Friday, February 27, 2015

Is Suboxone® the Best Treatment?

by Peter R. Coleman, M.D.

Recently, The Huffington Post published a lengthy article by Jason Cherkis on the various methods to treat patients with opiate dependence. It was an excellent article that featured a number of personal cases from families who had lost loved ones to an opiate overdose. In almost all of the cases, the overdose had occurred shortly after the patient had tried to get clean and sober.

The main message of the article seemed to be that traditional treatment programs don’t work well for opiate addiction and the only effective way to treat people who have this problem is to put them on agonist therapy, such as Suboxone®.

(An agonist is a chemical that binds to a receptor and activates the receptor to produce a biological response. Whereas an agonist causes an action, an antagonist blocks the action of the agonist and an inverse agonist causes an action opposite to that of the agonist.) 

The article indicated that Methadone, an agonist, could be a good treatment for opiate addiction, but Suboxone® seems to be better. Cherkis interviewed the Medical Director of the Hazelden Treatment Program – a traditionally abstinence-based treatment program – who implied that Hazelden had recently started putting all of their patients with opiate dependence onto Suboxone® and was recommending that patients stay on this medicine after discharge.

I have been working with patients who suffer from opiate addiction and studying this issue for the last 30 years. I have a number of observations and thoughts to share:

Recovery from opiate addiction is very difficult and success rates with traditional treatment are low. Opiate dependence seems to have a much higher relapse rate and the consequences of relapse can be devastating. For a long time, we have known that overdose can easily occur after any period of abstinence.  If an alcoholic relapses, it can be painful and difficult for all concerned, but if a heroin addict relapses, it can be fatal. 

It can be much easier to treat patients with alcoholism. Traditional treatment programs have a high success rate with alcoholics - around 60 – 70% - but, they have a much lower success rate with cocaine and/or opiate addiction/dependency. Some reports indicate treatment success with opiate dependence can be as low as 10%.

It is not entirely clear why the success rates are so much lower for opiate addiction. There are undoubtedly many factors. The main one seems to be the intensity and the length of time that individuals experience Post-Acute Withdrawal Syndrome (PAWS). When people stop using OxyContin or any other opiates, they go through a 7-10 day acute withdrawal period, followed by another period of time before they feel back to normal. During this Post-Acute Withdrawal Syndrome period, they have intense cravings, insomnia, and a profound lack of energy. The temptation to use “just a little bit” can be overwhelming and many people give in to the temptation.

Cherkis is correct. Traditional treatment programs do not do well. Even after 28 days in a treatment program, many people relapse as soon as they are back in their normal environment with all of its triggers, both emotional and physical. Outpatient programs have difficulty keeping people coming to their classes because opiate addicts usually relapse and stop showing up for appointments.

Cherkis advocates putting most patients on an agonist, such as Methadone or Suboxone®. These medicines are clearly the best answer for some people and are definitely better than using street drugs. However, these treatments have their own problems.

Many patients drop out of treatment and don’t make any progress. Many patients abuse the Suboxone®, continue to use other drugs, sell the drugs, and continue to use opiates. Most studies of Suboxone® and Methadone report up to 70% of patients in treatment continue to use opiates or other drugs. Many patients simply don’t like being on these Methadone or Suboxone®.  Most patients, given the choice, would much prefer to be completely free of drugs.

In order to help patients become completely drug free, many treatment programs are changing.  Over time, we have learned that the first six months of sobriety is the critical period when it comes to opiate dependence. We need and must help people through this period in order to get onto the road of long-term recovery. Many inpatient facilities are now referring patients to an outpatient counseling program directly after their inpatient treatment. Many patients are now moving into a halfway house for the first 6 – 12 months after treatment.

At TCI, our patients use Naltrexone implants or monthly Naltrexone injections. Naltrexone is a powerful antagonist that dramatically reduces cravings, prevents relapse, and allows patients the freedom to more fully participate in treatment. We have found that a combination of Naltrexone therapy and intensive treatment is very successful in helping patients stay clean for the long term.

I believe that all patients can achieve long term recovery if they work hard for it, but they often need some medication assistance to be successful. Rather than putting patients on another addictive drug, we believe many patients can achieve long term sobriety with the aid of Naltrexone.

Patients need a choice.

