In SAVVY, ASAM’s revamped definition of addiction and finding the balance between medication and psychosocial treatments. Consider effective alternatives to medication. In SKILLS, what to do with requests for medication for chronic pain and addiction. In SOUL, Santa, shopping and self-love. Adam Roa on “How to Truly Love Yourself”.
We live in a society and culture where the first intervention patients and physicians often think of is medication. I joke that some people don’t want to pay their co-pay if their doctor doesn’t give them a prescription for a medication: “He didn’t do anything. They didn’t give me a pill for my symptons. I’m not going to pay for this visit!”
In addiction treatment, the opioid crisis and the knowledge that addiction is a brain disease, has contributed to a focus on medication in addiction treatment. For some, this focus on medication has resulted in neglect of psychosocial treatments that are essential in achieving long-term recovery.
In September, 2019, the American Society of Addiction Medicine revamped its 2011 definition of addiction.“Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.”
“….complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences” reminds us that addiction is not just a ‘brain’ disease, but like all chronic medical diseases is biopsychosocial in its etiology, how it manifests in people’s lives, and in what is essential in treatment to promote long-term recovery.
TIP 1
Find the balance between medication as treatment versus medication and psychosocial services
While there are effective medications for alcohol, nicotine and opioid use disorders, the hunt is on for medications effective with stimulant use disorders. In a December 16, 2019 editorial comment by William Haning, MD, DFAPA, DFASAM, Editor-in-Chief, ASAM Weekly, Dr. Haning presents a balanced view of a December 11 article by Phillip O. Coffin, MD, MIA; Glenn-Milo Santos, PhD, MPH; Jaclyn Hern, MPH; et al. in JAMA Psychiatry that suggested a medication, mirtazapine, is effective in the management of methamphetamine use disorder.
Here’s what Dr. Haning said:
“…. it would be hard to imagine a mood-altering medication that has not been considered or deployed in the effort to reduce rates of methamphetamine use: bupropion, selegiline, n-acetyl cysteine, ondansetron, modafinil… and then re-deployed, as mirtazapine was a decade ago and is again now.”
Then he goes on to comment on how effective these medications are or not (remember addiction as a biopsychosocial disease):
“….they generally have some benefit over placebo, though not universally. This may reflect reliance on diagnostic criteria that remain phenomenological, and unable to account for cultural, genetic, or other influences. Recommendations for the employment of cannabis and even psilocybin, while not wholly irrational, suggest desperation or Hail Mary plays. Not excluded from consideration are agents that have shown promise in some clinical trials but not as yet definitively, such as methylphenidate.”
Finally, Dr. Haning concludes:”….the mainstay of therapy remains psychotherapeutic, whether in individual, group, or milieu settings, whether cognitive-behavioral, motivationally-enhancing or other.”
TIP 2
Review a variety of non-medication treatments in behavioral health that are just as effective as medication.
1. Mindfulness; John J. Miller, MD; Psychiatric Times Vol 36, Issue 12 December 11, 2019
“Over the past 3 decades clinical medicine and psychology have integrated the basic principles of mindfulness into many diverse treatment modalities. …..Given the general nature of the practice of mindfulness, not surprisingly, it has found its way into numerous applications.
These include:
2. Yoga Worth ‘Serious Consideration’ for Major Depression; Batya Swift Yasgur, MA, LSW
Medscape Medical News November 27, 2019 about a study published online November 13 in the Journal of Psychiatric Practice.
“Yoga practice consisting of physical postures and breathing techniques can be helpful in improving symptoms of depression and anxiety in patients with major depressive disorder (MDD), new research suggests.
“Yoga and regulated breathing practices have been used for thousands of years in diverse cultures to manage stress, anxiety, depression, pain, and many other conditions,” study coauthor Patricia L. Gerbarg, MD, an assistant professor in psychiatry at New York Medical College in Valhalla, told Medscape Medical News.
“Clinicians should seriously consider including mind-body practices such as yoga and coherent breathing in their treatment recommendations for patients with depressive symptoms,” she added.”
3. Non-Drug Therapies May Be More Effective At Easing Dementia-Associated Agitation, Research Suggests.
Canadian researchers at Li Ka Shing Knowledge Institute within Unity Health Toronto of analyzed over 163 studies involving nearly 25,000 patients. Their analysis suggests that “symptoms of aggression and agitation in dementia patients may respond better to non-drug therapies such as massage, touch therapy and outdoor activities.” Investigators “found that outdoor activities were more effective than antipsychotic medications for treating physically aggressive patients.” Also, in terms of “verbal aggression, massage and touch therapy were more effective than the patients’ usual care.” The findings were published in the Annals of Internal Medicine.”
One more study, just in time for the holidays:
4. Dark Chocolate for Depression; Chris Aiken, MD; Psychiatric Times Volume: 36 Issue: 11 September 5, 2019
“Dark chocolate lowers the risk of depression, according to a cross-sectional survey of over 13,000 US adults. The study compared self-reported chocolate consumption with self-reported depressive symptoms, as measured by the PHQ-9. People who ate dark chocolate in the past 24 hours were 70% less likely to report depression.”
