Advice for Consumers of Addiction Services

In the November issue of the prestigious journal Health Affairs, Anne Fletcher's book Inside Rehab got a very favorable review. Yours truly was highlighted with this paragraph from the review:

"Certainly the most useful part of the book is the advice provided by Mark Willenbring, former director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism. He recommends that those seeking treatment should see themselves as customers and seek the best treatment that will work for them. They should get a comprehensive evaluation from someone not financially invested in a specific treatment program, demand nothing less than master’s degree–prepared therapists, and make sure the program treats any co-occurring issues. They should also not go through the same treatment protocols over and over again when it is obvious that they aren't working."

Thanks to Anne of course, and also to the reviewer, Rick Mathis (Richard_Mathis@bcbst.com), a a health
researcher at the BlueCross BlueShield of Tennessee Health Institute.

MW

Advice for Mental Health Clinicians

A clinician recently sent me this email:

Dr. Willenbring,

I read an article in the New York Times from early this year discussing Effective Addiction Treatment that in part highlighted your comments and Alltyr's mission to be a 21st century model for addictions treatment.

As a therapist in an outpatient practice not specializing in addictions treatment--but who nevertheless encounters co-morbidity with substance abuse on a pretty regular basis--it can be confusing to know how to approach the psychosocial aspects of treatment. I believe in a multimodal approach for chronic forms of addiction but there are tons of options out there for my part in that process:  motivational enhancement therapy, cognitive-behavioral, contingency management interventions/motivational incentives, the matrix model, 12-step, DBT, family behavior therapy, interpersonal neurobiology, etc. There is so much out there it's dizzying, and I feel overwhelmed. There are some that seem more indicated for alcohol, others that seem better for stimulants, another for opioids. I've worked for agencies that are sold on one particular treatment for every type of substance abuser, and others that turn their therapists loose to use whatever they think best.

I want to use the best, empirically validated approaches and everyone seems to have an opinion on what that is. Where would you recommend I start, particularly for treatment options?

Here's my reply:

Hi Jxxxx,

It is indeed a confusing landscape out there, both for non-specialist clinicians and for patients and families. 

A good place to start is with the ASAM textbook on treatment of addictive disorders. It's coming out with a new edition (or it has just come out). Also, the American Psychiatric Association textbook is pretty good as an overall summary of evidence-based practice.

On an individual clinician level though it can be confusing. Here are some thoughts:

First, there is no ONE RIGHT WAY to overcome addictions. There are many different pathways. Our job is to help each person find his or her own best way.

Second, a skilled clinician is usually effective no matter the specific technique, as long as the clinician is focused on the patient, not the technique or path. Focus on general skills, such as empathy, reflective listening, unconditional positive regard, and instilling hope. There is no evidence that a specific technique is more effective than another, except in specific circumstances. The relationship is more important.

Third, be patient oriented. Take them where they are. Find out what they want, help them clarify their goals and how to reach them. Help them learn skills to achieve their goals, while also gently helping them realize that the ideal goal (use without consequences) is out of reach.

Finally, be patient and let them teach you about their disorder and its nature. Recovery is a two-steps-forward, one-step backward process. Trying and failing is a necessary step for most people, and the important thing is to accept that, learn from each step back, and then look forward. Persistence is the key. 

A couple of other things.

Never use the words denial, codependency, or enabling. Don't threaten, cajole or berate. Don't share your own experience unless it is (very) clearly in the best interests of the patient (it usually isn't). 

Never question their motivation to get better. I've never met an addict who liked being addicted. They all want to feel better, but sometimes it takes awhile to figure what the way forward is. 

Accept that you can't help everyone. Why should we be able to universally help everyone with a complex human affliction? Be humble, but hopeful and available. Never blame the patient/client for the failure of our treatments, which are modestly effective at best. People die of this disease, and too often we can't stop it or know how to help them. People die from all sorts of illnesses. It's no different to die of a dysregulation in our brain than in our heart, immune system or pancreas. We need to get over ourselves a little bit. We don't need to blame the person with the disease in order to protect ourselves from our inability to stop it. 

And keep working, and trying, and stay hopeful and alive and open hearted. That does the most of all.

Thanks for writing,

MW

We Still Have a Ways to Go

Very excited to feature a post written by Paula DeSanto, Founder and President of Minnesota Alternatives and a leader in the movement to bring paradigm change to chemical dependency and mental health treatment in Minnesota. Thank you, Paula

We Still Have a Ways to Go

Four years ago I was inspired to open a clinic to help people with substance use issues because of the many, many stories I was hearing about ineffective and often times, harmful treatment.

