Opioid addiction has been declared a national epidemic in America. President Obama called for $1.1 billion in new funding for opioid addiction treatment and research early in 2016.

Opioids are drugs that relieve physical and emotional pain. Opioids include opiates, which is an older term for drugs derived from opium, such as morphine. Common opioids include prescription painkillers such as OxyContin, hydrocodone, Percocet, methadone and Vicodin, as well as drugs like morphine and heroin. Opioids cause a rush of dopamine in the brain, conditioning the brain over time and altering pathways dealing with pleasure, memory, learning, and decision-making.

With continued use, the human body develops tolerance to opioids, which means the body no longer responds to the drugs unless the dose is increased. A person with a highly developed opioid tolerance may take doses to get high that would be lethal for a person without an opioid tolerance.

Unfortunately, people taking opioids illicitly may have an irregular supply, causing their tolerance to fluctuate. Illegal opioids are also of variable potency, and may be laced with stronger, faster-acting opioids like fentanyl. The combination of fluctuating tolerance and unpredictable potency creates a dangerous situation for people using illicit opioids. For example, someone using heroin whose tolerance has dropped may inject what they think is a manageable dose of heroin, not knowing it is laced with fentanyl; the added potency and reduced tolerance could cause an overdose, and this person could be at risk of dying.

Since 2000, opioid overdose deaths in the U.S. have increased 200%.

Some discussions about opioid maintenance involve black-and-white/good-or-bad thinking. Let’s explore the nuances of how opioid maintenance works for people with opioid addictions.

Why Opioid Maintenance Treatments Are the Best We Have

The opioid epidemic is alarming especially because so many people with families, dreams, and skills – like anyone else – are affected. People with opioid addictions are taxpayers and citizens of many races, religions, and backgrounds; they are people and they are valuable. How can we prevent them from dying?

Addiction is defined by NIDA as a chronic, relapsing brain disease characterized by repeated behavior despite negative consequences. Relapse rates for addiction are comparable to other chronic illnesses, such as diabetes and hypertension.

Given that relapse is likely and given that reduced tolerance is a primary risk factor for fatal overdose, it follows that maintaining tolerance would reduce overdose deaths. Sure enough, scientific research on opioid maintenance shows that stable doses of full or partial opioid agonists (drugs that completely or partially activate opioid receptors) maintain tolerance and reduce risk of death if a relapse occurs.

“If we really want to stop the overdose epidemic, we need to get serious about providing the only treatment known to reduce the death rate by 50 percent to 70 percent or more: indefinite, potentially lifelong, maintenance on a legal opioid drug like methadone or buprenorphine. The data on maintenance is clear. If you increase access to it, death, crime and infectious disease drop; if you cut it short, all of those harms rise.”
– Maia Szalavitz, The public scorns the addiction treatment Prince was going to try. They shouldn’t.

How Opioid Maintenance Works

“The principle behind MAT is this: Because opioid addiction permanently alters the brain receptors, taking the drug completely out of someone’s system can leave them less able to naturally cope with physical or emotional stress…”

– Maia Szalavitz

Two drugs are supported by scientific evidence as effective opioid maintenance treatments: buprenorphine, and methadone. A continuous, prescribed dose of either buprenorphine or methadone prevents people from experiencing withdrawals, stabilizes them in recovery, and reduces risk of fatal overdose. These medications do this by maintaining tolerance to opioids. People who are in opioid maintenance programs are not high when they take doses as prescribed (also because of tolerance), and are quite capable of driving a vehicle, going to work, providing childcare, and otherwise living life. Pregnant women who are addicted to opioids are advised to take buprenorphine (Subutex) to stabilize themselves and their babies until delivery.

Buprenorphine

Buprenorphine is a partial opioid agonist, which means that it binds to opioid receptors in the brain with only partial efficacy compared to full agonists (like morphine, oxycodone, and fentanyl). Effects of buprenorphine also have a ceiling dose, beyond which higher doses have no effect. This ceiling effect also means overdose from buprenorphine is less likely. Buprenorphine also affects the mμ receptor, which reduces the effects of additional opioid use.

Because it is safer than methadone, buprenorphine can be prescribed by physicians as pills or sublingual films, often under the brand names Suboxone or Subutex. Subutex is buprenorphine alone, while Suboxone also contains naloxone, an opioid antagonist. Suboxone was created to discourage misuse. When Suboxone is taken orally as directed, the opioid partial-agonist effects of buprenorphine predominate. If Suboxone is injected, however, the naloxone blocks opioid receptors and prevents the person from getting high. In an opioid dependent individual, the naloxone precipitates withdrawal effects.

