveness with meaningless or unnecessary risk taking, holding on to anger and vindictive thinking, etc.
– Abuse-addiction behaviors: abuse means behaving in ways that are expected to make the person feel better while having some knowledge that the behavior is ‘bad,’ that benefits do not justify probable or possible harm to others and/or self; people readily develop a pattern of abuse, if there is no stronger, competing emotion or emotional value.
– Humans’ inherent interest and fascination with intense suffering and cruelties, wanting to watch, sometimes even participate.
– Giving in to, mentally consenting to and/or enjoying unethical thoughts, fantasies and emotions. Thoughts and fantasies strengthen propensities, interfere with healthy human relationships and make perpetration more likely.
By broadening compassionate empathy, ethics challenges culturally taught values and helps express instinctive inclinations in ethical ways. People also have an ethical obligation to work towards changing institutions and traditions of cultures.
The application of ethical principles is pragmatic, not ‘black and white’; pragmatic ethical decision-making includes reviewing situations from many perspectives, evaluating data regarding possible consequences of possible actions, and considering affected individuals empathetically, as time allows. Ways of broadening perspectives regarding ethics may include asking self: Am I thinking in a caring, empathetic, compassionate way? Could I recommend my plans to my (same sex) child or my peers? What would a wise friend advise? What would a panel of very different people from many cultures conclude? Would it be o.k. if, what I plan, would be done by many? Would I later regret a planned action or inaction? The decision then follows intuition and conscience (unconscious processing).
2 Media, other girls and boys incite young girls to become prematurely sexually active. Girls may agree to sex in an attempt to ensure a lasting boyfriend relationship, but are often dropped after they had intercourse, or the relationship deteriorates. At least for girls, sex is not “an experiment”; early sex usually lowers their self-image, and most girls regret their early sexual experiences. Sex is much less rewarding and more dangerous for girls than boys. Sex should be the last step in a courtship. Boys should learn empathy, never exploit insecure girls who may foolishly seek or readily agree to sex, and never pressure a girl. Girls may need help in assessing a what stage sex may be right for them and they may need support regarding their self-image. Practicing ethical, courageous and caring behaviors and persevering in learning sciences, humanities and forms of art helps improve adolescents self-image,
For girls, the changes that occur in adolescence are usually much greater than for boys: from being in control over dolls, rarely risking bodily injuries and having been taught to be afraid of pain, the new and powerful sexual feelings include giving up control, and fear actually enhances sexual arousal. For boys, childhood propensities, play and interests often directly lead to their careers. Love and sex enrich men’s lives but men can keep distance from their children. For men and women, sex leads to a feeling of being bonded (hormonal effects), but for men this bond is easily broken when moving on to another girl/women and for men it is easier to feel that they can love two women equally.
For girls, fighting over an attractive boy is very serious. In addition, adolescent girls are often cliquish and mean rather than supportive towards each other. Many, particularly less popular girls, feel alienated from their mothers and also lose their childhood friends at a stage when they need female support most.
While girls may be proud of becoming women, they lose biologically control in a way boys never do. First, menstrual periods come without her having an influence or warning, and irregular cycles are often associated with hard to control emotions and pain. Love includes giving physical control to an attractive strong but possibly violent boy, expecting acute injury and pain with first intercourse and at a later time likely and much more painful childbirths. In spontaneous sex, she does not know what happens when; she may feel bonded to a strong but abusive man; she may become economically dependent on an abusive father of her child; she has no control as to what kind of children she will bear when, but she will be and/or feel responsible for her children for the rest of her life.
Feminism and access to contraception lead boys to feel free to express their aggressive sexual feelings without or before developing loving, committed relationships. Boys often enjoy the aspects of dominance and aggression in loveless sex. Girls believe they should be equally able to enjoy casual sexual experimentation outside a committed, loving relationship, including the enhanced arousal they may perceive when afraid and dominated. However a girl’s emotional system does not know about contraception. For girls/women, sex is always serious, and losing a sex partner-boyfriend, particularly to a friend, is always serious.
The turmoil in girls’ adolescence, particularly when sexually active, makes them vulnerable to seeing immature and/or selfish boyfriends like leaders and even father figures. There is usually significant anxiety, uncertainty and depression. If they have access to drugs through peers or their boyfriends, abuse and addiction disorders may develop. Sometimes girls become addicted because they want to go along with what a unstable boy friend does.
In the USA, sex education, with attention to psychological aspects of relationships and prevention of pregnancy, is often lacking. Many boys show little respect and compassionate empathy towards adolescent girls. In the USA the rate of births in teenage girls is 10-15 times higher than in Switzerland (which has less abortions than the USA).
Most important in all types of abuse-addiction prevention and treatment are insight and positive goals that are supported by emotions. People need a perception of meaning in life, and a sense that abuse behaviors are contrary to personal goals, family values and personal culture. (Most people who use drugs do not become addicted because of insights, a recognition that other behaviors are more meaningful, that drugs would soon be in the way.)
Steps in treatment probably should include the teaching of basic aspects of brain functions and abuse-addiction:
– Patients need an understanding and belief in scientific data concerning the plasticity of the brain or mind. Past does not determine future; many shortcomings can be overcome by new learning and/or be compensated for.
– Abuse behaviors are learned and cannot truly be unlearned. They change the brain in the same way as complex cultural activities do (e.g. studying law or evolution, military training). Similarly, becoming sexually active includes learning that changes the brain. However, there is no inherent necessity to practice what was learned.
– The young child’s brain contains many pathways. Reinforcement with enjoying instinctive actions, cultural fulfillment or drug use, strengthens pathways that lead to the reward feeling, making them into “highways”; unused are pruned. Drug addiction establishes “superhighways” that lead to the drug use; it then takes years of nonuse for “grass, later bushes and trees to overgrow the highway.” Instincts, cultural behaviors and addictions are reinforced with use, including enjoyment of memories and planning, but they are weakened with nonuse. Though normal and pleasant, there is no inherent necessity to be aggressive or binge eat, and the longer a person goes without fighting or binging on junk food, the less likely he/she will act out, impulsively and/or planned.
