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:

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.

photos_aug_3

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.

How Ithaca, NY Is Addressing America’s Opioid Epidemic

The mayor of Ithaca, NY has not seen his father since he was 6 years old due to his father’s struggle with a crack addiction. As mayor of an educated and forward-thinking town, he acted decisively to address addiction head-on, as a whole community. He assembled the Municipal Drug Policy Committee and told them to come up with the most ideal solutions they could based on latest evidence.

“Don’t think about money, don’t think about politics, don’t think about anything except for solutions … Whether you like an idea or not, that doesn’t really matter. Figure out what it is you can support and be part of it. If you don’t support a part of it, don’t fight it. What if it saves a life?” Travis Brooks, of the Greater Ithaca Activities Center, reported about his experience on the committee.

The Ithaca PlanThe report the Municipal Drug Policy Committee came up with is 64 pages long and titled “The Ithaca Plan: A Public Health and Safety Approach to Drugs and Drug Policy.” In an interview with the Ithaca Journal, Mayor Myrick describes the plan as having four pillars: prevention, treatment, law enforcement, and harm reduction.

Prevention in The Ithaca Plan is not limited to efforts people have made in the past to scare kids away from drugs, such as D.A.R.E. or “Just Say No.” Myrick explains that these programs have not been effective because they do not address the underlying problems that put people at risk for addiction, such as poverty and mental illness.

“So instead of just telling kids “Don’t do drugs,” if we could make sure that they were more engaged, maybe we wouldn’t even have to tell them not to use drugs. They wouldn’t want to in the first place. The same thing with drug dealing, because often the people engaged in drug dealing are doing it because they’re locked out of the mainstream economy.”
– Mayor Myrick, quoted in the Ithaca Journal

The Ithaca Plan stresses that treatment for opioid addiction must include medications and a detox facility in town. Presently the nearest facility is in Syracuse, NY, an hour and a half drive away.

Law enforcement is included in the plan not to put more people behind bars, but rather to engage officers in helping direct people into treatment instead. The Ithaca Plan models their law enforcement approach after the LEAD program in Seattle, WA.

The Municipal Drug Policy Committee is already working on their fourth pillar, harm reduction, proposing that the first safe injection facility in the US be opened in Ithaca. Safe injection, while not providing drugs, gives people with opioid substance use disorders a place off the streets to shoot their drugs in safety, with clean needles (a harm reduction measure known to reduce disease transmission) and a staff of nurses at hand. Safe injection facilities would give people a place to enter treatment when they are ready with a full set of options on hand, as well as a place to have other maladies addressed.

“They will have just had their fix, so that won’t be their first priority, and they might say to the doctor there, ‘Actually my tooth has been hurting and I have a puncture wound that has gone bad,’” Mr. Myrick said. “You can begin to treat the other physical things and get them prepared for their moment of clarity.’’
Ithaca’s Anti-Heroin Plan: Open a Site to Shoot Heroin, The New York Times, 6/22/16

Mayor Myrick expects that many parts of The Ithaca Plan will require jumping legal and financial hurdles. The full Plan is anticipated to take years to enact.

“I think we need a comprehensive plan because I think every community does. I think the federal government needs a different plan, but they’re not doing it, and the state’s not doing it. So we sort of had to do it ourselves. And we did it ourselves not because we’re the heroin capital of America — our problem is no worse than anywhere else — but we do lose people just like you’re seeing everywhere across the country.”
– Mayor Myrick on why Ithaca needs such a comprehensive plan

Those hoping to follow Ithaca will note that the process was gradual, gentle, and non-exclusive. Before the Municipal Drug Policy Committee wrote The Ithaca Plan, Ithaca’s mayor introduced the issue to the public, expressing the community’s great need for action and explaining why he had formed the Committee seven months prior. The Ithaca Plan’s unveiling was a public event, complete with an invitation to Ithaca citizens to attend. Mayor Myrick and the Municipal Drug Policy Committee acted in a way that speaks to their faith in Ithaca’s willingness to learn and to keep open minds to new solutions, no matter how controversial.

. . . . .

In her presentation “What’s a Town to Do About Addiction?” in Blacksburg, Virginia on August 3, 2016, author Maia Szalavitz referred to community initiatives to address addiction in Ithaca, New York.  This post is follow up on her suggestions.

A video and transcript of Maia Szalavitz’s presentation is here.