Methadone

Methadone is a full opioid agonist, and does not have ceiling effects like buprenorphine. For this reason, it is considered to have higher misuse potential and is only administered by SAMHSA-certified opioid treatment programs, usually methadone clinics. However, a 2014 Cochrane review of studies comparing methadone and buprenorphine determined that people are less likely to drop out of methadone programs.

Given the complexity of addiction, and the complexity of factors uniquely affecting each person, individuals with addiction need individualized treatment. Only the individual, in consultation with one or more physicians well-educated in opioid use disorder and its treatment, may decide.

“Extensive literature and systematic reviews show that maintenance treatment with either methadone or buprenorphine is associated with retention in treatment, reduction in illicit opiate use, decreased craving, and improved social function. … Further work is needed to directly compare each medication and determine individual factors that can assist in medication selection. Until such time, selection of medication should be based on informed choice following a discussion of outcomes, risks, and benefits of each medication.”
–Dr. Gavin Bart, 2012 (Emphasis added)

How Opioid Maintenance Treatments Discourage Misuse

Just as it is impossible to eliminate all supplies of illegal drugs, law enforcement and treatment providers cannot wholly prevent diversion and misuse of buprenorphine or methadone. In fact, in trying to reduce misuse of buprenorphine, authorities have restricted access to buprenorphine maintenance treatment, limiting the number of buprenorphine patients a doctor can treat at any one time.

Still, treatment providers, pharmaceutical manufacturers, legislators, and law enforcement continue to try to limit the potential negative impacts of opioid maintenance treatments. Methadone, for example, is only given in take-home doses if patients can provide drug-free urine for several months.

However, because Suboxone can be diverted to people who were not prescribed the medication, it can still be misused. People who do not have a tolerance for opioids can still get high on Suboxone, up to the ceiling effect. Arguably, it’s a safer high than heroin because it is less likely to cause fatal overdose, but it’s still an illegal high.

In this case, as citizens, we have to weigh the risks of the diversion of partial agonist, buprenorphine, with full agonists like heroin, morphine, fentanyl, and oxycodone. If the goal is to reduce overdose deaths and crime associated with the opioid epidemic, buprenorphine will remain an important tool despite diversion.

Why People Dependent on Drugs Are Not Addicted

People taking medicine for depression, diabetes, and many other chronic illnesses become physically, literally dependent on their drugs to stay healthy. In most of these cases, however, these people are not addicted to their medicines. Even chronic pain patients, who become physically dependent on their painkillers and suffer withdrawals without them, typically do not develop addiction – only 8-12% of chronic pain patients become addicted to pain medication.

Dependence and addiction are very different, and understanding this may sometimes make the difference between life and death. Addiction is defined by persisting in a behavior despite negative consequences. People who are only dependent on a drug suffer withdrawals, and are then free to continue their lives – they do not go looking for more of the drug or persist despite negative consequences. People who are dependent and addicted, however, will continue to seek the drug even after withdrawals are over.

In the case of opioid addiction, people are still at risk for relapse after withdrawals are through, and may die from a relapse if their tolerance drops. To treat opioid addiction, rather than only opioid dependence, opioid maintenance treatment – recommended by the World Health Organization, the Office of National Drug Control Policy, and others to be continued indefinitely, perhaps life-long – is necessary to keep people stable and to prevent fatal overdoses.

How Opioid Maintenance Disrupts Addiction Patterns

Addiction happens when people at risk due to trauma history, mental illness and other factors take a drug which they are predisposed to experience as extraordinarily rewarding. In the brain, when a person has an exciting new experience, the reward system responds with a release of dopamine and other neurotransmitters telling us it’s something we want to do again. Certain drugs are more likely to cause a magnified reward response in the brain, releasing far more dopamine than ordinary experiences.

The reward system helps people to learn which experiences are good and which are bad. Because some people biologically experience some drugs as more rewarding than anything else, they learn to associate the drug, and any cues relating to its use (paraphernalia, locations, people, symbols) with immense reward. Their brains begin to respond to the cues, more even than the drug itself, which reinforces use.