For some, Suboxone® can be a good maintenance treatment, but for many, the combination of Naltrexone therapy with a commitment to intensive and effective recovery work is very successful towards achieving abstinence. 

Monday, February 23, 2015

By Joan R. Shepherd, FNP

Several people completed opiate detoxes last week, and we even bumped some along more quickly so they could get back to their home states before the “Blizzard of 2015” kept them trapped in Richmond.

All my patients move me in some way, but I was particularly touched by a young man this week from the New England coast. He is a commercial fisher; young, strong, already his body bears the marks of a man who has one of the hardest physical jobs there is. He will probably always have some degree of physical pain because a regular part of his day job is pushing his physical body to extremes.

He told me that he’s never run his boat without being high. I was kind of stunned-even though I thought I stopped being surprised by drug stories a long time ago.

“Never?” I asked incredulously.
He dropped his head for a moment, then looking me in the eyes. “Never.”


He has pretty much convinced himself that without being on opiates, he can’t do this job. I understand from a physiologic perspective what he’s saying. When a person has been using opiates for as long as he has, his brain no longer manufactures dopamine. It’s kind of like, why bother? The brain can’t manufacture enough dopamine to compete with the overload of dopamine that comes from using opiates. When a person who has regularly been using opiates stops, his energy is going to plummet until the brain restores itself.

And that can take a long time.

But, the truth is, this guy—battered as he is—is young and strong and has an incredibly specialized skill. He’ll be able to pull off anything he needs to do, physically. His muscle mass isn’t going to deteriorate just because his dopamine is low, as long as keeps exercising those muscles.

It’s the self-defeating thoughts that are going to be his big problem.

I suggested he get a tattoo across his left forearm so whenever he’s about to do anything at all on that boat (or anywhere else for that matter) and his crazy thoughts start harassing him, he can read on his arm the same simple question Zen Master Rinzai asked to a room full of monks long ago:

What at this moment is lacking?

If our fisherman can be in the precious present moment, not dwelling on choices made in the past, or anticipating future suffering, he can bear anything. It’s a matter of putting one moment after the next, then the next, and the next. And being there for each one.

Everything any of us need is present for us in this moment.

Friday, February 13, 2015

LOVE is in the Air!

by Gabriella Pinto-Coehlo

Ah, Valentine’s Day. The holiday that people either love or love to hate. A holiday rooted in both Roman and Christian traditions, we now celebrate with greeting cards, chocolates, and flowers lovingly gifted to our significant others. 
A tongue-and-cheek response to this holiday is the re-labeling of February 14th as Single’s Awareness Day, aptly abbreviated S.A.D. Whether you are single or not, most of us are missing a wonderful opportunity to do something for ourselves this time of year - cultivate self-love.

Our culture has primed us to believe that self-love is indulgent, perhaps arrogant, and certainly unnecessary. Of course, everything can be taken to an extreme - a little too much self-love can result in an inflated ego, but for most of us, this isn’t the case. I would even argue that most people who appear to have inflated egos have just the opposite - a deep-rooted feeling of inadequacy masked by the illusion of smoothly overdone self-assurance. But, the reality is, our societal beliefs that self-love is selfish has lead to an epidemic of self-loathing and low self-esteem. Many of us with low self-esteem seek external validation for a little boost, only to find compliments and praise uncomfortable and undeserved. And in an image-conscious world, we often seek self-love from external factors like our bodies, our careers, and our paychecks. Unsurprisingly, any boosts in self-esteem from these are minimal and fleeting.

Truth is, authentic and lasting self-worth comes from within. The only way that you can cultivate an enduring sense of self-love is through something else enduring - your own internal capacities, your heart and soul. In the words of Thich Nhat Hanh, “To be beautiful means to be yourself. You don’t need to be accepted by others. You need to accept yourself.”

So, in this season of commercialism targeted toward doting on others, why not offer yourself a little self-love? Consider trying these exercises:

·      Change your focus to the positive. Every day, write down a list of all of your positive qualities. Force yourself to come up with at least one new quality each day, no matter how challenging this may seem. At the end of your “free write,” choose your favorite three to five qualities and write down examples of how you have exhibited these characteristics. Even doing this for a month will do remarkable things with how you view yourself - shifting your lens from the negative to the positive.