7 Science-Savvy Ways to Evaluate Research

Popular interpretations of science often oversimplify research and lead us astray. Some people have thrown up their hands and declared, “Research can be twisted any way to say anything anyone wants it to say.” The statement is not wrong, but it is also not grounds for dismissing science entirely. We can respond to bad science and misinterpretations of science with caution and discrimination. Fortunately, science professionals have been obsessing over how to do this for decades now, and we can approach the problem with some useful techniques.

Scientist in field by Risa Pesapane
Epistemology, the discipline that attempts to answer, “How can we know anything?” is not reducible to science. Many questions can be answered outside of science. Sometimes we can use deductive reasoning, personal experience, or trust an authority on the topic. The last of these, trusting an authority, does not seem very rigorous, but can be reasonable if the person has developed a reputation for high epistemological standards.

Some epistemological methods are good for some questions but not for others. I wouldn’t ask an authority on any subject to tell me my preference for slippers, and I wouldn’t trust someone who is not an expert on a topic to give an accurate opinion about it. Almost always, with epistemology, people are working with degrees of certainty rather than with perfect and absolute Truth. (Our culture tends to seek closure and absolutes when these are actually quite rare.) Still, carefully researched hypotheses are better than a shot in the dark – a delicious espresso drink but a poor epistemological practice.

It may be true that anyone can twist a single scientific study to seem to say something it doesn’t. It’s much harder to twist many controlled, randomized, and blinded studies with large sample sizes.

Scientific rigor refers to a number of scientific attitudes and practices demonstrating an unswerving loyalty to finding truth, setting aside any opinions or biases the researcher might have. It is a term referring to how close a statement or the results of a study are likely to be to the truth. The intentions of scientific rigor is disciplined accuracy.

Good scientists design studies using scientific rigor, report degrees of probability, indications rather than certainties, and always follow up with a call for more research. They welcome peer review – evaluation of their work by experts. Relying solely on the peer review process has its risks and limitations, however. While people conducting peer reviews are trained, experienced, scientific professionals, they are not infallible.

Armed with understanding the limits of “knowing” – epistemology – and the intention of research to seek truth beyond the personal – scientific rigor – we can use the following criteria to examine the research meaningfully on our own.

1. Sample sizes must be sufficiently large. Each scientific study, if it is to be of any use, must have a sufficiently large and representative sample. “Sufficiently large,” or meaningful sample size, can be evaluated with statistics, but as a rule the larger the sample size the better. Typically, sample sizes are limited to the amount of funding a study has.

In the field of addiction, people have asserted that one must have experienced addiction in order to understand it. In some ways this is true; the personal experience of having an addiction is not replaceable by science and is immensely valuable for helping others relate to the condition. Personal experience may even provide insight for the initial formation of scientific hypotheses. However, personal experience is a sample size of one. Science is used to evaluate things about a condition beyond the individual and personal.

2. One or more controls must be used for each experimental variable. Science attempts to break a large question down into a series of studies, each addressing very few, measurable variables. Human studies are notoriously difficult to engineer because of the number of variables potentially influencing the outcome. The tension is between the usefulness of a study general enough to apply to many people, and a study specific enough to be rigorous.

First, scientists attempt to narrow the focus of the study to a limited population, for example, to people with heroin substance use disorders in prison. Next scientists must determine what variables still remain. Ideally, they will make all relevant variables consistent, except for the ones being tested. The more potential, unaccounted-for variables, the less useful the results. Statistics allows scientists to sort out some of this complexity, but as a general rule, fewer confounding variables are better.

For each experimental variable – for each variable being measured – scientists come up with one or more controls. In the case of addiction, if the treatment is 12-step attendance, scientists may compare it to no treatment at all. If multiple treatments are being evaluated, scientists may compare 12-step attendance with cognitive behavior therapy,  dialectical behavior therapy, and no treatment. A new treatment may be compared to “treatment as usual,” or “TAU,” which must be explicitly defined.

3. Placebos are a particularly useful control for evaluating medical treatments. Using this type of experimental control, scientists will compare new treatments to false treatments, or placebos. The placebo effect refers to the ability of the human mind to fabricate some kind of change even if the treatment was a sugar pill with no effect. Scientists investigate whether treatments can physiologically improve a condition more than the brain can on its own with sufficient belief.