– Patients must understand that abuse is never o.k. – it is not a matter of opinion, religion or dominant culture. It is a matter of ethics; abuse diminishes one’s humanness.
– Abuse is unethical because it competes with and ‘cheats’ nature (social instincts, etc.) and culture (mostly civilizations’ adaptations of instincts): abusable drugs feel good ‘for no good reason.’ Addiction is a core disturbance of our emotional-behavioral system.
– Abuse behaviors reward ‘bad’ feelings, thoughts and behaviors; they lead to neglect of self and loved ones. Addicts learn rationalizations that are more destructive than usual thoughts (people generally consider themselves to be more rational than they are, thinking that instinctive and cultural behaviors are done for rational reasons).
– Learning with abuse-addiction includes reinforcement of “bad” behaviors, moods, thoughts, etc.; everyting associated with abuse behavior patterns is reinforced, soon feels natural and even beautiful and pleasurable.
– Abuse behaviors involve more and more aspects of the mind, comparable to a mental cancer.
– Abuse-addiction behaviors slow or halt psycho-social development and positive learning; they often lead to regression (reverting to or being stuck in adolescent conflicts).
– Abuse-addiction behaviors may be understood as artificial, in cultural ways fulfilled instincts. The behaviors follow a learned internal readiness activated by indirect and direct triggers in the environment that the patient seeks. With treatment, the abuse behaviors are essentially erased and the meaning of triggers eventually changes.
Instinctively, we are not attracted to abusable plants. Natural instincts are also often expressed in cultural ways and children unlearn natural ways of eating (insects, wild berries and roots – when hungry, squirrels do not make our mouths water!) As with instincts, abuse behaviors are weakened and eventually erased by avoiding triggers and avoiding acting out the behaviors, stopping even the enjoyment of memories and imagined fulfillment. Eventually the meaning of the triggers is changed, e.g. beer may be perceived as disgusting since many people drink when wanting to insult and fight.
Abuse behaviors are by definition unethical. Abuse means doing something that is ‘bad’ with the goal to relieve tension, feel a thrill or “get high”; and abuse behaviors generally reward and reinforce bad feelings, thoughts and behaviors. Abuse behaviors are immature (adolescent): selfish, risk taking, rebellious (cultures are correct when seeing alcoholism and drug abuse as bad). The learning processes in addiction treatment may address:
– Sobriety, abstinence from abuse behaviors is not primarily for the patient, it is for his/her loved ones, including future friends and relatives that are not born yet.
– Patients need an understanding of human nature including inherent need to be “right” or “good”. Normally, humans want their children/next generations to do better, that civilizations develop and become more humane.
– Patients need to create an image of how they want to be in future. They then must learn feel how reaching the goal state would be, through meditation, contemplation and visualization. Some aspects of previous life may need to be grieved. Goals may need to be fine-tuned.
– For changes: self-monitoring (avoiding automatic and thoughtless actions), observing rhythms of high and low tension and danger; doing ‘reruns’ of situation where one failed, imagining how it would have felt to do ‘right’ thing; structuring behaviors; changing habits, settings and environments around times of high risks (when behavior anticipated), usually without telling others why routines are changed; etc.
– Lapses must not leed to relapse: it is most important to distinguish between impulses, including lapsing feelings, thoughts or behaviors, versus going into unethical fantasies, enjoying them, mentally consenting to them, and, in specific circumstances, executing them. Mentally consenting to thoughts of drug use, thinking it is now o.k. or giving up (“I knew I could not do it”) is typically the root of a relapse. Patients must assume that lapsing thoughts and actions may occur at any time, are normal, even though they usually decrease over time. Lapses are recognized as ‘wrong’; the person knows that a turn of at least 90 degree is needed; lapses rarely lead to relapse.
– “Stress”, meaning negative stress, negative anxiety with conflicts, typically translates into drug craving and/or focus on “withdrawal.” When in conflict the person is uncomfortable and the mind scans what worked in the past for relief. In extreme stress, the person shortly regresses, feeling like an infant, grade-school child, then like and adolescent.
Approaches in stress management include cognitive therapy, interpersonal therapy that fosters good human relationships (relationships with animals are also helpful), healthy lifestyle, relaxation-meditation techniques (autogenic training, self-hypnotic techniques, contemplation). Meditation is defined as narrow mental focus, e.g. on breathing alternately through right and left nostril, and non-judgment, i.e. not judging temperature or noises, letting an ache be, etc. Contemplation consists in looking at facts, past, present and probable future, without judging, without guilt, disgust or revenge feelings.
Patient must define all misuse/abuse behaviors (that may become addictions). [Social drinking and cigarettes are probably main factors leading to relapse in drug addiction patients.] Any potentially abusive and addictive behaviors may interfere with progress, and/or lead to relapse after discontinuation of opioid maintenance treatment. Abuse behaviors include many drugs and medications, nicotine, food for stress relief, gambling, inappropriate shopping or sex, etc. Patients should set clear guidelines, e.g. sweets allowed in culturally appropriate situation, as deserts, with guests. Patients must find positive motivations to stop them, and, possibly with specific help (e.g. buproprion for nicotine and psychostimulant craving), stop behavior completely before leaving treatment [coffee is healthy and generally not dangerous]. Particularly groups may be effective in helping patients gain insights and motivation.
Patients typically enter treatment for negative reasons: pressures, fears, etc. The human mind does not respond well to negative factors; cautious behaviors due to negative factors are generally short-lived unless there is an instinctive component, such as fears of snakes or deep water. Patients need to move from primarily negative to primarily positive motivation, mainly through learning, better understanding of human nature (instincts, culture, abuse) and through changing perceptions, thought patterns and values. At the same time, patients should explore and recognize what is positive and negative about abstinence versus use, acknowledging that a drug-free life is often hard (no quick relief when there is stress and pain), while during addiction, the quality of life is good (excitement and “highs” while dangers and adversities hardly bothersome). The main difference is meaning in life versus lack thereof. This aspect of treatment mainly deals with growth, learning and maturing.