“Just give me medication” – two clinical situations; and how to discuss medication in chronic pain and in addiction treatment.
TIP 1:
Distinguish between wanting chronic pain help or wanting addictive medication
Clinician: “Good morning, how can I be of help?”
Patient: I have severe chronic pain and need Oxycontin (oxycodone).
Clinician: “Well let’s do an evaluation of your pain and see if that’s the best treatment for your pain?”
Patient: It’s the best treatment alright, I’ve tried everything else and that’s the only thing that works.
Clinician: “So you’ve done physical therapy and some other no-medication treatments like mindfulness and massage?”
Patient: The only thing that works for me is Oxycontin and I’ve run out and need a new prescription.
Clinician: “I can hear and understand your concern for medication; and I am not saying I won’t give you medication. But first, we should re-evaluate your pain; what treatments you have had and what worked or not; and then collaborate on a plan that has the best chance of improving your pain.”
Patient: The only thing that works is Oxycontin. Are you going to give it to me or not?
Clinician: “As I said, I’m not saying I won’t give you medication if you need it and it is part of an overall plan for your pain. But are you wanting help for your pain, or are you just wanting Oxycontin?”
Patient: Yes, of course I want help for my pain, but I need Oxycontin. I don’t need all these other treatments you are talking about.
Clinician: “If I’m going to help you with your pain, I need to re-evaluate your pain and past treatments and then collaborate with you on the best plan going forward.”
Patient: Are you going to give me Oxycontin or not? I don’t have time for all this evaluation. If you’re not going to give me a prescription, I’ll find someone who will.
Bottom line Tip: If the patient was willing to re-evaluate their pain with you, I would continue the Oxycontin even if I thought they were addicted to the medication. To cut them off precipitously would only push them out of treatment before you have enough time to form a better relationship with them and use motivational enhancement therapy to engage them in a more holistic plan.
TIP 2:
Try a “discovery” plan for the person who wants medication for addiction, not psychosocial treatments
Clinician: “Good morning, how can I be of help?”
Patient: I have an alcohol problem and my wife is mad that I lost my job and I need help.
Clinician: “That’s great that you realize you need help. A lot of people with addiction don’t reach out.
Patient: Well yes, but I don’t want to go to any treatment program or AA.
Clinician: “So what help do you want for your alcohol problem?”
Patient: Well isn’t there some medication or pill you can give for this?
Clinician: “Yes, there are medications that can help people with alcohol addiction. But treatment is more than just medication. It is about changing your lifestyle and attitudes and who you hang out with and other behaviors.”
Patient: Well, as I said, I don’t want to go to a treatment program or those AA meetings. I just want the medication you talked about.
Clinician: “Are you wanting to keep your marriage and find another job? If you do and if your addiction is messing up your marriage and work, I don’t think medication alone is going to fix that.”
Patient: I just want medication. Maybe if that doesn’t work, I’ll talk about treatment and AA, but I just want medication.
Bottom line Tip: After trying to educate the patient about addiction and recovery, if he still just wants medication, I would start with the “just medication, no treatment groups or AA” Discovery plan. After agreeing on how to track if that plan is working or not (involving his wife in the planning to see if the relationship is improving or not; random alcohol and other drug testing, tracking progress in finding a new job), the plan is a medication-only plan with frequent visits to track outcomes. If all is going well, we continue with the medication-only plan. If marital and job-hunting problems flare up, the therapeutic relationship is established to explore changes to the treatment plan and eventual psychosocial strategies and meetings.
How much did you spend on Christmas or holiday gifts this year?
Statistics from the World Economic Forum predicted:
Around Thanksgiving, my sister-in-law, Annette, shared a YouTube from “a cool poet in his mid 30s, Adam Roa…I find him engaging” she said. I do too. See what you think.
In this time of consumerism, the message is ‘you are not enough’ so:
Unless you are narcissistic person, it is easier to give to others than to give to yourself; to empathize with their needs rather than fully embrace your own needs.It comes down to mixing up selfishness with self-love:
Empathizing with others:
“Why was I so stupid to make that mistake.”
Don’t be so hard on yourself, no-one’s perfect.
We all make mistakes.“Yes, but I should have known better. This is not the first time I gave in so easily.”
I know, we often shoot ourselves in the foot. But it’ll be a good learning experience to help prevent the next time hopefully.
Self-talk and being hard on yourself when it comes to self-love:
“Why was I so stupid to make that mistake.”
Yes, how come I did exactly the same thing again. I didn’t learn a thing from last time.
“Yes, I know. I’m such a sucker. I gave in so easily.”
I sure did. What’s wrong with me? I’m such a loser.
The only relationship you will have for life until the day you die, is the relationship with yourself. So Adam Roa’s message is so important:
Treat yourself like someone you love. Or in the Christian biblical tradition, love your neighbor as yourself.