Opioid maintenance does not involve the cues to which people with opioid addictions respond. Commuting to a methadone clinic is very different from shooting up heroin. Receiving one dose of Suboxone from a designated family member is very different from self-administering indefinite pills. The “people, places, and things” associated with use are changed when a person enters opioid maintenance. Opioid maintenance treatment helps keep neurocognitive cravings and physiological withdrawals at bay while the person rebuilds his or her life to remove cues for use.

In this way, opioid maintenance disrupts the addiction pattern of cue > pursuit of drug > use. Essentially, opioid maintenance attempts to replace an addiction with simpler dependence, rather than with another addiction. The difference between physical dependence and addiction is crucial to understanding why opioid maintenance does not replace one addiction with another.

How Opioid Maintenance Supports Healthy Recovery

At this point, it may seem overly simple to say that because opioid maintenance prevents people from dying, it supports lives in recovery. Still, this is a key truth. Beyond keeping people alive, opioid maintenance allows people to find enough stability to build new lives in recovery.

Many people believe that a person must abstain completely from all drugs in order to truly be in recovery. However, if a person in recovery from addiction needed medical treatment for diabetes and were prescribed insulin, that person would certainly not be expected to abstain from insulin for the ideal of abstinence. Nor would a person refuse needed antibiotics on the principle that they must not take any drugs if they are to be in recovery. Opioid maintenance is no different from these examples of medication for medical necessity.

A person in opioid maintenance treatment is not high. The steady dose of a partial or full-agonist opioid basically establishes a “new normal” biologically – biochemically – without which normalcy is disrupted. A person with depression who benefits from an anti-depressant is said to have a chemical imbalance, which is stabilized by the anti-depressant. Similarly, a person with an opioid addiction has a chemical imbalance from chronic opioid use, and may be unstable without some level of continued opioid administration.

People in recovery from opioid addictions will still need to do everything a healthy person must do to survive and succeed, such as keep a job, pay bills, provide child, pet, or elder care, or maintain a household. In order to be stable enough to manage all of these challenges and the attendant stress, people in recovery from opioid addictions need access to opioid maintenance.

To Sum it Up

• People with opioid addictions are at risk of dying. As health professionals, concerned citizens, or families and friends, we owe it to people with opioid addictions to do what we can to prevent this.
• Buprenorphine/methadone maintenance is the only evidence-based treatment that reduces death risk by 50%. To prescribe other treatments without considering maintenance is, frankly, malpractice.
• People are not high when taking buprenorphine or methadone as prescribed. Opioids produce tolerance in the human body, such that consistent doses no longer make the person high.
• Opioid maintenance treatments include measures to prevent or discourage misuse. Buprenorphine, as a partial agonist, has a “ceiling” dose, beyond which further amounts have no effect. Suboxone discourages injection misuse by the action of naloxone, which precipitates withdrawal symptoms in opioid dependent individuals. Methadone is primarily delivered in controlled, daily doses in a clinical setting.
• Addiction is different from dependence. Addiction involves a learned behavior that continues despite negative consequences. Dependence is only the body’s physical adjustment to a drug, and can happen without addiction. Unlike addiction, dependence does not involve persisting in use despite negative consequences.
• Maintenance disrupts addiction because doses are not rewarding and are not associated with addiction cues. People in opioid maintenance programs are receiving their stable doses of methadone or buprenorphine under very different circumstances than their usual addiction-related rituals. By disrupting the patterns of addiction and providing doses that are not rewarding (do not get the person high), maintenance maintains tolerance and dependence without maintaining or creating addiction.
• Indefinite maintenance allows people to focus on improving their lives in recovery. Opioid maintenance treatments allow people to lead lives in recovery without worrying about coping with withdrawal symptoms or risking fatal overdose. In the event of a relapse, people can focus on learning which cues to avoid next time – how to prevent another relapse – rather than recovering from a severe overdose or dying.

Further reading:

Why We Have Wait Lists for Opioid Addiction Treatment

What the Opioid Epidemic Means in Virginia

How Ithaca, NY is Addressing America’s Opioid Epidemic

Addiction or Dependence: A Life and Death Difference

How to Talk with Someone About Getting Help with Addiction

This post was last updated on 10/27/16.

In the 1980s, when addiction science professionals sat down to agree on terminology for the DSM-IV, the room decided by only one vote to call addiction “dependence.” The issue did not rest there. The latest Diagnostic and Statistical Manual of Mental Disorders, DSM-5, labels addictions as “substance use disorders,” because “dependence” does not quite cover what addiction really is.

