Archives for September 2016

Sound Sleep Makes for Sounder Addictions Recovery

Sleep disturbances are a sad fact of life for many people in recovery from substance use disorders. Sometimes sleep problems put people at risk for addiction, sometimes people develop sleep problems because of the drugs they take, and sometimes both. But causality aside, the correlation between disturbed sleep and substance use disorders is indisputably high.

Sound sleep aids addictions recoverySleep disturbances are known to occur across widely different substance use disorders, including nicotine, alcohol, opioids, and cocaine. Alhough sleep disturbance is a common experience, different substances affect sleep in different ways.

Alcohol helps people fall asleep faster and increases slow wave sleep in the first half of a sleep period. For this reason many people have turned to alcohol to cope with sleep problems, especially if they have a co-occurring mental disorder. Yet alcohol disrupts the second half of a sleep period, reducing overall REM sleep for the night and ultimately making sleep problems worse.

People dependent on cocaine and alcohol tend to have disturbed sleep architecture as they age, with increasing REM (Rapid Eye Movement) and accelerated age-related decreases in slow wave, stage 3 sleep. People trying to become abstinent from cocaine report better quality sleep, but one study reveals that even as their perception of sleep quality goes up, their actual quality and quantity of sleep goes down. People recovering from cocaine substance use disorders may therefore be at higher risk of relapse because of poor sleep without knowing it.

Opioids are notorious for detrimentally affecting sleep, but in a different way. Long-term opioid use causes sleep apnea (in 30-90% of long-term opioid users) and otherwise disrupted breathing, sometimes resulting in hypoxia, and contributing to fatal overdose. Unfortunately, though indefinite buprenorphine and methadone maintenance are most promising for treatment of opioid substance use disorders, methadone is documented to cause sleep problems and burpenorphine may as well.

Studies of alcohol substance use disorders have demonstrated that greater severity and frequency of sleep disturbances put people at greater risk of relapse. Researchers think this correlation may be generalized to all types of substance use disorders. Berro et al., in 2014, found that sleep deprivation affects the dopaminergic systems in the brain in a similar way to psychostimulants, like cocaine. They hypothesized that sleep deprivation could prolong recovery by extending the association of cocaine with environmental cues, and so cause people to relapse.

Poor quality sleep is known to cause other health problems, and to compromise immune function, an especially grim prospect for any person who contracted HIV or hepatitis while using. Improving sleep quality is thus an important goal for anyone in recovery to reduce risk of relapse and reduce craving, and also to improve quality of life overall.

Addictions treatment providers may help their patients tremendously by providing cognitive behavior therapy to encourage beliefs and behaviors that improve sleep, and to refer people in recovery to sleep specialists when possible.

. . . . .

This post is one our series of reports on what the current science says about addictions and addictions treatment.

Partial list of reports, listed most recent first:

How to Talk with Someone About Getting Help with Addiction

If you’re concerned about someone’s drinking, use of drugs, spending, gambling and other behaviors that might qualify as addiction – using or doing that continues despite negative consequences – and want to talk with them about it, here’s a suggested to-do list based on my personal and professional knowledge and experience.

Truly inform yourself about addiction. What most people think they know about addiction is belief-based, not evidence-based. My suggestion is to start with information from NIDA, a division of the National Institute of Health. NIDA’s publications on the science of addiction meet these rigorous standards. If other sources you read don’t link to sources that also use these standards, I suggest distrusting them. What works and didn’t work for one person cannot be generalized as applicable to your person.

Helping requires negotiationSeparate the condition from the person. Addiction is identifiable at the molecular level as a brain abnormality. While the first drink or drug or action or subsequent ones may have been the person’s “fault,” once addiction occurs, brain changes can impair the person’s ability to use judgment, make decisions, and choose based on criteria – whether good or bad. The abilities to make plans and to follow through with them are impaired. The ability to learn from the error of one’s ways, to learn from punishment or reward, to be shown a fork in the road and implored to take this path or that path and to decide which is the most helpful – all impaired. The person looks like the person we know, but the brain no longer works the way it used to. Addiction presents a horrifying double bind. The individual’s very skills and abilities that help make them who they are – and are needed to stop doing something – are the very ones that are impaired.