12-step models (AA/NA) may be counterproductive. If a belief in a “higher power” seems right to a patient, this “higher power” must not be an external god, a meeting or “whatever”; it has to be the core of his/her being, the part of the human mind that wants to be ethical, in some ways “right” and “good”. Religious people may benefit from the Quaker concept of “that of God” or “the Light” being in everybody; focusing on “the inner Light”. Advertising an abuse history to strangers is not helpful, abuse histories should be very private, to be revealed to psychotherapists and spouses, possibly adult children and a rare confidant, not friends and distant relatives. Former drug addiction patients must not believe in having a permanent “disease” and being permanently in “recovery”, they must not become dependent on meetings, they need to mentally move on, not become professional patients.
Treatment should strengthen motivation for education: academic, artistic, etc. Young people then should recognize how a good education allows them to do what they are interested in and get paid well for it while lack of education forces people to do what they may not like, getting paid poorly.
Ethical discussion should address broad range of issues: counselors and teachers should deal honestly with problems in our culture – laws are wrong in principle and law enforcement is bad in execution, there is no justice (everybody is different, fate is random, same treatment of different individuals is not justice), social political systems are deficient; then move on to pragmatic acknowledgment of what seems to, more or less, work, how the presently unchangeable judicial system functions, how each individual needs to work on improving his/her personal culture to an ethically higher level than present standards, etc.
Substance abuse treatment is like initiation into true adulthood, a level of maturity, a stage where adolescent behaviors become taboo. For young people, it is normal to at least consider ignoring guidelines, overstepping rules and laws, and adult people, hopefully more cautiously, do the same. However, young people have not established taboos for themselves and/or often questioning taboos; adults should have and obey cultural taboos. Taboos defined as cultural laws that have been proven over time to be meaningful with no exceptions; if pondered and researched, the result should always be that the taboo is justified. Obviously, they are occasionally overstepped – otherwise nobody would talk about them; however, even thin king of breaking taboos generally leas immediately to feeling shame, guilt and disgust – not following taboos is an indication of immaturity and/or mental disorder. Adulthood includes accepting many behaviors, which may be open to question or acceptable to adolescents, into the category of taboos. Most important: suicide, other than in final stage of a terminal illness, is unethical and must be considered taboo; if suicide is considered, relapse becomes much more likely. Other example of taboos in adulthood include physical fighting and other forms of using physical force (e.g. in rape); promiscuous thoughts and behaviors, any sexual behavior with a child or first degree relative. The primary positive motivators are meaning in life, ethics, and a higher standard of personal culture (as opposed to culture at large and drug subculture).[To explain: guidelines and recommendations are least important but often convenient; regulations and laws are usually followed but often overstepped and most people like to think of sometimes overstepping them; taboos are considered absolute, shameful to think about, to be followed even if no uninvolved person can find out.]
If the patient (temporarily) lacks protective mechanisms, e.g. lack of insight and sense of directedness and/or depression with little appreciation for the future, abuse behaviors tend to become more frequent and grow into major psychiatric disorders.
Patients should lean that the more intense a feeling/emotion (craving, anger, manic feeling, attraction to person) the more one has to acknowledge and accept the feeling while letting it slowly go, without acting on it, expressing it or talking to others about it; simply staying kind, caring and friendly. Finding reasons for feelings reinforces them. [Feelings, including craving, are contagious; when showing bad feelings towards others, retaliatory feelings are reinforced; if feeling very good, people easily make unreasonable promises or raise exaggerated expectations. Positive feelings and criticisms may be verbally discussed after some observation and contemplation.]
Patients may need to understand weight problems since some people revert to psychostimulant abuse when overweight, and foods themselves may become addictions.
Hunger results from that the body’s physiology switches from burning nutrition in the gastrointestinal tract to using glucagon reserves in the liver, then burning fat. Hunger also follows rhythms that a person developed and there are often conditioned reflexes. Biologically, people normally want to eat much to build up reserves when food is available and stress is relatively low. Appetite is suppressed by stress (positive or negative) except when people find easily digested, calory-dense “comfort foods”. Weight problems are aggravated by the ready availability of foods to be designed to stimulate appetite (salty, spicy appetizers) or to be eaten on a full stomach (deserts) and generally by calory-dense, overprocessed foods that lead to an endorphin-based feeling of calm. Frequently feeling hunger is normal but temporary and much of the time, we may acknowledge hunger without acting on it. Significant exercise helps regulating apetite and prevent, halt or reverse weight gain. Focusing on other activities that are positively stressful (physical, exciting to person) allows losing weight. Weight loss due to stress is similarly temporary and usually not a problem.
Patients may need to understand chronic intermittent pain which often leads to opiate addiction. Chronic pain is a misnomer, it is greatly misunderstood: the CNS is designed to tune down and ignore irrelevant continuous or intermittent information, including bad smells and pain stimuli (there is, however, progressive pain e.g. with cancer or rheumatoid arthritis). People with completely rotten teeth eat sweets and become obese. Nursing home patients with miserable backs often smile and walk, carefully, around. Most of the time, people should be able to distract themselves from pain stimuli, forget their disorders and even sleep without pain medication. People have chronic pain when they assume/were convinced that their pain will be persistent, when there is a lack of meaning in their life, and when there is secondary gain. High functioning people without depression learn to tune pain out, may be use self-hypnotic techniques, but hardly ever need narcotics.
Patients must address psychiatric and psychosocial issues that lead to vulnerabilities. Virtually all drugs seem to alleviate sense of negative stress, turning anxiety positive or decreasing it. Opiates serve particularly to alleviate sense of loneliness, not being part of family or clan, human relationships lacking meaning. Many or most opiate addicts need work in this area (interpersonal therapy and/or treatment of posttraumatic stress symptoms, exaggerated shyness, etc.)