Dependence is when a person becomes physically reliant on a substance, and experiences withdrawals without it. While dependence often happens as addiction develops, full addiction is much more complex, and is defined by continuing to use drugs or engage in behaviors despite negative consequences.

As an example, physical dependence can happen with many different medications. People who take antidepressants, for example, become dependent on them and undergo withdrawal symptoms if they stop taking the medications. In this case, these patients are dependent on antidepressants but are not addicted to them, and antidepressants are not considered to be addictive.

People in pain go to their doctors for relief, take pain medicine as prescribed, and if they take it long enough, their bodies get used to the medication, expect it, and throw a fit without it. When (if) their chronic or acute pain is over, doctors know to taper patients from pain medicine if physical dependence happens, and to treat withdrawal symptoms to ease the process. The patients may or may not know they are feeling sick because of withdrawal, but if they are otherwise happy in their lives they won’t bother with trying to find opioids illegally on the streets.

They do not persist in using the drug despite negative consequences, which defines addiction. They were dependent on the drug, but not addicted to it.

(Note: Among pain patients prescribed pain medication, only 8-12% develop addiction. Maia Szalavitz reports for Scientific American that “75 percent of all opioid misuse starts with people using medication that wasn’t prescribed for them—obtained from a friend, family member or dealer.”)

Addiction develops in 10-20% of people when multiple risk factors coincide with drug use (whether prescribed or recreational). If people have genetic predispositions, a history of trauma, and/or mental illness(es), they will be vulnerable to developing addiction. Even for these individuals, addiction takes time as they learn to associate the substance or activity with pleasure or relief, and the absence of the substance or activity with misery.

Individuals addicted to opioids are usually also physically dependent on them. Often a first line of treatment is to enter people with opioid substance use disorders into detox, where withdrawal symptoms may be treated while the person is monitored by medical staff. What happens next unfortunately depends on which doctor is managing the case (not all treatments are equally effective).

But to whatever treatment they are referred, individuals with opioid use disorder are at risk for relapse long after withdrawal symptoms are gone. This is why addictions, or substance use disorders, are very different from physical dependence. Once a person has gone through withdrawals and been abstinent from the substance for a period of time, the body readjusts and is no longer dependent on the substance. But people with substance use disorders still crave the drug.

Moreover, with certain drugs, like opioids, the body builds up tolerance with repeated use, which means the drug no longer affects the body unless the dose is increased. When a person enters a period of abstinence, their tolerance drops substantially.

Sadly, people with opioid use disorders often relapse and die when trying abstinence-based treatment, because they’re still addicted and their tolerance is gone. When they take the opioid at their usual dose, they overdose. What was once an okay amount is now fatal. Buprenorphine and methadone maintenance are recommended to keep people alive by keeping tolerance stable (without being high). Life-long maintenance may be necessary. If a person is tapered or otherwise terminates maintenance treatment, they are at higher risk of fatal overdose.

In the case of addiction, distinguishing between “substance use disorder” and “dependence” is a life and death debate. Understanding that substance use disorders – addictions – are more than physical dependence means we will help these individuals long after withdrawals are gone and for as long as they need treatment.

This post was last updated 5/4/17.

For a long time since Bill Wilson and Dr. Bob Smith founded Alcoholics Anonymous (AA) in 1935, AA’s twelve steps were the standard of care in addictions treatment. AA is a mutual help group for people with alcohol use disorders, guided by standard literature and twelve steps aimed at helping people make amends, develop spiritually, and connect with others in similar situations.

AA’s model has been adopted by other groups such as Narcotics Anonymous (NA), Gambler’s Anonymous (GA), Overeater’s Anonymous (OA), and other variations. In each case, these groups continue to rely on the twelve steps, with minor adaptations, and have been generally known as 12-step support groups.

People in 12-step groups help each other with bits of collective wisdom beyond official literature, including the admonition to change “people, places, things” to remove triggers for use; the acronym HALT, reminding members never to get too Hungry, Angry, Lonely, or Tired; and the serenity prayer:

God, grant me the serenity to accept the things I cannot change,
Courage to change the things I can,
And wisdom to know the difference.

While meeting formats vary, they tend to include members sharing about their experiences and struggles while living in recovery and readings and discussions of the 12-step literature. Twelve-step groups also encourage members to find sponsors to provide advice based on their own recovery experience. Generally, people who have been abstinent for awhile become sponsors for other, newer members.

