Insights After Reporting on Addiction for 3.5 Years

I felt that paradox of shock and recognition that shadows the human experience of time when I realized I had been writing and researching on addiction for Handshake Media, Inc. for 3.5 years.

Laurel Sindewald waves to leave at Maia Szalavitz's visit to Blacksburg, VA

Anne Giles and I have worked diligently together on investigating and reporting on addiction. I have felt like a detective, or a mythbuster. Anne, in her work as an addictions treatment advocate, would come across a new concept or quandary, or a common belief about addiction, and she would task me with investigating. While researching and writing for Handshake Media, I have authored 26 articles on addiction and addictions treatment. After hundreds of hours of research over the past 3.5 years, Anne asked me these questions.

What is addiction?

Addiction is a disorder or disease of the brain, of varying severity, that compromises willpower and executive functions, sensitizes the brain’s stress system, and desensitizes the reward system. Addiction is defined by a person’s inability to stop a behavior despite negative consequences.

What causes addiction?

Addiction happens when a combination of risk factors (e.g., genetics, past trauma, attachment style, co-occurring disorders, and a poor socioeconomic support system) coincide with a person’s use of substances or behaviors regularly to cope with stressful situations in place of other emotion regulation strategies.

What treats addiction?

Each person requires a personalized treatment plan based on his or her individual situation, developed in consultation with his or her doctor. Three main components can be listed, however, that are often helpful for most people most of the time for recovery from addiction.

  1. Medication-Assisted Treatment (MAT). Foremost, medications are available that directly or indirectly treat the brain problems that develop with addiction. Counseling is not required for treatment of addiction with medications to be effective.
  2. Individual or Group Counseling. Adherence to medical treatment in general averages to around 50%, and addiction is likely no exception. Counseling may help people stick with a treatment plan, and to meet their abstinence or harm-reduction goals. People with substance use disorders (the medical term for addiction) may also need assistance with developing new emotion regulation skills and strategies to replace the behaviors and/or substances they previously used when stressed. Dialectical Behavior Therapy (DBT) and Cognitive Behavioral Therapy (CBT) are two treatment options available, and may be especially helpful for people with co-occurring disorders. We don’t know whether counseling directly affects the changes in the brain resulting from addiction, but by supporting abstinence or harm reduction, counseling may play an important part in indirectly affecting those brain changes over time.
  3. Recovery Support Services (RSS). RSS is not actually treatment, but may be helpful in supporting people in recovery. Some people find support groups (also known as Mutual Help Groups or MHGs) to be helpful for social support in building a new recovery lifestyle. While 12-step groups are the most common support groups available, they are not for everyone, and they are not the only option. SMART Recovery is a secular, CBT-based support group teaching concrete skill sets to help people reduce or stop any kind of behavior. RSS is not limited to MHGs, however, and may include legal, housing, or nutritional assistance, and help with dependent care.

Is addiction a condition that would benefit from healing? Can it be healed?

Yes, addiction is a condition that benefits from healing because there are brain changes involved that require medications to stabilize, and eventually alter them. The term “healing” also implies an element of long-term care, which is helpful because the brain changes involved in addiction happened over time, and new changes also require time.

Addiction can be healed, and remission is considered stable after 5 years. Much as a habit or learned behavior can eventually be changed, an addiction can be changed too, but requires a deal of time and patience with mulligans and suffering. The brain networks of connection will always be there (one never forgets how to ride a bike or drive a car), but over time other networks will be stronger or will predominate.

Why do some people with addiction behave badly?

I believe people with addictions who behave badly are suffering – in pain – and do not know how to cope with that pain or adequately express it. When they use a substance, their ability to make decisions is further compromised and they are unable to stop or control the behavior. As addiction progresses, they lose more executive function in the brain and are unable to stop or control behavior, whether they are presently using the drug or not.

What might prevent people with addiction who behave badly from doing so again?

I think that first of all, people with addiction require a medical treatment plan for a brain condition involving medication and counseling as individually required. All co-occurring disorders must also be treated appropriately, and past trauma if in evidence. People with addiction may need help with an action plan to regulate emotion when they are upset, instead of using. Many people may require socioeconomic support, legal defense, and job training to have better lives in recovery.

I believe people with addiction also need compassion and forgiveness from those they love, even if harm has been done. Tough love is not helpful, and may worsen a person’s addiction. If a person is constantly focused on repenting for past deeds or making amends, how can he or she focus on the full-time self-care required to prevent a relapse, much less to build a new life worth living? I believe forgiveness frees a person to stop self-punishment for past actions, and to instead practice self-love and self-care.

I know that my position of compassion for people with substance use disorders is fairly uncommon, because unfortunately, addiction often has concussive effects on families and communities for generations. People who are close to people with addictions may be physically or emotionally abused, stolen from, cheated on, molested, raped, or otherwise traumatized – trust broken. People are suffering who did their best to help their loved ones with addiction, over and over, and yet those loved ones behaved incomprehensibly, cruelly, despite all efforts.

The elephant in the room of addiction is raw suffering, and hopeless defeat.