Introduction and general issues:
Specific problems with AA/NA:
Proposed adjustments to 12-step approach:
Introduction and general issues:
In summary, the 12-step community is very helpful to many patients; however, it is not “evidence-based treatment”; it is essentially a religion that needs reformation. Some aspects of the 12-step doctrines appear counter-therapeutic. Some adaptations of the teachings are proposed.
12-step groups help many people by offering a community of like-minded former addicts who struggle with their abuse thinking, problems with positive motivation to stay drug-free, poor coping skills, etc. The sense of belonging can be healing. Fostering patients’ religiosity within this church-like organization is often helpful, particularly if it includes meditative practices. Many people benefit from pursuing a religious culture and finding support by people who profess membership of the religion, even if their lives in no way reflect their professed beliefs.
The assumption that AA members accept new members in a nonjudgmental way is helpful though unrealistic; people with primitive religiosity judge pantheists and agnostics (and vice versa); and people do not consider different drugs equal. However, attenders of AA meetings may accept and discard any comment and statement and in this way broaden their ‘tools’ to stay sober and/or process new insights at a later time. This process is possible in any support group and is not specific to AA/NA.
Within the AA/NA community, members as well as professionals tend to misunderstand the nature of abuse and addiction, seeing it usually as a progressive disease caused by the use of toxic drugs and the physiological reactions to them. It is more helpful to see addiction as a psychological disorder with varied prognosis, often associated with a difficult phase in life, other emotional problems and immaturity. Many people overcome addiction without any counseling, treatment or support group attendance. The political decision by the DSM commission (of the American Psychiatric Association) to call addictions ‘dependence disorders’, was less than helpful. Obviously, humans are dependent on many things: water, calorie, protein, mineral and vitamin intake and also the sense of being part of a clan or community; many medications lead to adaptations, that is, after short-term use, more medication is needed to maintain efficacy and sudden discontinuation leads to an uncomfortable physiological imbalances – however, neither tolerance nor abstinence symptoms occur in certain addiction disorders but are characteristics of physiological dependence. AA members, psychiatrists, psychologists and academic scientists rarely agree on a definition of abuse or addiction disorder, and AA members are particularly prone to consider medication use ‘addictions’, while they continue smoking with overuse of coffee and/or engage in eating or sexual conduct that others would consider abusive.
AA must not be considered ‘evidence based treatment’; it is always a treatment adjunct in which social support and the patients’ prior propensity to religiosity may improve the patients’ prognosis. Claiming that the AA teachings are treatment, a specific cause of the improvements, is akin to stating that dictionaries in a household make people literate: religious people seeking support groups of people who want to change are likely to do better than isolated, cynical people, whether they follow Islamic religious texts dealing with alcohol use and ethics or the AA book; similarly, people owning dictionaries correlates with literacy and helps improve literary skills, but buying a dictionary does not give an illiterate person the ability to read. Furthermore, the time investment, promise of recovery and religious talk has benefits comparable to those of faith healers.
Specific problems with AA/NA:
– AA is a religion that demands reformation. A book, written by two alcoholics some 80 years ago, has been revered like a holy text. It offers a religion-based model of alcoholism that is tailored to the founders: affluent white males who basically rationalized continued drinking because they were aware that they had some control over it. [The founders were influence by a patient of the Swiss psychoanalyst Carl Gustav Jung; Jung was not able to help his patient with traditional psychoanalytic therapy and advised him to seek guidance in his religion; focusing on his religion helped him to stop drinking.]
– The concept of being powerless over alcohol or drugs is meaningless: being ‘in control’ is relative. Scientifically, there is no free will, or at least there is virtually no space for free will. Will is always relative; sober people often do things that are, objectively, “out of control”, when ‘powerless’ concerning their emotions; conversely, worst addicts sometimes chose to seek treatment or suddenly find emotional insights that make them stop the pattern of abuse behaviors. People always feel partly free, and they typically feel freest when following ‘spontaneously’ an instinct.
– The mandate that patients have to admit powerlessness over the drug and turn control over to a god is unacceptable, even offensive, to the depressed female patient who drinks because her life was out-of-control, and because her religion did not help her when she felt most alone and hopeless. However, since women are more prone to pragmatically comply with their culture and religion, no matter how male chauvinist, many women still seek comfort in AA groups – they may then be helped by the acceptance and support of the group and the changes in their perception of themselves within their communities, not by specific teachings of AA/NA.
– Asking a personal god to intervene in one’s life is a primitive religious act; it is not ‘spirituality’. If people believe that prayers are responded to by a personal god’ s intervention, they are likely to be, sooner or later, disappointed, when loved, good persons have bad luck without their god saving them. People adhering to such primitive religiosity also appear to be oblivious to the extreme ‘injustices’, with many beautiful children suffering horribly and dying without having reached any meaningful goal, frequently not even a meaningful level of maturity [compare the beautiful article by Frank Bruni, “Rethinking His Religion”, NY Times 4/24/2012].
– The ‘disease’ concept is dangerous and often becomes a self-fulfilling prophecy. When patients leave our clinic and, after years, relapse, we sometimes hear the explanation “I guess I stopped going to meetings” – these patients have not moved into a new stage in life and adhered to the ‘permanent disease’ concept. Disease generally refers to damaged tissue that takes time to heal or, due to genetics or later damaged, faulty physiological function. Addiction competes with a healthy use of the mind, it may temporarily alter balances in brain chemistry, but it does not destroy ‘the hardware’ in a different way than other, undesirable learning. It is not unusual that an emotionally powerful motivator pulls a person out of addiction with no (slow) healing process or any treatment, and some patients fluctuate between patterns of addiction and healthy priorities. It is much more helpful to recognize abuse, addiction and healing as stages in life; the person learned something he/she should never have learned and then may fluctuate for some time between old pre-addiction functioning, addiction patterns, and mature priorities and functioning. Everybody is susceptible to become addicted at times when stress is great and the environment may move people close to the abuse behaviors; and former abuse disorder patients are more likely to become addicted again than people never having had problems with abuse disorders. However, a person who is in some danger of becoming addicted is not suffering from and addiction ‘disease’.