Many hundreds of people have testified that 12-step support groups saved their lives, and some scientific research seems to support the efficacy of 12-step groups (Humphreys et al., 2014; Witbrodt et al., 2014; Moos & Moos, 2006).

Other people have criticized 12-step groups, pointing to the high rates of dropout, the heavy spiritual and moralistic emphasis, the inconsistent and contradictory logic in its literature, and the variability of groups depending on who is in them. Furthermore, about half of women who have participated in AA have experienced “13th-stepping,” the practice where group members, usually men, target new members, usually women, for dating or sex. In some cases this common practice has resulted in rape.

Despite their limitations, 12-step support groups remain an important part of many peoples’ lives in recovery, particularly if they feel belonging to their group. Research shows that social support is an important part of recovering from addiction. People who are a part of a strong group of people committed to sobriety are more likely to stay abstinent than people surrounded by old friends who may still be drinking or drugging.

Twelve-step groups are not the only addictions support group option, however. For people who want the social support without the spiritual emphasis, other mutual help groups exist, such as SMART Recovery (Self-Management and Recovery Training) and Moderation Management.

The Minnesota Model and Modern Rehab

The ubiquity of 12-step support groups was expanded to treatment in the 1950s by the Minnesota Model, a 12-step-based program developed by two people (not yet trained in addictions) working in a state mental hospital that was quickly adopted by the Hazelden Foundation, one of the oldest and most well-known rehab centers. The Minnesota Model is an intensive program including mandatory 12-step meetings, lectures, and counseling.

Rehab centers like Hazelden provide this type of care for 28-day periods on an inpatient basis. For many people with addiction, inpatient rehab may be their first contact with addictions treatment. Rehab centers have been criticized for high relapse rates, and for not following up with patients following discharge. Research on the efficacy of standard, 28-day rehab programs is notoriously scarce.

Twelve Step Facilitation (TSF)

Much later, in the 1990s, Twelve Step Facilitation was developed as a standardized adaptation of 12-step support groups, intended as an early, individual therapy delivered by a counselor. TSF helps to introduce many of the concepts of 12-step support groups, and encourages patients to engage in support groups following therapy. However, TSF is distinct from AA and other 12-step support groups.

“TSF is not officially related to or sanctioned by AA. It is available as a manual for standardized use by addiction treatment facilitators with a focus on abstinence as a treatment goal. Participation in AA meetings and other official AA activities (such as service and AA social events) is encouraged as a means to that end.” – Nowinski, Baker, & Carroll, 1999.

Some studies have demonstrated that Twelve Step Facilitation has helped people use 12-step support groups to support abstinent lifestyles, though when compared with TSF, cognitive behavioral therapy may be better for long-term support. As a first step toward engagement in 12-step support groups, TSF seems to be helpful and is often used in inpatient rehab settings.

Despite the ubiquity of 12-step groups and programs, scientific studies evaluating how well they work have not yet established, conclusively, whether 12-step-based approaches are effective. Reviews of the literature find mixed results, with some studies finding positive effects, some finding negative effects, and some detecting no statistically significant influence. Studies face methodological challenges (particularly self-selection bias), and most often do not distinguish between 12-step support groups, inpatient rehab, and TSF (perhaps because their content is so similar).

The first mandate of medical treatment is to do no harm. Because some studies have found 12-step programs to be detrimental to people, and because their effects are otherwise inconsistent and inconclusive, 12-step-based treatments cannot be considered to be evidence-based. Evidence-based treatments for addiction do exist, and include cognitive behavioral and dialectical behavior therapies, mindfulness training, and a range of pharmaceutical treatments. Typically, addictions treatments must be individualized, and must account for the type of substance or behavior used, co-occurring mental disorders, and trauma history.

With a scarcity of evidence, treatment providers must decide on a case-by-case basis whether 12-step groups, inpatient rehab, TSF, or some alternative is best for a person in recovery. Twelve-step groups and facilitation do work for many people, but they are not for everyone.

The primary benefit of 12-step support groups and programs is subjective, depending on the quality of the human relationships in a given group and on the importance of spirituality to the person in recovery. Social support is recommended for people in recovery from addictions, but other mutual help groups may provide this without the problematic aspects of the 12-step approach.

After extensive research, the most balanced recommendation I can make is if you are a person in recovery, consult your doctor first, and choose the treatments that work for you. The goal is to create a stable and positive life in recovery, and if a treatment is not adding to this goal, it is not for you. In this case, if the medicine tastes bad, it is bad.