“People suffering from addictions are not morally weak; they suffer a disease that has compromised something that the rest of us take for granted: the ability to exert will and follow through with it.”
– Nora D. Volkow, M.D, Director of the National Institute on Drug Abuse (NIDA), quoted in What We Take for Granted

Know what you’re asking the person to do without. People with addictions describe the experience of using or doing as a feeling of love, a sense of belonging, bliss, meeting an unmet need, oblivion, sacred space, the only way to be pain-free, relax, sleep, be around others, and many others. Many people with addictions have anxiety, depression and other mental health challenges, trauma symptoms, issues of temperament, physical pain, and debilitating sleep disturbances for which drinking, using or doing provides the only relief.  Pause to reflect deeply on what purposes you think using or doing serves in the person’s life. Suspend judgment. Imagine you are the person and use this simple cost-benefit analysis tool from SMART Recovery to get a sense of what it might be like for the person to give up drinking, using or doing. To deepen your insights, put the items you’ve listed, regardless of the section, in rank order.

Know what you’re offering as a replacement. When people with addiction stop drinking, using drugs, or engaging in an activity, many are thrown into an acute state experienced as mind-breaking, spirit-shattering, life-threatening distress. And, for many, for the rest of their lives, they have to do without something that met needs that nothing else can meet. Based on your best judgment of what needs the person has that are met by their use of alcohol, drugs, or activities, what is your plan to get their needs met if the substance or activity is removed?

Specifically, what’s your short-term plan to help the person deal with acute suffering? (This guide to getting health care for addictions may be helpful.) What’s your long-term plan to help the person handle the on-going whine of distress that could spike at any time? Relapse relates for alcoholism, for example, don’t drop significantly for 5 years. “Just stop” is not a plan. The person has tried that plan more times than you can ever know. Drinking, using and doing again, when a person is experiencing what feels unbearable, is not weakness, but mercy.

Your plan will depend upon your locale’s resources. Feel free to use this guide to getting help with addictions in the Blacksburg, Virginia area to customize your own plan. (If the person has an opioid addiction, more specifics are at the end of that guide, and here and here and here for myths about heroin.)

Ask: “What do you think would be helpful?” Once you understand that addiction is medical, not personal, i.e. neither about the person nor about you, and you’re savvy about your locale’s addictions treatment resources, you know what’s on offer. With goodwill, good intentions, a clear mind and calm heart, you can essentially enter a business negotiation. You want the person to buy some combination of addictions treatment products and services but which ones match this person’s needs and preferences? You have to ask to find out. Then you’ll have to discover whether or not what you’re offering is perceived as valuable enough for an exchange.

What we know isn’t helpful and we know doesn’t work: negative consequences.

Persistence in spite of negative consequences defines addiction. Therefore, negative consequences don’t arrest or cure addiction. Emotional punishment such as shouting or the silent treatment are akin to psychological abuse and are destructive to you and to your person. Physical punishment – including getting locked up in rehab or jail – can traumatize the person, which is already a pre-existing condition for many people with addictions.

Plan for yes. Plan for no. If the person says they want help, you better be able to act on that immediately, i.e. put them in the car and start driving. If you don’t know your locale’s resources and you don’t have things lined up, you’re going to put that person in a world of hurt. Any delays decrease chances for engagement in treatment. They’ll very likely have to return to what they were doing and their trust in you will be harmed. If the person doesn’t want help, this will require a terrible judgment call on your part. It’s time to use the cost-benefit analysis tool on your own dilemma. Just replace “using/doing” with “helping,” be sure to rank order what you list, and see what comes up for you.

“Love, evidence & respect.”
Maia Szalavitz’s answer via Twitter to the question, “What fights addiction?”

Acknowledge the complexity of the situation. People with addiction continue to do what they do for reasons that make sense to them – even with impaired cognitive functioning –  and, with a little imagination and empathy, we can make sense of those reasons. Given that people with addictions, depending upon the substance or activity, may or may not experience dependence, given that addiction is classified as a brain disease, and given that the brain’s executive functioning is impaired by addiction, well, who would know how to talk with someone about addiction or would know what to say? By what criteria would we measure rightness or wrongness of a layperson’s – even a professional’s – attempt to broach the subject? For both parties, it’s a wicked, wicked problem.