– Sponsors and former addicts serving as primary counselors is often problematic. For them, it is very hard to be objective and see the wide variety of problems and needs addicts have, the many ways abuse-addiction disorders develop, etc. Too often, sponsors want to explain to addicts what their problem is, why they got addicted (talking about how they perceive themselves) and what the way of recovery is. Reasons why addictions develop include: too much testosterone (with urge to show that one can get away with stupid, dangerous, counterproductive behaviors), ADD/ADHD with difficulties to ascertain likely future consequences of a behavior, suicidal and parasuicidal thinking that interferes with looking at the future in a positive way, PTSD with sense of absolute loneliness and fear of the future, utter loneliness because of (temporary) anger at all ‘loved ones’, seeing own culture as collapsed, inability to make sense of one’s position and/or inability to make crucial decisions with, consequently, hard to tolerate anxiety. Actually the question is not: why do people who found an abusable drug, continue using it?, but: what gives many people the strength, to stop before they wasted precious time and resources, started hurting their loved ones and overstepped cultural limits? Once found, using drugs feels like an instinct, and we need a strong reason that is supported by our emotions in order not to follow that drive.
Proposed adjustments to 12-step approach:
– Patients may look at abuse patterns like any unethical behavior that has a powerful inherent attraction. As with instincts, following a specific instinct strengthens it and with repetition, an internal rhyme develops where the behavior feels periodically necessary. The longer the behavior was missed, the less powerful a key stimulus is needed to elicit the behavior and the more intensely the person seeks a stimulus (an opportunity to exercise the behavior). Only when frustrating the urge for an extended time will it weaken. However, any lapsing thoughts and behaviors strengthen the urge again. The mind has a tendency to move towards instinctive and addictive behaviors; the closer we come to key stimuli, the more powerful they are. Like with a heavy piece of metal and a large magnet, at some point, while gradually moving closer to it, the magnet is so powerful that we can no longer hold the metal away from the magnet. Mind and body automatically fulfill the instinct or substance use behavior; at that point, the sense of loss-of-control is very real.
– As a model of addiction development, we may consider learning in layers: there is functional or cultural learning, we learn ways of fulfilling instincts in a natural and culturally appropriate way; we also have ‘bad’ learning, e.g. enjoying instincts out of context including unethical sex, dangerous and aggressive sports, vicarious aggression in computer games, or food abuse; additionally, people learn using substances that feel good as if an instinct were fulfilled.
– If looking at the concept of a ‘higher power’, it must be the core of the being, not some god in the universe or anything with symbolic meaning. A ‘higher power’ may be, as in Quaker tradition ‘that of God’ in every body, ‘the Inner Light’; or in secular thinking, the part of the person that makes the individual social animals part of a larger clan or group. In the folkloristic sense of ‘brain’, ‘heart’ and ‘gut’, the heart, which seeks and gives love, trust and care, would be the higher power.
– The substance of the recovery process consists more in the establishment of a higher personal culture with taboos, than in working the steps per se. Counselors must be careful in working step four. The traumatized and depressed patient does not need guilt, even if symbolic steps to make amends may be helpful. Generally we must accept: the past ‘just is’, not ‘good’ or ‘bad’. Given the circumstances, the patient did his/her best, but because of learning and changed personal culture, he/she will not, nor can, repeat the past.
– A diligent review of ethical principles may be most helpful, with the recognition that abuse, by definition, is unethical. [compare: Natural Ethics, chapter 3.4] Abuse-addiction is like a devil’s contract, as in many fairy tails [particularly the tales collected by the brothers Grimm]; the abuse feels good, the loved ones suffer first, eventually the negative consequences also reach the abuser-addict.
– When having reached psychological changes, the patient should consider him/herself ‘cured’ but in some danger of re-addiction, quantitatively but not qualitatively different from a person who may be in danger to become, first time in his life, an alcoholic at a later age. Patients should keep their addiction history secret towards most people, while able to assertively clarify that they do not use legal and/or illegal addicting drugs that may be offered.
– While in AA/NA meetings, the issue of patients being on slow-onset, long-acting drugs such as methadone or time release alprazolam, should not be mentioned. However, high dosage patients should consider to taper their dosage as soon as they reach a certain level of stability, and, for most patients, treatment with such medications should be a phase of life, more than a few months, but not decades.
1. Short summary of conclusions of literature and overwhelming anecdotal evidence I found in my work with opiate addiction-multiple diagnosis patients:
– Opioid abuse and addiction are mental (psychiatric) disorders that tend to be progressive if there is not good, comprehensive treatment and/or if the environment is very difficult. However, some patients improve without major intervention, some go through multiple episodes of abuse-addiction to opiates and/or other drugs.
– Treatment generally requires years (opioid maintenance or possibly long-term placement in therapeutic community), but the prognosis with long-term treatment is often good. Unnecessarily long opioid maintenance is a concern (some patients feel trapped and dependent on methadone, afraid of withdrawing). Other concerns are overmedication with multiple medications (including tranquilizers and muscle relaxants), and non-treatment of other psychiatric conditions.
– For most opiate addicted patients, opioid maintenance is the treatment of choice (methadone is the ‘gold standard’2, buprenorphine is in most patients inferior3).
– Detoxification is not treatment; it is very dangerous. There is overwhelming anecdotal evidence that many patients, following withdrawal in a hospital or jail, overdose lethally and/or destabilize, leading to major deterioration in many areas. Detoxification does not address the psychological addiction.
– Detoxification disrupts all functions that have been maintained during the addiction; children may need foster care, careers are disrupted, etc.
– Patients who leave treatment prematurely have high rates of relapses, move to other addictions (particularly alcoholism), morbidity and deaths that are directly related to drug abuse, worsening of psychiatric conditions, and suicides.