·      Turn negativity on its head. Write down any negative beliefs you hold about yourself in a journal. Tackle this list one day at a time. At the top of a journal entry, write one belief, then draw two columns: one that demonstrates evidence to the contrary in the past and present, and one that demonstrates contrary evidence in the future. The first column is logical - write down anything about you in the past or present that disproves your negative core belief. The second column allows you the opportunity to identify actions you can take in the future to continue disproving your negative beliefs. Notice how you might feel a little lighter as you realize that your core beliefs are a distortion of reality.

·      Hold yourself accountable for self-care. Keep a daily journal with a list of all you did in that day, and label each activity or task as one of the following: achievements, fun, or relaxation. Notice what you tend to be heavy on and what you are neglecting. This exercise shifts your mindset to realize that fun and relaxation are not luxurious or frivolous, but in fact a valuable use of your time and energy.

Consider doing at least one of these exercises everyday for a month, and then check in with how your self-esteem has shifted. There is no better time to change our habits than now.

Wednesday, February 11, 2015

Supporting Recovery Without Enabling

This article is a copy of a recent blog posting by A. Thomas Horvath, Ph.D, president of SMART Recovery®

In Epidemics, Hippocrates said, “Make a habit of two things–to help, or at least to do no harm.” How can we apply that idea to helping family and friends with addictions?

When we care about individuals who are trying to overcome addictions, we often face dilemmas in how best to help them. For instance, if I help someone by providing money for some critical need, am I supporting recovery by preventing some degree of “disaster”? Or, am I just shielding the person from negative consequences that might motivate lasting behavior change? The latter, of course, is AKA the E word: Enabling.  This article will identify some things to consider when you face that kind of decision.

What is support? I suggest that support, at its root, consists of two things: paying attention and active helping. I could pay attention to a friend who wants to quit smoking by listening to her talk about her cravings to smoke and how she copes with these cravings. I could actively help her by informing her of new tobacco cessation products (if she was unfamiliar with them). I could take her to a SMART Recovery® meeting (especially if she felt awkward going alone), or spend a non-smoking evening with her  (when her other options were to be alone or be with smokers).

How does support differ from enabling? One aspect of support–paying attention– is unlikely to shield someone from negative consequences. I probably am not making matters worse by complimenting successes or joining in celebrating them. It’s unlikely to cause harm if I take time to brainstorm alternative activities, take time to listen about stresses, express confidence in future success, or just listen to the ups and downs of the process of change.

Because paying attention is unlikely to harm, I encourage significant others, even if they are ready to cut off other forms of helping, to continue paying attention: “Son, your mom and I are drawing a line. We have provided money for bail, for attorneys, for treatment, for rent, for food, on and on. We have decided to stop, because we honestly don’t think it is really helping. We help you out of a crisis, but as soon as you are out of it, you go back to using. We think you have major addiction problems, but it’s up to you to decide how to live. We think maybe you need to get yourself out of your crises, that maybe that’s what’s needed to persuade you to change. But we are not ending our relationship with you. We still want to see you and talk with you, every day if you want. We hope you will see that we still love you deeply, and we hope our love will help. But you are going to need to solve your own problems from now on.” Note that although this statement may contain elements of “preaching, complaining, criticizing, and nagging,” they are not prominent. The addiction is discussed directly, but not judgmentally.

If we distinguish between paying attention and active helping, it becomes possible to maintain some type of relationship with the addicted individual, to the extent that both parties will make time for it. It is not necessary for a family to tear itself apart over an addiction issue, although this often happens. It is important for the family to make an early distinction between paying attention and active helping, before painful feelings build up. 

Even though the addiction may continue for awhile, the presence of valued relationships may be the key element of a later cost-benefit analysis, when the addict decides that these relationships are actually more valuable than getting high. If the relationships are not present, the addict is another step closer to the suicidal types of addictive behavior that arise when there is “nothing left to lose.”

Paying attention is unlikely to cause harm, but active help could either support or enable. It depends completely on the specific situation and the actual intentions of the recovering person. Intentions are difficult to judge, so we need to assess behavior. If I knew for sure that my loved one was finally on the road to recovery, then I would do a lot to help make that journey smoother and to prevent old problems from affecting the present. For instance, I might pay off a drug debt to stop the dealer from “collecting,” and consider that payment a loan payable at some later date. The problem is that we don’t know until much later how firmly someone was on the road to recovery.