When attempting to help people with addictions, I use the words of Maia Szalavitz for guidance – sometimes as prayer: “Love, evidence & respect.”

Photo by Zane Queijo

Addiction Recovery with Others is Easier than Recovery Alone

Recovery from addiction is incredibly time consuming. The stakes are so high; people in recovery must spend their limited time, resources, and energy on treatments and practices that help the most. Support groups have been criticized, especially 12-step groups, for low or inconsistent results. Why should anyone serious about recovery bother attending?

Quite simply, recovery with others is easier than recovery alone.

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Many psychologists have dedicated their careers to understanding attachment theory and how attachment styles can affect the ways people develop. Attachment theory examines the quality of infant relationships with their caregivers, and correlates these relationships with the quality of relationships people have later in life. Basically, the more securely an infant bonds with a caregiver, the more secure that infant will feel in other relationships later in life.

Psychologist Mary Ainsworth was the first to classify three attachment patterns or styles based on infants’ responses to the “strange situation” procedure, which involved a researcher observing the mother and infant in a series of 8 situations while hidden behind a one-way glass. The situations were a standard set of combinations of the mother, baby, and a stranger (mother and baby alone, stranger and baby alone, baby alone, etc.). The infant’s behavior was scored in each situation based on four types: proximity and contact seeking, contact maintaining, avoidance of proximity and contact, and resistance to contact and comforting.

Ainsworth developed the attachment styles based on the results of this experimental and scoring procedure. Attachment theory has since been expanded to evaluate adult attachment styles as well, and the 3-style framework has been expanded to 4 attachment styles: secure, anxious-preoccupied, dismissive-avoidant, and fearful-avoidant.

Attachment styles are extremely important because they describe the quality of a person’s relationships, which influence just about every aspect of a person’s life. A 2013 study of 5,692 people found that insecure attachment styles were associated with greater likelihood of suicidal ideation and attempt, and mental disorders overall. Secure attachment styles were associated with the opposite trend.

Dr. Philip Flores, a psychologist examining the importance of early attachment styles on the development of addiction, has written that substance use is an attempt to self-medicate the stress of ineffective attachment styles. Substance use ultimately results in further distance rather than the desired closeness and connection.

The primacy of social interaction is studied by neuroscientists as well. Neuroscientist Matthew Lieberman gave a Ted Talk on how social interaction is vitally important for healthy, fulfilling human lives, and may even precede food, water, and shelter in importance. In fact, increasing evidence suggests that social pain is processed very similarly to physical pain in the brain; the body processes social pain as a threat to existence.

A recent article in the New York Times, How Social Isolation is Killing Us, documents evidence of increased loneliness in America and the effects. Since the 1980s, the number of Americans who report loneliness has doubled, and that 1/3 of Americans over the age of 65 live alone. The article emphasizes that, “Loneliness can accelerate cognitive decline in older adults, and isolated individuals are twice as likely to die prematurely as those with more robust social interactions.”

So it’s clear that everyone benefits from social connection, but how much we need still goes unanswered. People with addiction still need to know whether support groups are worth the bother. While neuroscience is still working on understanding how psychotherapy, group therapy, and even basic social interaction works in the brain, psychologists are working on questions of efficacy.

Evidence indicates that support groups for addiction help people stay in recovery. Researchers in 2011 assessed 1,726 patients at 3, 6, 9, 12, and 15 months after residential treatment, and concluded that support groups help people in recovery change “people, places, and things,” reducing triggers for craving and relapse. The researchers published a follow-up study in 2012, analyzing potential reasons for improved outcomes, and found that patients surrounded by pro-abstainers were more likely to stay abstinent than patients surrounded by pro-drinkers. Another study in 2012 found that stronger AA group cohesiveness, a sense of belonging, predicted increased participation and abstinence in group members. Other researchers, in 2011, have taken a closer look at some of the reasons for support group successes, and found that AA groups may increase self-efficacy, a person’s belief that he or she can succeed and recover.

According to these studies, building stable social networks appears to yield better results for people in recovery than going it alone. So far, it seems, what matters most in addictions recovery groups is the level of belonging people feel. (Sebastian Junger explores the universal human need for belonging from a sociological perspective in his book, Tribe.)