If you are a treatment provider or a drug court judge, please be advised that 12-step groups and programs are not evidence-based, may sometimes do harm, and therefore, if recommended at all, should be one of many treatment and recovery support options offered.

I wrote this post following a discussion with Anne Giles, in which she requested balanced research on the efficacy of and difference between 12-step support groups, inpatient rehab, and Twelve Step Facilitation. The positions I take in this post are mine, and cannot speak for her, or for Handshake Media, Inc. 

The article annotated and excerpted below, published in 2013, offers a conceptual framework through which to apply the findings of neuroscience to addictions treatment. It may be explosively important. Translating its offerings into practical applications will be difficult. The article is lengthy, written in highly technical language, weighs in at 9,300+ words, and cites 182 sources.

My intention is to attempt, however, to do just that. The work by Eric Garland, et al. – new research funding was just announced 9/6/16 –  could have weighty implications for individuals with substance use disorders (SUDs) and for SUD treatment professionals. My intention is to continue writing about addiction and addictions treatment as simply and directly as I can.

To that end, I have excerpted, annotated, added explanatory links to, and re-formatted the conclusion from Mindfulness Training Targets Neurocognitive Mechanisms of Addiction at the Attention-Appraisal-Emotion Interface and intend to link to this post from other writings.

We offer the following speculative, hypothetical account [demonstrating the conceptual framework described in this paper that applies findings of neuroscience to addictions treatment] based on our clinical and research experience using MBIs [mindfulness-based interventions] to treat persons diagnosed with substance use disorders.

When a recovering addict with a history of using drugs to cope with negative emotions encounters a cue associated with past drug-use episodes while in the context of a stressful environment (e.g., walking past a bar after getting in an argument with a work supervisor), this encounter may activate cortico-limbic-striatal circuits subserving drug-use action schemas. [In other words, the encounter may activate brain structures related to feelings, thoughts and behaviors associated with drug use. The authors write, “The urge to seek intoxication from addictive substances is driven, in part, by reactivity to substance-related stimuli [cues] which have been conferred incentive salience [priority importance], and is magnified by negative affective states.” The authors define “drug-use schemas” as “memory systems that drive drug seeking and drug use through automatized sequences of stimulus-bound, context-dependent behavior.”].

After completing a course in mindfulness training, the addict may become more aware of the automatic addictive habit as it is activated, allowing for top-down regulation of the precipitating negative emotional state and the bottom-up [brain structured-based reactivity] appetitive urge. [“Top-down regulation” is not to be confused with “willpower” or  “suppression” which, according to neuroimaging research, actually results in “hypoactivation in cognitive control circuits.” Attempts to suppress urges, paradoxically, result in 1) increased urges, 2) decreased resilience with regard to emotionally stressful events which is correlated with return to use, and 3) depletion of cognitive resources, thus increasing the likelihood of a return to automatic behavior to use vs. conscious behavior to abstain.]

Specifically, the individual may engage in mindful breathing to first disengage from and then restructure negative cognitive appraisals, thereby reducing limbic (e.g., amygdala) activity, autonomic reactivity, and dysphoric emotions related to the stressor. Concurrently, the individual may become aware of when his attention has been automatically captured by the sight of people drinking in the window of the bar, and, through formal mindfulness practice, activate fronto-parietal mediated attentional networks to disengage and shift focus onto the neutral sensation of respiration.

During this process, as sensations of craving arise, the individual may engage in metacognitive [the ability to become aware of, and direct, one’s thoughts] monitoring of these sensations, and in so doing, facilitate prefrontal down-regulation of limbic-striatal activation. [Author Maia Szalavitz uses the metaphor of a “volume control” to explain a person’s ability to up-regulate or down-regulate his or her own inner state.] As mindfulness of craving is sustained over time without drug-use, the sensations of craving may abate, promoting extinction learning to weaken associative linkages between conditioned addiction-related stimuli and the attendant conditioned appetitive response. [If “appetite” for drinking or using is present, but is not satiated with the anticipated reward, the tie between use and the reward lessens over time.]

Once working memory has been cleared of active representations of substance use, the individual may shift attention to savor non-drug related rewards, such as the sense of accomplishment that may arise from successfully resisting the temptation to drink (i.e., self-efficacy), appreciating the beauty of the sunset on the walk home without being clouded by inebriation, or the comforting touch of a loved one upon returning home safe and sober. [“Savoring” is defined by the authors as “selective attention to positive experience.”]