– Methadone maintenance treatment has multiple psychiatric benefits, including decrease in aggression and sexual acting out (due to decreased testosterone level) some antidepressant effect (serotonergic) and, in some patients, significant antipsychotic effects. Methadone, in proper dosage, does not interfere with normal feeling and thinking; intellectual functions are not impaired.
– In many patients, methadone treats the addiction but patients continue some substance abuse (usually at least ten times less than when addicted). Patients who are not yet willing or ready to address abuse patterns may function quite well but would relapse into addiction if withdrawn from treatment.
– Proponents of alcoholics and narcotics anonymous (AA/NA) usually claim that opioid treatment programs (OTPs) make patients more ‘addicted’, that methadone is merely a legal continuation of the addiction. Obviously we must distinguish between medication that makes the patient more functional versus abused drugs that interfere with functioning. However, some OTP patients feel dependent and stay primarily on methadone because they fear withdrawal and/or an erroneous belief in an endorphin deficiency. In additions, many OTP patients function poorly due to use of, tranquilizers, muscle relaxants and/or alcohol. OTPs should utilize treatment approaches that allow many patients to taper off methadone with an excellent prognosis.
– Addiction professionals must not go along with the 12-steppers’ “terminal disease-permanent recovery” model. Neither should we propagate the “endorphin deficiency” model. OTPs must compete with a better model. Addiction is not a progressive, terminal illness and opiate addicts do not have an endorphin deficiency.
– OTPs must not run like franchise-style non-medical “programs”, with by non-clinician administrators conceived policies and procedures; over-regulated, and with contrived treatment plans and treatment models.
– OTPs must not look for psychiatric clinics to treat their patients: they treat psychiatric patients, they are psychiatric clinics and they should treat all psychiatric problems of their multiple-diagnosis patients (what can be treated in outpatient settings).
– OTPs must treat pain in their patients.
– Patients dosages must be highly individualized in a very wide range (about 20 – 300mg). Stabilization dosages vary greatly over time. Of concern is that the higher the dose range, the more patients use/abuse benzodiazepines (hardly a cause-effect relationship).
1 Raw statistics indicate that most patients who leave methadone treatment relapse. However, if we look at raw data of patients leaving methadone, there is, according to our anecdotal data from patients, a very poor prognosis for four reasons 1. the patient leaves for non-therapeutic reasons (e.g. pressure by relatives, law enforcement and other and agencies, lack of financial resources/support, move, shortly jailed), 2. the conditions of patients are such that there is a poor prognosis (e.g. still nicotine, alcohol and/or benzodiazepine use, psychiatric problems that were not properly treated), 3. inflexible, relatively rapid tapers when patients want to leave treatment (or are assumed to be rehabilitated and ready); the patients may then perceives withdrawal symptoms and returns mentally back to abuse-addiction thinking, 4. the patient embraces the “disease/permanent recovery model” but gets tired of attending meetings; he/she then feels defenseless when, unexpectedly, drugs become available; the relapse is a self-fulfilled prophecy (I often ask: “Why do you think you relapsed?” some patients answer: “I guess because I stopped going to meetings.”)
Our own survey of many patients who properly withdrew and, years later, relapsed due to medical prescription of pain medications (mostly after surgery) indicated: they had good quality of life off all drugs/medications; they were glad that they tapered off methadone even though they eventually relapsed. They returned to treatment before there were major problems due to their re-addiction (i.e. not using prescription medications properly and/or using shortly heroin again).
2 Medical withdrawal (detoxification) is, for most patients, an obsolete treatment. It may be compared to treating tuberculosis with surgery.
3 Much has been written about the ‘partial agonist’ action of buprenorphine making it less addicting. Obviously, no opioid is ever used as full agonist: fully agonizing endorphin receptors leads to immediate coma and death. Buprenorphine is weaker and longer acting with consequently more drawn-out withdrawal symptoms, similar to low dosage LAAM [no longer available].
The studies indicating that buprenorphine and methadone have essentially equal effectiveness do not correspond with experience: studies have admissions biases, by who choses to particpate and by exclusion criteria that are used in studies. Different studies show a significantly higher drop-out rate with buprenorphine, including in double-blind studies.
Broad Benefits of Widespread Use of Opioid Maintenance Treatment:
Methadone and, to a much lesser degree, other opioid maintenance treatments have been extremely successful in my native Switzerland, decreasing the deleterious consequences of heroin addiction and minimizing contagion. With most addicts in treatment, new addiction dropped in the nineties to one fifth (The Lancet, Volume 367, Issue 9525, Pages 1830 – 1834, 3 June 2006).
In the USA, the biggest problems with opioid maintenance treatment are:
- misconceptions and public attitude discouraging opioid maintenance treatment,
- lack of knowledge by professionals (including physicians, supervisors and clinicians in a broad range of state agencies) and in the health care profession itself
- inadequate access to and poor quality of clinics.
Short Summary of Literature Regarding Detoxification from Opioid Dependence
– Large Italian study by Marina Davoli et al., (Article first published online: 19 Nov. 2007 DOI: 10.1111/j.1360-0443.2007.02025.x):
10,454 heroin users who entered some form of treatment were followed, in the average, about one year. Most patients were much or all of the study period in long-term treatment including opioid maintenance.
While in treatment, mortality rate was 0.1%/year; out of treatment (after short-term treatment), mortality rate was 1.1%/year; in the month after leaving treatment, the risk of lethal overdose was 2.3%, in subsequent months, the risk of lethal overdose was 0.7%. Independent of treatment type, treatment was protective of overdose deaths. [Since mortality rate is highest in the first few days of entering opioid maintenance treatment (sometimes suicidal or parasuicidal), long-term opiate overdose risk is even less than 0.1%/year.
Other studies document that length of treatment, independent of type of treatment, is the best predictor of a good prognosis.]