While the research supporting recovery groups is not as conclusive as we would like, neuroscientists are currently testing the efficacy of oxytocin as a treatment for addiction. Known fondly as “the love hormone,” oxytocin performs many roles in the body. Oxytocin is naturally released in response to positive social situations, such as during childbirth and family bonding, and when seeing the face of one’s partner. Oxytocin is also found to be released in response to certain drugs.

“Heroin, it’s my wife and it’s my life”
– Lou Reed, “Heroin

Lou Reed was never alone in feeling love for his drug of choice. People subjectively and literally describe addiction as falling in love with a substance or activity, and love as becoming addicted.

In 2014, a group of researchers chose to study prairie voles, Microtus ochrogaster, who are notorious for forming life-long partner bonds. From previous studies, the scientists knew that oxytocin is crucial for healthy pair bonding between prairie voles. When they gave the prairie voles amphetamine, the prairie voles failed to bond. Amphetamine had disrupted the oxytocin and dopamine pathways in their brains, responsible for partner formation. The researchers concluded that oxytocin and dopamine systems are important both for addictions treatment and for social bonding, probably for humans too.

Now scientists are investigating the use of oxytocin as a treatment for addiction. So far studies have documented that oxytocin alleviates withdrawal symptoms and craving (Mitchell et al., 2016; Baracz and Cornish, 2016; Peters et al., 2016Sarnyai and Kovács, 2014Stauffer and Woolley, 2014; Bowen et al., 2014; Carson et al., 2013). Preliminary evidence suggests that oxytocin may be effective for methamphetamine, alcohol, and opioid addictions. Scientist Jennifer Mitchell is beginning a clinical trial with volunteers to test whether oxytocin may be safely and effectively used to relieve the stress response, with the ultimate goal of treating active-duty military personnel for PTSD and alcohol use disorders.

The addiction-love connection is promising as a direction for neurobiological research, beyond oxytocin alone. We stand to improve our understanding of both addiction and love, and how even in healthy brains, love provides the most important incentive for human behavioral learning.

We don’t know whether oxytocin will continue to hold up as an effective pharmacological intervention for addiction. We don’t know either whether addicted individuals need supplemental oxytocin to gain satisfaction from social connection in recovery. We don’t know for sure whether people in recovery can get the same benefit from spending more time around others they care about. We don’t know how much social interaction any person needs, really, and it probably varies from person to person.

We do know that everyone needs some social connection to develop properly, and to be stable later in life. Studies examining the efficacy of support groups emphasize that belonging to a stable group, committed to recovery, improves a person’s chances of staying in recovery from addiction. Social support, especially high-quality support from close friends or family members, is generally important for mental health and for coping with chronic stressors and stressful life-events. Yet, as helpful as it is, social support is not sufficient to prevent severe mental disorders, or to reduce their effects once they have developed. Social support is not a replacement for treatment.

Still, while we continue learning more, the safest bet is to recover together, not alone.

This post was last updated 5/4/17.

Trauma and Addiction: Common Origins and Integrated Treatment

addiction-trauma connection

As much as anything can be known, we know there is a strong connection between trauma and addiction. Of a sample of over 10,000 men and women, 34% of those with PTSD had one or more substance use disorders (SUDs). About two-thirds of people with substance use disorders have experienced trauma in their pasts, and about half meet the criteria for PTSD.

Scientists have investigated the trauma-addiction connection and, while causality cannot be proven, current evidence indicates that trauma causes addiction rather than the reverse. Maia Szalavitz, in her book Unbroken Brain, reports that, “Even just one extreme adversity – like losing a parent or witnessing domestic violence – before age 15 doubles the odds of substance use disorders, according to a study of the entire Swedish population” (Unbroken Brain, 65). Consistent with the self-medication hypothesis, the theory that people use substances to cope with psychological distress, PTSD tends to precede and predict SUD.

Furthermore, scientists have discovered common biological mechanisms for the development and persistence of both PTSD and SUD. For example, both disorders involve dysfunction with the same neurotransmitters (though researchers don’t yet understand how they are specifically involved in the development of comorbid PTSD and SUD).