4. Randomization is a key part of most experimental designs to prevent bias. Randomization involves using a computer program to select test subjects or experimental plots, match test subjects with treatments, and etc. It is a technique that attempts to make samples representative of whatever is being studied. Randomization is an important precaution against bias, i.e. it prevents the scientist from engineering the results of an experiment.

Especially with human studies, scientists often try to overcome some of the potential effects of human diversity (i.e. gender, race, income level, etc.) by randomizing which test subjects are assigned to which experimental group. For example, in a study on Medication-Assisted Treatment (MAT), scientists may use a computer program to determine which person receives buprenorphine, methadone, or no medication at all.

5. Double-blind experiments are a gold standard. In addition to randomization, scientists will use double-blind experiments, where possible, to assess new treatments. Not only are the patients unaware of whether they are receiving treatment or placebo, but the experimenters are, too. After randomizing which patients receive a placebo and which receive the experimental treatment, the people administering the treatments are not told which is placebo and which is not so that they can’t give the patients any unintentional hints. Double-blind trials are not always possible, especially with behavioral therapies.

6. Minimal extrapolation from results is preferred. Even a well-conducted study can be followed by fairly wild speculation on the part of the researcher. Scientists are sometimes guilty of drawing conclusions that are not supported by their research design or by their results. Usually, due to experimental limitations, the conclusions drawn should be modest. After reading the results of a study, reading the conclusion should feel like a “duh” moment.

7. Regardless of a study’s level of rigor, one study is never enough to draw a strong conclusion. As a secondary researcher, I need to use a large sample size, too. Just as my personal experience is limited as a sample size of one, each scientific study has limits to its usefulness. One of the most important aspects of the scientific method is the repeatability of experiments. Until we repeat experiments or approach a problem with multiple experiments, our ability to draw conclusions from the results is very limited. So, when I see a news article making a sensational claim that only cites a single study, I’m going to recognize that even if that study is as rigorous as it could possibly be, its results have limited value until it has been repeated.

Science is accessible to anyone and is extremely useful, though its expense, the limitations of each study, the number of repeat studies, and the work required to understand it may make it seem like an epistemological tortoise. It may be true that anyone can twist a single scientific study to seem to say something it doesn’t. It’s much harder to twist many controlled, randomized, and blinded studies with large sample sizes. Science-savvy readers, at least, will be harder to fool and will be looking for more modest, nuanced conclusions.

Photo credit: Risa Pesapane

5 Addiction Myths Challenged by Maia Szalavitz in Unbroken Brain

Unbroken Brain: A Revolutionary New Way of Understanding Addiction braids together three narratives: Maia Szalavitz’s personal story, what the science reports about addiction, and a call to action to change belief-based addictions treatment to evidence-based treatment.

Prior to the release of Unbroken Brain, Maia Szalavitz shared these images about the myths surrounding addiction and the science that refutes them through her Twitter stream.

Unbroken Brain Myth #1: There is an "addictive personality" that all people with addiction share.

Myth #1: There is an “addictive personality” that all people with addiction share.

People with addictions are more likely to have higher levels of certain traits like impulsivity or anxiety, however, not all addicted people have all of these traits and no single “addictive personality” has ever been found. Further, extremes on either end of the personality spectrum – like fearfulness and recklessness – can both increase risk.

Unbroken Brain Myth #2: Once an addict, always an addict.

Myth #2: Once an addict, always an addict.

Conventional wisdom has it that addictions are always a lifelong struggle. But in fact, half of people with illegal drug addictions overcome their problems by age 30 – and many do so by cutting down, rather than quitting entirely.

Unbroken Brain Myth #3: Addiction is an "equal opportunity" disease.

Myth #3: Addiction is an “equal opportunity” disease.

Not everyone is equally at risk. Addiction typically kicks people who are already down or who have unstructured or otherwise difficult lives. It is far more likely to affect people who have mental illness, those who have suffered severe childhood trauma, people with personality disorders and those who are poor and marginalized (although it is probably more common in the extremely rich who have more unstructured time than the middle class, as well).

Unbroken Brain Myth #4: Babies can be "born addicted" to drugs.

Myth #4: Babies can be “born addicted” to drugs.

Infants can be born with physical dependence on drugs like heroin or pain relievers if their mothers take them daily during pregnancy. But newborns cannot be addicted, even though they can suffer withdrawal. Addiction requires knowing that the drug is what you need to fix your symptoms, as well as being able to obtain it repeatedly and then taking it despite negative consequences.