My position comes from these years of research, and hard-won experience, knowing and loving people with one or more addictions who hurt me or other people I love. Yet, while my personal experience tallies with the research I’ve done, it’s the research that I rely on when I report on addiction. Good research is based on careful methodology, transparency about funding and potential bias, and conservative conclusions from carefully-analyzed data. The research I have reviewed, compiled, and reported on pulls together information about hundreds of thousands of cases of addiction. Any experiences I have are singular data points, and only helpful when viewed as a very small, biased sample of the whole, complex picture.

So, what do I advocate after 3.5 years of research and reporting no addiction?

I strongly advocate compassionate delivery of evidence-based treatment, a focus on harm reduction rather than abstinence, dollars allocated toward treatment and not punishment or incarceration, and love-love for people with addiction—never tough-love.

Photo from Maia Szalavitz’s visit to Blacksburg, Virginia

On Counseling and Medication-Assisted Treatment

Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health categorizes substance use disorders, a.k.a. addictions, with “chronic and expensive medical illnesses” such as heart disease, diabetes, cancer, hypertension, asthma, arthritis, and chronic pain. The first order of treatment for these illnesses is medical care, primarily through medication. Patients with these illnesses are not required to receive multiple counseling sessions prior to receiving medication.

Challenging Myths about Medication Assisted Treatment for Opioid Use DisorderCounseling and support groups do exist for assistance with these illnesses. But counselors help patients comply with the course of treatment determined by their physicians. Support groups can help people live life while having the illness. But counseling and support aren’t replacements for medication and medical care. Except in addictions treatment.

Counseling is not medical care for a medical condition. We need to give people with the medical condition of substance use disorders (SUDs) medical care first – which may or may not include medication-assisted treatment (MAT) – but which may include stabilizing medical treatment for co-occurring mental and physical illnesses. Confusing medical care with counseling results in what the New England Journal of Medicine reported in December 2016: “Despite the demonstrated efficacy of maintaining abstinence by treating patients with opioid agonists, patients can remain on clinic waiting lists for months, during which time they are at risk of premature death.”

With regard to MAT and counseling, my conclusions from reading the research are that for most people most of the time, counseling has no significant effect on abstinence among those receiving MAT for SUDs, whether for opioid use disorder or other SUDs. Counseling may have a larger effect on those with co-occurring SUDs and mental disorders, but those effects would occur over time. People with the medical condition of SUDs do not have time for the possibility that counseling might be effective. They are at higher risk of dying as long as they are not on opioid maintenance medication. They need medical care stat.

From the Surgeon General’s report, page 4-21: “Nevertheless, multiple factors create barriers to widespread use of MAT. These include provider, public, and client attitudes and beliefs about MAT…”

“Buprenorphine is an effective medication in the maintenance treatment of heroin dependence, retaining people in treatment at any dose above 2 mg, and suppressing illicit opioid use (at doses 16 mg or greater) based on placebo-controlled trials…Methadone is superior to buprenorphine in retaining people in treatment, and methadone equally suppresses illicit opioid use.”
Cochrane Database of Systematic Reviews, 2014

We need to shift our policies from belief-based practices to what the science reports is best practices addictions treatment for people with substance use disorders: medical care first. Then, we can work on secondary, individualized assistance, perhaps counseling, case management, support groups, or support services according to each client’s case.

. . . . .

“In fact, no rigorous study has ever been able to show that the addition of psychosocial services to opioid agonist therapy alone improves outcomes in the treatment of opioid use disorder.”
Lean Forward, Harvard Medical School, May 2017

“Despite the demonstrated efficacy of maintaining abstinence by treating patients with opioid agonists, patients can remain on clinic waiting lists for months, during which time they are at risk of premature death. The use of interim treatment with buprenorphine without formal counseling while patients remain on waiting lists may mitigate this risk during delays in treatment.”
New England Journal of Medicine, December 2016

“Unfortunately, despite decades of research, it cannot be concluded that general group counseling is reliably effective in reducing substance use or related problems.”
Surgeon General’s Report, November 2016

“The commonly held belief that opioid agonist treatment alone is inferior treatment to such treatment combined with psychosocial treatment (which many will understand to mean counseling) is not supported by the research evidence and it results in limitations on the use of these effective medications.”
Journal of Addiction Medicine, July/August 2016

“[T]here is little empirical evidence suggesting which psychosocial treatments work best in conjunction with medication-assisted treatment as there are relatively few studies comparing the differential effectiveness of various psychosocial approaches (eg, CM [contingency management], MI [motivational interviewing]) for individuals receiving medications for the treatment of opioid addiction.”
Journal of Addiction Medicine, March/April 2016

“Patients who received only psychological support for opioid dependence in England appear to be at greater risk of fatal opioid poisoning than those who received opioid agonist pharmacotherapy.” – Addiction, November 2015

“Clinical trials show that opioid agonist therapy (OAT) with methadone or buprenorphine is more effective than behavioral treatments, but state policymakers remain ambivalent about covering OAT for long periods…OAT is associated with lower total healthcare expenditures compared to other forms of behavioral treatment for patients with opioid addiction.”
– Journal of Substance Abuse Treatment, October 2015