When you can help wholeheartedly, I suggest you do so. We are in relationships to give and receive. A friend in need is a friend indeed. There are two times to consider being wholehearted about giving: (1) early in an addictive problem, after the first crisis or two, before someone has established a history of twisting help into enabling, and (2) well into a recovery process, when it is clear that even without you the person is likely to continue to improve.

Aside from these two times, we typically need to be cautious about actively helping, but not about simply paying attention. I suggest a few simple guidelines. If you provide money, pay the bill or debt directly, not by providing cash (you might be amazed how often this suggestion is ignored!). 

Remember, it’s often easy to tell the difference between helping and enabling. Provide a little help, and observe the effect. If it goes well, consider another small helping step. Don’t help so much that it jeopardizes yourself, because your help may be of no use and then you will both be in bad shape (don’t spend money you don’t have). 

Take care of yourself (and watch out for your addictions). Someday, the person you love may be ready to meet you halfway, and it would be good for you to be ready, too.

By A. Thomas Horvath, Ph.D.

Thursday, February 5, 2015

Damn Right, You Are Anxious

by Joan R. Shepherd, FNP

Prior to beginning an Accelerated Detox, we ask patients to rate their anxiety and depression on a scale from 1-10.  The depression varies, but I don’t think I’ve ever seen anyone weigh in with an anxiety score less than 5—and that’s a low one.

When people make the decision to stop using opiates, benzo's or booze, it’s scary. Likely they’ve tried to stop in the past. They know the physical realities of withdrawals, or they’ve suffered the humbling self defeat of relapse. Alcohol and other drugs that are used to reduce anxious discomfort will provide some anxiety relief in the short run, but cause bigger problems in the long run.

It is possible that, in addition to having a diagnosis of addiction to a substance, a patient has the co-morbidity of one of the many flavors of anxiety: Post-traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder (GAD), Obsessive-Compulsive Disorder (OCD), or Social Anxiety to name a few.

While an Accelerated Detox is not going to ‘fix’ those conditions, it will certainly help to take the physical component of the addiction piece off the table, creating more opportunity for a person to deal squarely with their particular issue.

If you’re anxiety is mostly part of your Post-Acute-Withdrawal-Symptoms (PAWS) package, you’re likely to be feeling better within a couple months. If your anxiety persists, it may be helpful for you to know a little more about this condition.
For one, you are not alone. People with anxiety disorders are everywhere and affect up to 30 percent of the general population at some point in their lifetimes. Number two; anxiety disorders tend to be chronic, so it’s important to get help. Number three, anxiety and fear are different, and both can be useful.

Fear is an intensely felt alarm response that we all need to survive. It is a present-oriented state that alerts us to nearby dangers and prepares our body to deal with them. We’ve all heard about the fight/flight/freeze response.
Anxiety, on the other hand, is a future oriented state. People describe an anxious apprehension or a sense of foreboding; the physical response is not as intense as a fear response, but it can linger much longer. For some people days, weeks or even years.

Here’s an example. You are in the woods and you see a bear (a big mean one coming at you). That should evoke a fear response. Thinking about the possibility of seeing a bear as you plan for a hiking trip, can evoke an anxiety response. Generally, anxiety tends to be fueled more by what your mind says than by real sources of danger or threat.

Clearly both fear and anxiety can perform a useful function. Fear will get you running away from that bear, anxiety will propel you to buy some bear spray before you hike in grizzly territory.

People get into trouble when anxiety and fear go beyond serving a useful purpose. Dr.’s Forsyth and Eifert state in “The Mindfulness & Acceptance Workbook for Anxiety

“People with anxiety disorders struggle with, avoid, and run away from their fear and anxiety. This tendency defines the actions of just about every person with an anxiety disorder. And, struggle turns out to be the most important toxic element that constricts lives and transforms anxiety from being a normal human experience into a life-shattering problem.”
Research suggests that figuring out exactly which "official anxiety" diagnosis you have seems to be far less important that understanding, as specifically as possible, what triggers your personal anxiety response and is keeping you stuck. In future blog articles, I will suggest some strategies that people have found particularly helpful in dealing with their anxieties.

In the meantime, if we can help you with taking the opiates, booze or benzo's off the table, give us a call.