Unbroken Brain Myth #5: Addicts have "hijacked brains" and are powerless over their behavior and unable to learn until they stop taking drugs.

Myth #5: Addicts have “hijacked brains” and are powerless over their behavior and unable to learn until they stop taking drugs.

While much of addictive behavior seems irrational, no one deliberately shoots up in front of the police or in court – and people with addiction clearly plan and work hard to ensure their drug supply and avoid detection. On the other hand, they do all this hiding and planning in order to gain access to something that is harmful for them.

This means that people with addiction can have impaired decision-making abilities, but they are not zombies without free will. While addicted, they can and do take important steps to protect their health like learning to use clean needles and how to reverse overdose.

Here’s a transcription of the text in these images (.pdf).

Maia Szalavitz has written extensively in multiple publications on how addiction myths are contradicted by the science of addiction.

Maia Szalavitz, author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, has graciously agreed to speak in Blacksburg, Virginia on Wednesday, August 3, 2016.

Learn more about Maia Szalavitz’s visit to Blacksburg, Virginia

Understanding Why We Have Wait Lists for Opioid Addictions Treatment

by Laurel Sindewald and Anne Giles

Wait lists for medication-assisted treatment (MAT) for opioid addictions treatment can be months long, especially in rural areas. While opioid addiction is considered an epidemic in the U.S, patients struggle to access and then to pay for medications known to support opioid addictions recovery.

Buprenorphine is a partial opioid agonist used in maintenance therapy for opioid use disorders. As is methadone, buprenorphine is an evidence-based treatment for opioid use disorder. Buprenorphine has been shown repeatedly to improve treatment outcomes more than behavior therapies (Clark et al., 2015; Bart, 2012) and more than abstinence-based treatment.

Wait lists for buprenorphine can be months long

Yet federal and state governments have intervened to impose a number of strict regulations, effectively limiting patient access to buprenorphine, beginning with the federal Drug Addiction Treatment Act of 2000 (DATA 2000):

  • DATA 2000 mandates that only physicians may prescribe buprenorphine. This is unusual, because nurse practitioners, as well as physicians, are typically given clearance to prescribe a number of schedule II opiates, including Oxycodone. Source
  • Physicians are required to complete DATA 2000 Certification. The government usually allows doctors discretion in determining what techniques and medications require what training. Source
  • DATA 2000 imposed 30-patient limits on physicians prescribing buprenorphine. Due to the Office of National Drug Control Policy Reauthorization Act of 2006, physicians must apply, after one year, to raise their patient limit to 100. Patient limits were imposed to reduce diversion of medication for street sale. However, the abuse potential for buprenorphine has been found to be less than that of full opioid agonists such as heroin or oxycodone. Diversion for illicit use has been limited in the US, and has typically been used therapeutically when diverted. There are no patient limits for prescription of other opiates, including oxycodone. Source
  • On July 8, 2016, Substance Abuse and Mental Health Services Administration (SAMHSA) and the US Department of Health and Human Services (HHS) published new regulations for MAT in the Federal Register, allowing doctors to prescribe up to 275 patients at a time. In order to do so, doctors must have credentials in addiction medicine or addiction psychiatry from a specialty medical board or professional society, or work in a qualified practice setting providing comprehensive MAT treatment. These regulations will be effective on August 7, 2016.
  • Some states, including Virginia, require physicians to refer patients to counseling in order to prescribe buprenorphine. Counseling has not been shown to improve treatment outcomes for MAT patients. Source from 2016 / Source from 2015 / Source from 2011
  • While the Mental Health Parity and Addiction Equity Act of 2008 requires health insurers to cover behavioral health services, this does not extend to MAT. Not all insurance plans cover buprenorphine, and in some cases doctors insist on payment in cash. If a patient has no insurance, the requirement to comply with counseling adds an extra expense that may be prohibitive.
  • Some states set limits on how long patients may be treated with buprenorphine. The SAMHSA guidelines for treatment with buprenorphine state that some patients may require many years, or even life-long maintenance.
  • Some states set age restrictions on who can receive buprenorphine. In Virginia, no one under the age of 16 is allowed to take the medication. This is clearly not because people under 16 never develop substance use disorders. The 2014 SAMHSA National Survey on Drug Use and Health reports that 1.3 million adolescents aged 12-17 had substance use disorders. This means 5% of adolescents, or 1 in 20, met the criteria for a substance use disorder in 2014. 168,000 of these adolescents were addicted to pain relievers, and 18,000 were addicted to heroin.