Through repeated practice of regulating addictive responses and extracting pleasure from life in the absence of substance use, the individual may re-establish healthy dopaminergic tone [to replace atrophy resulting from substance use] and foster neuroplasticity in brain areas subserving increased dispositional mindfulness. [“Dispositional mindfulness” is defined as awareness of, and attention to, what one is feeling and thinking in the moment.]

Ultimately, mindfulness may facilitate a novel, adaptive response to the canonical “people, places, and things” that tend to elicit addictive behavior as a scripted, habitual reaction. In so doing, the practice of mindfulness may attenuate [reduce the power of] stress reactivity and suppression while disrupting addictive automaticity, resulting in an increased ability to regulate and recover from addictive urges.

Posts that link to this post:

• Forthcoming

For those beginning to discover they’re doing something they want to stop – or have tried stopping something and are having trouble – SMART Recovery welcomes all. Whether one struggles with alcohol and other drugs, smoking, gambling addiction, Internet addiction, sexual addiction, self-injury, problematic eating behavior, problematic relationships, or issues with other substances and activities, SMART Recovery meetings are the place to gather and talk with people addressing similar challenges.

What science is telling us and we know from personal experience is that we do better making changes with support from others!

If you’re interested in helping your community address its challenges with addiction, I invite you to train to become a SMART Recovery discussion host.

Based on my professional and personal assessment, holding SMART Recovery meetings is the closest we can get to community-wide, evidence-based, group-based addictions recovery assistance using resources already in place.

If we can, as a community, host SMART Recovery meetings every day at different times all over the area, we can provide free, near-treatment-level assistance to our people with addiction challenges. We don’t need to form task forces, write grants, or lobby public officials. We just need community members to do the training and sign up as hosts with SMART Recovery, and for community organizations with buildings to offer spaces for meeting locations.

• SMART Recovery discussion meetings are free and open to anyone in the community.
• Volunteers hosts DO NOT have to be in recovery from addiction to serve. Any community member – from the mayor to the maki maker to the mechanic – can serve as a discussion meeting host.
• While discussion meetings are not generally facilitated by experts or licensed professionals, meetings focus on learning skills termed “tools” and are guided by trained hosts, thus extending the therapeutic value beyond more sharing-oriented support group meetings.

Here’s more information:

• Train to serve as a SMART Recovery discussion meeting host
• Main handout distributed at SMART Recovery meetings (.pdf)
• What a SMART Recovery discussion meeting is like
• Discussion meeting script used for the Blacksburg, VA SMART Recovery meeting at NRVCS (.pdf)
• How to get help for a loved one with addiction in the New River Valley of Virginia
• How to talk with someone about getting help with addiction
• What Ithaca, NY is doing about addiction in its community

If you’d like to experience in-person what a SMART Recovery meeting is like, this meeting is open to all and you are welcome to attend:

Sundays, 4:00 PM, New River Valley Community Services, 700 University City Boulevard, Blacksburg, Virginia.

We’re compiling local recovery support resources here.

If you have any questions, feel free to contact, Anne Giles, [email protected], 540-808-6334.

(If you email me and don’t receive a reply, please check your spam folder. If you don’t see a reply in your spam folder, please phone or text me and we’ll connect that way!)

Hope to join you in volunteering with SMART Recovery!

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.

Separate 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

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.

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., 2016; Sarnyai and Kovács, 2014; Stauffer 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.

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., 2012; Berenz 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.

• Eye Movement Desensitization and Reprocessing (EMDR)
  (Schubert, Lee, and Drummond, 2016; Novo Navarro et al., 2016; Acarturk et al., 2016; Smith, 2015; Chen et al., 2014; Jeffries and Davis, 2013; Leer, Engelhard, and van den Hout, 2014),
• Cognitive Processing Therapy (CPT)
  (Morland et al., 2014; Lloyd et al., 2014; Forbes et al., 2012; Resick et al., 2008; Monson et al., 2006),
• and Prolonged Exposure Therapy (PE)
  (Resick et al., 2012; van Minnen et al., 2012; Killeen, Back, and Brady, 2011; Powers et al., 2010; Schnurr et al., 2007; Rothbaum, Astin, and Marsteller, 2005; van Minnen, Arntz, and Keijsers, 2002)

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., 2014; Ehring et al., 2014; Watts 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.