– British study by John Strang et al., published in the British Medical Journal 2003; 326 : 959 (5/3/2003):
In follow-up of 137 opiate addiction inpatient admissions (28 day program), only 37 completed treatment, of these three died of overdose within four months. 57 left prematurely after detox; of these two patients relapsed and died within a year of causes other than overdose. 43 left during detox, none of these died during the one year follow-up.
– British study by M Gossop et al., published in The British Journal of Psychiatry 1989; 154: 348-353, titled: Lapse, Relapse and Survival among Opiate Addicts after Treatment, A Prospective Follow-up Study
In this study of 80 young opiate detoxification patients (inpatient, 21 day methadone), there were, on six month follow-up, many opiate abstinent patients, but two had died of overdose shortly after discharge.
– Canadian study by Benedikt Fischer et al., published in the Canadian Medical Association Journal 2003 171 (3) (8/3/2004), titled “Determinants of overdose incidents among illicit opioid users in 5 Canadian cities”:
Drug treatment in the past 12 months was one of three predictors of opiate overdoses. The other two were homelessness and non-injection use of hydromorphone in the past 30 days.
– Irish study by Bobby P. Smyth, published in The British Journal of Psychiatry (2005) 187: 360-365
Retrospective study involving 149 consecutive admissions with primary diagnosis opiate dependence in Dublin Ireland 1995-96. Median age of patients: 23 years, median duration of opiate abuse 4 years, 60% living with parents, 5% with other relatives; 6wk. program including 10 day methadone detoxification, with long-term follow-up treatment (few stayed long in treatment). 81% completed methadone detoxification but 58% did not complete six weeks treatment (medium 14 days).
Of the 149 patients, 5 died within the study period, and 109 of the remaining 144 completed a follow-up structured interviews 18-42 months (median 29 months) after the treatment episode: 23% were abstinent without methadone maintenance at the time of the interview, 15% used heroin daily, and 57% were in methadone maintenance (no data as to how many patients went to methadone immediately after discharge or later after failed or completed treatment). 50% reported recent misuse of at least one opiate, 43% reported no recent misuse of opiates, (study gives no indication of drug testing, no data on other treatment between discharge and interview).
The paper concludes that “Abstinence remains an attainable goal”, and 5 deaths is reportedly the expected ratio of deaths in this population, however it is the expected ratio in untreated heroin addicts: the treatment did not decrease the high death rate in young opiate addicts. This indicates that the treatment helped some (and many sought appropriate, safer treatment), but several patients appear to have died due to the treatment.
Some studies seem to indicate that many patients enter some form of treatment when they seem ready to move into a new phase in life and consequently do relatively well. Some studies show good results for decreased use of opiates without evaluating alcohol or other drug misuse. I am not aware of a U. S. study, but the overwhelming anecdotal evidence, as reported by patients and relatives, confirms the conclusions of these studies.]
With regard to detoxification versus maintenance treatment, the 2012 White House document:
states (p. 3) in the chapter Detoxification vs. Stabilization and Maintenance
For opioid abusers who do not wish to enter treatment or do not qualify for ongoing maintenance therapy, some treatment programs provide medically assisted detoxification services, which involve weaning patients off addictive substances and managing withdrawal. However, research shows such programs are closely associated with relapse.27 And because tolerance to opioids fades rapidly even during a short period of abstinence, one episode of opioid misuse following detoxification can result in a life-threatening or deadly overdose.
2. Treatment admissions and treatment adherence; treatment levels, transfers to other treatment facilities:
The goal of OTP treatment is ready admission and treatment adherence until the patient is safe to get off opioid maintenance. Opiate addicts who seek treatment are emergencies and must never be put on a waiting list. They are patients who need medical-psychiatric care as urgently as a patient with out-of control diabetes or in acute psychosis. Withholding access to treatment may also be compared with having thieves and violent offenders put on a waiting list to serve their prison sentences. Interim maintenance is CSAT’s answer to the problem, however, few, if any OTPs that should utilized this treatment actually offer it. Furthermore, there are still widespread funding and treatment criteria that lead to hardly justifiable expenses, offering a few patients supposedly superior treatment while keeping most addicts on long waiting lists. Damages to the communities, including costs of emergency room visits and hospitalization, harm to patients’ children and other relatives, contagion of addiction to younger people, are hard to underestimate.
Dropping prematurely out of treatment, premature medical withdrawal, administrative withdrawal and other disruptions of treatment must be avoided whenever possible; they are very dangerous and wasteful: previous treatment gains are lost, dysfunctional behavior patterns that were distant memories are again regularly practiced and compete with all life functions.
Rather than having two levels of treatment: interim maintenance and comprehensive treatment, multiple levels are needed, including treatment that includes case management, groups and TH privileges (needed for work and to reduce unnecessary travel time and costs), but no individual counseling.
3. Main aspects of treatment and treatment stages include:
Treatment should start when the patient applies for treatment, no waiting lists, no delay in medical, psychosocial and psychiatric evaluation; the intake is often the beginning of psychotherapy; occasionally a patient has to be referred to an emergency department at time of screening (e.g. for indications of generalized infections and/or possible endocarditis).
Review of systems, health history, physical examination including V. S., chest auscultation, inspection of skin and check for enlarged and/or tender lymph nodes and dipstick (clinistix) urine analysis are to be performed on day of admission, if possible when patient drops in and applies for treatment. Treatment programs should immediately start comprehensive treatment of severely depressed, PTSD, and other acute multiple diagnosis patients. Private OTPs should never have waiting lists, publicly funded and non-profit OTPs with limited capacity should put patients without pregnancy or major psychiatric disorders into “interim maintenance”. If the OTP is not capable to treat a patients’ psychiatric conditions, it should have close cooperation with psychotherapists and psychiatrists; referrals should be timely and effective. [Sadly, many mental health professionals are afraid of dealing with OTP patients and they may not understand what treatments are inappropriate; cognitive behavioral therapy, EMDR, sometimes hypnotherapy should be first choice treatments; physicians must consider dangers of certain medications , e.g. compound side effects, (no naltrexone for alcohol craving or bulimia!)]