Opioids produce tolerance in people over time, which means their bodies no longer respond to the drug as strongly as before. As tolerance develops, people take higher and higher doses of opioids to get increasingly lessened effects. If people with opioid use disorders are abstinent, their tolerance drops. This means if they relapse, they may try to take the kinds of high doses they had been used to, and so are likely to overdose and die.

As only a partial agonist, buprenorphine and methadone do not produce highs in patients who have, already, developed tolerance to opioids. Rather, these medications are designed to stabilize opioid levels while patients rebuild their lives, staving off withdrawal symptoms as well as cravings, and reducing the risk of lethal overdose.

“[T]he treatment delivery strategies that are often used and that can produce excellent patient outcomes (eg, frequent clinic visits, observed dosing, provision of intensive psychosocial services, limited take-home doses) may simultaneously decrease treatment availability, practicality, acceptability, enrollment, and retention for some patients. Alternatively, treatment paradigms that may be most convenient for patients and physicians (eg, infrequent clinic visits, reduced oversight, and providing longer-duration supplies of medication) may increase the risk of medication diversion and abuse and undermine treatment outcomes. This paradox poses significant barriers to the widespread therapeutic delivery of effective medications to opioid-dependent patients, particularly in rural areas with few services and significant unmet need for treatment.”
– Stacey C. Sigmon, Ph.D., Access to Treatment for Opioid Dependence in Rural America, 2014

When talking about MAT, we must be clear about our values and objectives. Above all, MAT is a non-punitive approach to opioid addiction recovery. Abstinence may be wished for, but in the meantime, treatment providers are hoping to reduce disease risk, crime, and death. Lessons from the AIDS epidemic may be helpful in understanding and implementing best practices quickly.

A recent pilot study indicates that buprenorphine dosing while patients are waiting for comprehensive addictions treatment significantly reduced illicit opioid use, including intravenous use, compared to patients on wait lists who did not receive buprenorphine. Even without additional addictions treatment, buprenorphine seems to be effective. The authors suggest that their findings could be especially useful for treating people with opioid use disorders in rural areas where treatment is hard to access due to limited transportation.

Latest science indicates that incarceration and punishment are ineffective, even harmful. Yet this did not prevent drug courts from lobbying against Human Health Services’s efforts to increase patient limits to 200. Fortunately, their efforts were not successful, and we may see patient limits increased in the near future.

The question remains whether patient limits should be imposed at all. In other areas of medicine, we trust doctors to limit their patient load to what they can effectively handle. We still trust doctors to prescribe painkillers, like hydrocodone and oxycodone, without restriction of dose or patients. Not that we should begin imposing arbitrary restrictions on other aspects of medicine. It is simply time for government to recognize addiction as an illness requiring treatment, not punishment, and that sometimes treatment includes medications such as buprenorphine.

With millions of Americans addicted to opiates and close to a  million still left without treatment, a 200 patient limit may not go far enough to ensure people get the treatment they need. Meanwhile, people are dying while they wait.

Updated 12/28/16

Image: iStock

The opinions expressed here are the authors’ and do not necessarily reflect the positions of Handshake Media, Incorporated, its associates, clients, or vendors.

The content of this post is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

DBT Improves Emotion Regulation Skills for Addictions Recovery Success

Emotions are powerful. From emotions come passions, wild and driving, which spur us to create or to destroy.
How Self-Regulation Builds Recovery Success

We define emotion regulation as “the ability to assess and change one’s emotional state, particularly in cases of extreme distress.” Emotion dysregulation – also termed “affect dysregulation” – can manifest as under- or over-regulation.

In our post a year ago, we cited the literature that links emotion dysregulation to substance use disorders:
Emotion regulation requires both-and thinking

“Substance use disorders are strongly linked to emotion dysregulation in the literature (Beckstead et al., 2015, Nikmanesh et al. 2014, Fox et al. 2008, Matthias et al. 2011, Axelrod et al. 2011, Dishion et al. 2011).  It has been proposed that substance use begins as an effort toward emotion regulation or self-regulation, but if use leads to addiction, it only worsens one’s ability to self-regulate.  This is known as the self-medication hypothesis of addiction, an older hypothesis which is still supported by scientific literature.