“Dopamine, norepinephrine, and serotonin have been independently implicated in mechanisms associated with PTSD and A/SUD such as reward, impulsivity, arousal, and anxiety.” – Norman et al., 2012

Norman et al. also reports that the neuroendocrine system, responsible for processing stress, is affected by both PTSD and SUD. Corticotropin-releasing hormone (CRH) is secreted under stressful conditions, and is found in higher concentrations in patients with PTSD. It is associated with higher drug intake in rat studies, as well as stronger cravings in human studies. CRH  is also known to worsen withdrawal symptoms.

“In other words, individuals with PTSD may experience elevated CRH in the brain which may increase the euphoric feelings caused by many drugs and/or worsen withdrawal symptoms. Additionally, CRH elevations seen during withdrawal may increase hyperarousal symptoms, which in turn may increase other PTSD symptoms triggering relapse (i.e., self-medication).” – Norman et al., 2012

Given the strong statistical and biological connection between PTSD and SUD, it makes good sense to study treatments that address both disorders at once. Meta-studies examining treatment efficacy for comorbid SUD and PTSD have documented that trauma-focused treatments reduce symptoms for both disorders more effectively than SUD treatments alone (Norman et al., 2012Berenz and Coffey, 2013). Pioneering researchers, including Jennifer Mitchell, are exploring the possibility that oxytocin, the hormone that allows people and other mammals to form social bonds, may lessen the stress response and treat both PTSD and addiction.

Pharmaceutical and behavioral therapy treatments for PTSD abound, but certain treatments have more scientific support.

are all effective therapy treatments for PTSD, supported by randomized controlled trials and meta-studies of the PTSD treatment literature (Haagen et al., 2015; Gerger et al., 2014Ehring et al., 2014Watts et al., 2013). A meta-study of pharmacological interventions for PTSD found that serotonin selective reuptake inhibitors (SSRIs) are most effective for treating symptoms of PTSD, such as depression.

PTSD and SUD therapists alike have been suspicious of exposure-based treatments for years. For example, well-known trauma therapist Babette Rothschild shares case studies of patients she has treated who were retraumatized by exposure therapy. Rothschild also writes in her book, Trauma Essentials: The Go-To Guide, that there have been both documented and unofficial reports of high dropout rates from prolonged exposure treatments, citing Kubetin, 2003. This article by Kubetin, published in Clinical Psychiatry News magazine, quotes Dr. Richard Bryant reporting that 20% of patients (sample size of 40) find prolonged exposure therapy too intense to continue and another 20% do not respond to the therapy within 6 months.

However, the position that exposure-based therapies are retraumatizing is not supported by the literature. A meta-study examining the potential contraindications of PE found that while PE is not advised for patients who are actively suicidal, the treatment is safe for patients with other comorbidities, including substance use disorders. Another meta-analysis, examining dropout from trauma treatments, found no difference in dropout rates due to the degree of clinical attention placed on the traumatic event.

Prolonged Exposure Therapy has been shown to be effective in treating PTSD with many different origins, as well as comorbid PTSD and SUD (McCauley et al., 2012; van Minnen et al., 2012). Randomized controlled trials of PE for comorbid PTSD and SUD have demonstrated greater benefits for patients receiving PE than those receiving cognitive behavioral therapy or usual treatment for SUDs (Sannibale et al., 2013; Mills et al., 2012).

Still, just as a single case cannot be stretched to apply to all cases, statistics do not invalidate an individual’s experience. If a patient is experiencing worse symptoms after beginning exposure therapy, the treatment should be stopped. People may feel worse at first in exposure therapy, and often in other psychological therapies too, as they address the problems they have been having. But if they continue to feel distressed after a period of time decided upon by both patient and provider, other treatments need to be explored.

The significant relationship between trauma and addiction, and the success researchers have seen in integrating trauma and addiction treatments is well-established. Evidence-based trauma treatments, such as PE, EMDR, and CPT, should be a first-line approach for the 50+% of SUD patients with comorbid PTSD.

In fact, if trauma is a causal factor in the development of addiction, trauma treatment may be one of the most important preventative measures to invest in to reduce addiction rates across the country.

Image by No Lotus Design, used with permission.

This post was last updated 5/4/17.