“Supplementing standard medical management with cognitive-behavioural therapy did not further reduce opioid use or promote abstinence among primary care patients being maintained on buprenorphine.”
Drug and Alcohol Findings, 2013

“For the considered outcomes [retention in treatment and use], it seems that adding any psychosocial support to standard maintenance treatments do not add additional benefits.”
Cochrane Database of Systematic Reviews, 2011

“Consistent with results from a previous study of predominantly heroin-dependent patients receiving buprenorphine-naloxone in a primary care setting, individual drug counseling did not improve opioid use outcomes when added to weekly medical management visits.”
Archives of General Psychiatry, 2011

“We conducted a 24-week randomized, controlled clinical trial with 166 patients assigned to one of three treatments: standard medical management and either once-weekly or thrice-weekly medication dispensing or enhanced medical management and thrice-weekly medication dispensing…All three treatments were associated with significant reductions from baseline in the frequency of illicit opioid use, but there were no significant differences among the treatments.”
New England Journal of Medicine, July 2006

The Comprehensive Addiction and Recovery Act (CARA) requires that an MAT treatment provider be able to provide or refer patients to counseling. Other than this wording in CARA – “appropriate counseling and behavioral therapies” – neither mentions the type, length or number of sessions of counseling required. Wisely, for an individual, the law does not require him or her to receive counseling in order to receive MAT. Unwisely, in Virginia, Medicaid patients are required to receive SUD counseling in order to be covered for either methadone or buprenorphine.

Image: Challenging the Myths about Medication Assisted Treatment (MAT) for Opioid Use Disorder (OUD) from The National Council for Behavioral Health

Laurel Sindewald contributed to the research for this report.

Last updated 7/30/2017.

Addiction Is Not a Choice

Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health makes the current discussion we have about addiction, i.e. helping people with addiction “make better choices,” “make better decisions, or “understand the consequences of their behavior” – whether coerced through drug court or supported through counseling – well-meaning but, unfortunately, irrelevant. Addiction compromises all of those functions in the brain.

The brain no longer does what it needs to do in a person with addiction, just as a pancreas no longer does what it needs to do in a person with diabetes. Medical care for a brain illness – not tough lovearrest, commitment to a mental institution, or recovery support services – needs to be the first order of treatment, including assessment for suitability for medications. Medications need to be prescribed by qualified medical professionals, not by non-qualified court officials or lawmakers.

Surgeon General: I'll stand up for recovery with you

We would rush our neighbor with acute diabetes to the doctor. Why don’t we rush our citizens with an acute brain disease to the doctor as well? Because, at essence, contrary to scientific evidence, we still believe addiction is a choice. We believe that if people with addiction could just see the errors of their ways and would work hard on those errors (rather than be lazy, immoral, selfish, self-indulgent, or inadequately faithful or spiritual), addiction would go away.

Working hard on one’s ways may help one live a better life. Might working hard to be a better person alter the brain in targeted ways that reverse or  ameliorate addiction? Possibly. Neuroscience research may ultimately support that. Certainly on ways to live a better life, many people, both with and without academic or medical credentials, can offer helpful guidance. But, for now, what we know is that addiction is a medical condition, 1 in 7 Americans is expected to get it, a person dies of a drug overdose every 19 minutes in the U.S., and only a fraction of those who need help are receiving it. For this dire medical condition, insufficiently treated such that a public health crisis has occurred, medical care is an imperative.

Do no harm” is a principle of health care. By stubbornly holding onto the concept of “choice” – in spite of the data that says we’re simply wrong to do so – we’re harming, even killing, our own citizens when we require them to, at essence “be better and do better,” rather than provide them with medical care.

May the Surgeon General’s report inform and direct the treatment we provide our fellow citizens struggling with the grave and dangerous medical condition of addiction.

. . . . .

On 11/17/16, the U.S. Department of Health & Human Services issued Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health.

Here’s a link to the YouTube video of the 3-hour presentation of the Surgeon General’s report.

Here’s Maia Szlavitz’s commentary on the Surgeon General’s report.

This post is an updated and expanded version of my letter to the editor about the Surgeon General’s report published by the Roanoke Times on 12/13/16.

Why Opioid Maintenance Does Not Replace One Addiction with Another

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%.

A nuanced discussion rather than a black-and-white debate

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, deathcrime 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.

Addiction or Dependence: A Life and Death Difference

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.

Addiction and Dependence : Apples and Oranges

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.

Are Twelve Step Approaches Evidence-Based for Addictions Recovery?

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.

Original 12-Steps of Alcoholics Anonymous

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., 2014Witbrodt 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. 

Applications of Neuroscience Findings to Addictions Treatment

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

Want to Help Our Community? Volunteer for SMART Recovery

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.

Welcome to SMART Recovery!

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:

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!

Sound Sleep Makes for Sounder Addictions Recovery

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

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

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

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

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

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

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

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

. . . . .

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

Partial list of reports, listed most recent first:

How to Talk with Someone About Getting Help with Addiction

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Photo by Zane Queijo