The perceived need to self-medicate begins when emotions become intolerable, and when an individual is unable to regulate those emotions. In fact, “negative affect,” or unregulated, negative moods such as anger, frustration, and depression, is the primary predictor of relapse for addicted individuals.”
How Self-Regulation Builds Recovery Success

In the year since that post was published, Dialectical Behavior Therapy (DBT) is showing increasing favor as the treatment of choice for those struggling with addictions. DBT is a behavioral therapy developed by Marsha Linehan to help individuals with Borderline Personality Disorder (BPD) begin to simultaneously accept themselves and accept that change is needed. The skills DBT teaches patients are applicable beyond BPD, however: mindfulness, interpersonal relations, emotion regulation, and distress tolerance.

While scientists recognize more research is needed to evaluate DBT’s effectiveness outside of BPD, studies have been promising in demonstrating that DBT may improve distress tolerance, reduce depression, anxiety, and other negative affect moods, and has promise for treatment of substance use disorders. As early as 1999, Linehan found that DBT was more effective than treatment as usual in reducing drug use for women with co-occurring BPD and substance use disorders (SUDs). The mindfulness component of DBT has been extensively researched, and shows the most promise for treatment of substance use disorders.

“It is important to note, areas of the brain that have been associated with craving, negative affect, and relapse have also been shown to be affected by mindfulness training.”
Witkiewitz et al., 2013

Mindfulness is essentially a meditation technique borrowed from Zen Buddhism. To practice mindfulness, one must simply become more aware of the present moment, without thought of past or future, and accept it without judgment. Scientists have studied Mindfulness-Based Relapse Prevention (MBRP), a repeatable mindfulness-based training program, and have found as recently as 2014 that those practicing MBRP report significantly fewer days of substance use and decreased heavy drinking, as well as significant decreases in craving, and fewer legal and medical problems.

Addictions treatment has historically been a field riddled with unsupported and even unconscionable “treatments.” With already such strong support in the literature, dialectical behavior therapy may be the very best behavioral therapy available to people in recovery.

This post was updated on 12/17/2016.

Smokestack Lightnin’ Blues Band Rocks The Lyric

Hailing from Snow Creek, Virginia, Moonshine Capital of the World, Smokestack Lightnin’ Blues Band had everyone tapping their feet on April 20th at The Lyric in downtown Blacksburg, Virginia. For anyone who thought The Black Keys were the best of modern blues, be prepared to experience the full power of these blues songs, brought to life by Smokestack Lightnin’. These local musicians play with passion.

Smokestack Lightnin Band

Members (not in order of picture): Jeff “Sunshine” Criner (Guitar/Vocals) David Gregory
(Drums/Vocals) Marcus Morris (Bass/Vocals) Harry “Buster” Sink
(Harp) Henry Lazenby(Guitar/Vocals)

Podcast produced by Laurel Sindewald of Handshake Media.

What Makes a Good Podcast?

Zoom-H1 by Handshake Media, Inc.A podcast, much like other media, is most popular when it entertains or enriches the listener’s life in some way. In answering the question of “what makes a good podcast,” we decided to take a peek at what people are already enjoying, and investigate why these podcasts have captivated listeners. Other articles have listed popular podcasts, but in this post we break a handful of different podcasts into the elements that make them engaging.

Serial by This American Life and WBEZ Chicago“One story told week by week”

Serial began as a true crime story of a girl who was murdered in Baltimore in 1999. Much like a TV show, listeners were kept in suspense as the host, Sarah Koenig, interviewing local people, family members, and dug deep to document what happened. The full story is told through Season One. A dedicated audience awaits a new story in Season Two.

Serial features:

  • Several musical themes to introduce the episode, ease transitions, and to cue the listener into important parts
  • A brief, compelling introduction with music telling the listener who is producing the show, who is speaking, and what the podcast is about
  • Interviews with many different people
  • Interesting, true subject matter
  • A common theme and a question to answer
  • An engaging storyteller
  • Professionally edited audio (no filler words such as “um,” and no background noise)

Embedded by NPR – “Takes a story from the news and goes deep”

Kelly McEvans chooses a story she finds intriguing and investigates the story further. Stories are varied and shocking, including coverage of an HIV epidemic due to prescription opioids in a small town in Indiana, a recent biker shootout in Waco, and how gangs stopped buses in El Salvador. Kelly asks the hard questions, such as what is it like to experience withdrawals from pain pills. She takes a story and makes it personal.