3.2 Medical treatment of acute withdrawal (approx. first week of treatment).
In early treatment, patients often need multiple dosages, e.g. receiving first dosage when intake essentially completed and second dose approx. 3 hours later. On following days, patient may receive first dosage at 6 a.m., second and possible third dosages at 9:30 a.m. and 1 p.m. Patients should receive adequate dosages to treat withdrawal for most of 24 hours. For follow-up dosages, a 4-7-10 or 5-10-15 rule may be used: low dosage if no withdrawal but patient is alert and fears later withdrawal; middle dosage if subjective withdrawal, high dosage if some objective withdrawal.
To judge indication for same, higher or lower dosage on days 2, 3, 4, and 5, we must consider when and which opioid the patient last used before admission: is the patient expected to be in early, worst or late withdrawal? Did the patient use illicit methadone, buprenorphine or another agonist-antagonist medication? If the patient has not used opioids for over 30 hours and/or if he/she recently used buprenorphine (SUboxone), second or third day dosage may have to be decreased to avoid buildup of methadone serum level (Dilaudid withdrawal is most acute and shortest, most popular pharmaceutical opiates have somewhat slower onset and longer duration of withdrawal than heroin; buprenorphine partly antagonizes methadone for up to three days).
3.3 Time of stabilization of methadone dosage:
This time may include dosage increases when the patient still handles stress poorly. Patients may continue to complain of withdrawal (methadone “not holding”). Obviously, since heroin withdrawal lasts six days, patients have after the first week no longer withdrawal, no matter whether they get placebo, 40mg or 100mg of methadone, but they still have craving and feel stress. Patients must learn that, early in treatment, stress is perceived as craving , and craving leads to psychosomatic withdrawal-like symptoms. Dose decreases often lead to a fear reaction that is perceived as withdrawal. [If patients ask to go on a blind “detox”, patients often complain that the taper is too fast before the first dose decrease went into effect.]
3.4 Stabilization of all mental and life functions:
Counselors/case managers, social workers, psychotherapists and psychiatric physician help patients with the following issues, individually and in teaching and therapeutic groups:
– practicing a healthier lifestyle and learning relaxation, meditation and possibly also self-hypnotic techniques;
– patients addressing psychosocial, legal and medical problems;
– patients are to receive and cooperate with effective treatment for psychiatric problems including psychotherapy (EMDR often indicated), psychotropic medications, usually antidepressants, mood stabilizers, possibly antipsychotics, rarely long-acting slow-onset benzodiazepines.
Often non-pharmacological pain management is indicated. Sometimes patients benefit form TCA or seizure medications for specific pain conditions.
Patients may benefit from support when dealing with social agencies, school or work, legal issues, etc., but OTP staff should primarily guide and encourage, not make calls for patients. Sometimes patients need help when discriminated against/mistreated and inappropriately referred, e.g. by CPS or drug courts, or when needing special consideration because of ADHD and/or other psychiatric disorders.
3.5 Patients need to deal with specific tasks:
– Patient must define all misuse/abuse behaviors (that may become addictions).
– Patients need to perceive abuse behaviors, and life in a broad sense, differently.
– If patient is benefitting from NA, adjustments are probably needed. The “higher power” must be inside the person. The addiction must be moved into the past and, except for very rare situations, be kept secret.
3.6 For many or most patients, eventual withdrawal from maintenance treatment is indicated.
Many stable patients falsely assume they need continued treatment to maintain abstinence. When more mature, having done well for 1-2 years, patients should decrease methadone or buprenorphine dosage significantly, e.g. to 2/3 dose of methadone or 1/2 of buprenorphine, then test themselves (enjoy more intense perception of nature and art, better bowel and sexual functions, higher pain tolerance). Then they may decrease dosage in further steps, until they feel good on what previously would have been considered a placebo dosage. At that point, discontinuation of maintenance treatment is safe, with an understanding that “in case of lapse-relapse, it is never too early or too late to return to treatment.”
3.7 For many or most patients who tapered off opioid maintenance treatment, continued group attendance and some follow-up individual counseling, continuation of psychiatric treatment, etc. is helpful, if not needed, and should be offered by OTP at low fees or no charge. [Former patients tend to be an asset to teaching and counseling groups.] However, follow-up is not meant to be permanent relapse prevention. Patients are informed that they may return at any time: it is never too early or too late to return when the patient feels he/she may benefit from further help.
4. Treatment strategies:
Strategies, including medication dose levels and offering TH privileges (often exceptions form SAMHSA needed) must be very flexible, adapted to the patients’ life circumstances, work and/or studies, psychosocial conditions and emotional readiness to address psychological issues. The therapist may benefit from a problem list that includes all issues that appear problematic (including old traumas which the patient is at the time unwilling to work on or considers resolved). We must never limit counseling to the issues the patient wants to change (most patients are not eager to change sedentary lifestyles, stop certain drugs and junk food addictions, etc., nor do they want to address obvious anxiety issues which they treat with benzodiazepines as prescribed by some MD). The therapists educate and motivate, as much as possible in groups. Rewards for group attendance may be valuable incentives (e.g. unearned TH dosages for convenience, if patient is assessed to be able to safely handle them). Individually, the therapist continues to evaluate the patient and works on all problematic issues as the patient allows and/or shows readiness. Treatment plans are rarely very helpful. Often, the therapist is surprised how the patient changes, how situations change, and how new problems surface. Asking patients to spend time writing an essay as to how they see themselves in six months may bring insights not easily reached in a treatment plan session. Some patients may then spontaneously work towards change. “Pushing” them and/or giving “no progress” evaluations in the next treatment plan session, may have paradoxical consequences.
In long-term treatment, patients tend to stagnate and resist change for extended times. Group leaders may introduce material that changes the patients’ views and motivates them. Progress is usually unpredictable and influenced by many factors OTP staff has no control over and which may never be known.