Embedded has some of the same features as Serial:

  • Music to introduce the episode, for transitions, and for emphasis
  • A brief introduction of the show producer, the speaker, and the topic
  • Interviews with people involved in the story
  • Interesting, true subject matter
  • A common theme
  • An engaging storyteller
  • Narrated parts are carefully edited (no filler words or background noise)

Freakonomics Radio by Stephen Dubner and Steven Levitt – “The podcast that explores the hidden side of everything”

Covers the enormous economic relevance of ideas that may have been obscure or unpopular in the past. The show is hosted by Stephen J. Dubner and Steven D. Levitt, who supplement their own research and insights with excerpts of recordings and interviews with the major players in each topic. Examples of the subject matter they have investigated include whether the world is ready for a guaranteed basic income, the economics of sleep, and the real-world effects of payday loans.

Stephen and Steven’s initial partnership yielded a book first, described on their About page; “Levitt and Dubner wrote Freakonomics, a book about cheating teachers, bizarre baby names, self-dealing Realtors, and crack-selling mama’s boys. They figured it would sell about 80 copies. Instead, it took up long-term residency on the Times best-seller list, and went on to sell more than 5 million copies in 40 languages.”

  • Music backs the entire episode, with a variety of excerpts of songs from artists the hosts enjoy.
  • Each episode is introduced with music, the episode’s sponsor, speaker, a little bit about what the show covers before introducing the episode’s topic.
  • The hosts interview relevant people and leaders for each episode.
  • Hosts have vibrant, engaging speaking styles.
  • Topics are highly relevant to modern professional Americans.
  • The channel has a common theme.
  • Voice tracks and interviews are clearly edited and mastered to remove “ums” and improve audio quality.

The Joe Rogan Experience by Joe Rogan

Joe Rogan, an actor and comedian, hosts long conversations (two hours!) with various prominent people, including “comedians, actors, musicians, MMA instructors and commentators, authors, artists, and porn stars.” According to his about page, “The Joe Rogan Experience was voted the Best Comedy Podcast of 2012 on iTunes.”

  • Podcast is introduced with episode sponsor and the speaker. The channel, as well as each episode is sponsored by multiple companies, who are introduced at length before the podcast starts.
  • The entire show is videotaped, presented as audio and video on the podcast site. The video is also available on YouTube, while the audio is available on iTunes.
  • Episode audio is professionally recorded and mastered, but fillers such as “um” are not removed.
  • Though the show has a wide variety of content depending on the guest, it does have a common theme: two different personalities and minds chatting casually about the world

Radiolab by WNYC

“Radiolab is a show about curiosity. Where sound illuminates ideas, and the boundaries blur between science, philosophy, and human experience.” Various hosts from Radiolab interview experts and prominent figures sharing stories on interesting topics, such as two prominent scientists discussing the earliest evolution of multicellular life. The Radiolab website also has a blog and a collection of videos.

  • The episode begins with an introduction of the show, the host, the guests, and the topic.
  • Episodes are professionally recorded and mastered.
  • Diverse, theatrical music and sound effects are added in different places to illustrate the topic being discussed.
  • Guest speakers and hosts are tonally expressive and playful with their speech.
  • The show has the feel of a performance rather than simply an interview.
  • Sponsors are showcased at the end of the podcast.

2 Dope Queens by WNYC

Phoebe Robinson and Jessica Williams have made their show popular with their incredibly funny and vivacious personalities and relaxed repartee. 2 Dope Queens is an increasingly popular comedy podcast featuring primarily Phoebe and Jessica, “with their favorite comedians, for stories about sex, romance, race, hair journeys, living in New York, and Billy Joel. Plus a whole bunch of other s**t.”

  • The episode begins by introducing the sponsors, a joke, music, and the hosts.
  • Jokes and pop culture references are continuously woven throughout their content.
  • A live audience is present for their show.
  • The show is professionally recorded and mastered in a studio.

Common qualities from all of these great podcasts are clearly great content, professional quality audio, and reliable, themed content. Podcasts reviewed here also bring in a variety of voices and minds, indicating that the best podcast shows, while consistent in content and hosts, keep things fresh with new personalities and human voices.

For more great podcasts, take a look at Buzzfeed’s review of podcasts in 2016, Time’s analysis of the best podcasts in 2015, and podbay.fm’s top podcasts.

Inspired? If you would like to start your own podcast channel, take a look at Handshake Media’s Podcast Services.