While we are making progress with embracing more person-centered, stage matched interventions; I continue to have experiences that affirm how far we still have to go.  For example:

I was training a large group of clinicians and practitioners about person-centered care, and we were having a very spirited discussion about why drug and alcohol counselors seem compelled to report their clients use to probation officers.  I have worked as a mental health professional for over 2 decades and mental health clinicians don’t share this compulsion.   In fact, I can’t recall any MH worker ever thinking that this was their professional responsibility.

As this discussion progressed, a man raised his hand and offered a useful perspective.  He commented, “I worked as a probation officer for over 8 years, and throughout that time, we always thought of addiction providers as extensions of us.  There was a strong sense of “we – they” and the counselors job entailed trying to catch the clients using.”

Why do drug and alcohol clinicians think their job includes the role of a correctional officer?

No wonder clients “go underground” in treatment and say whatever they think others want to hear.

Another example:

I was interviewing a young woman who smoked a large quantity of cannabis daily and her parents were very concerned about her well-being.  She had been in treatment previously including some very prominent programs.   I asked this young woman why she smoked pot but before she had a chance to answer her mother jumped and stating, “She smokes because she has a brain disease, and her disease is controlling of her life”.

I again asked the young woman why she smokes, and she proceeded to explain that she smokes to relax especially at night before bed. What unfolded was a discussion about other motives for use and exploration as to whether this young woman even thought she had a problem.

A few days later her mother called me and shared this comment:

“My daughter has been in some of the best programs in the state and I have never heard anyone ever ask her why she uses.  She has always been told that she has a brain disease and they have the fix for it.”

“Kudos to you for asking.”

The Inadequacy of Mental Health Treatments

I've written about treating addiction in its chronic or recurrent form much like we treat other chronic illnesses. Arguably the most painful part of doing so is accepting the limitations of our current treatments. It does not diminish the progress we have made to acknowledge that our current treatments are far from ideal. They fail too many people. (Yes, fellow treatment providers, treatment does fail people, we can't keep blaming our patients for not responding.) Addiction has a significant mortality rate. Cigarette smoking alone kills close to half a million Americans a year, and hundreds of millions globally. Alcohol addiction kills 85,000, and other addictions perhaps another 10,000. It is hard to live with this, to work so hard with people only to see them struggle in spite of everyone's efforts.

But as time goes on, and as I've done more clinical work again, I'm finding that mental illness is at least as hard if not harder to treat. Depression and anxiety are the most common mental illnesses, and they frequently co-exist with addiction. One thing I've learned is that the more chronic illnesses you have, the harder it is to manage any of them well. And our treatments for depression and anxiety are far from adequate. Between the two, anxiety is the most difficult, because for most people none of the treatments are very effective. Psychotherapy done well is probably the most effective, but it is hard to access good therapy and many patients are ill suited for it. (On the other hand, lousy psychotherapy can be had on every street corner it seems.) Antidepressants are the primary medications used to treat anxiety, but although some people respond very well, most do not. Benzodiazepines such as alprazolam (Xanax), clonazepam (Klonapin), lorazepam (Ativan) and diazepam (Valium) are extremely effective in the short run, but often become ineffective over time, leading to ever escalating doses. Unfortunately, one of the more common alternatives to the "benzos" is a second-generation antipsychotic, such as quetiapine (Seroquel) or aripiprozole (Abilify.) Sec-gen antipsychotics are effective for treating schizophrenia and bipolar disorder, and may be useful as adjuncts to antidepressants for depression, but they come with a lot of baggage and risk. They are terribly expensive, and they frequently lead to substantial weight gain, diabetes and heart disease. And they don't even work very well. Antihistamines such as hydroxyzine (Vistaril, Atarax) and diphenhydramine (Benadryl) don't really work at all in my experience. Anticonvulsants such as gabapentin (Neurontin) are usually not helpful. Most of the time, we struggle to find anything that works. And an uncontrolled panic or generalized anxiety disorder in an individual with an addictive disorder is a prescription for chronicity of both.

Depression is a little, but only a little, better. In the STAR*D trial, going through multiple iterations of medications yielded a remission or recovery rate (not at all depressed, or normal mood) in about 50% of participants. This rate is as good as it gets, because participants were screened out if they had addictive disorders or serious medical problems, or were homeless or did not have transportation, and they had sterling follow up and pharmacotherapy focused on adherence. In real life the figure is likely to be substantially lower. A majority, even in real life, do eventually show a response although in most people there are residual symptoms such as low energy, pessimism or irritability. However, finding a medication that works is trial and error, because the science is not yet available for us to predict who will respond to which drug. Thus, it may take weeks or months, trying multiple medications for several weeks each before finding something that works. So, many patients are left struggling with a serious depression that is not responding well to treatment, even while they are trying to establish recovery from a substance use disorder.

Bipolar disorder, schizophrenia and other psychotic disorders respond to acute treatment, but the long-term course does not appear to have changed significantly as a result of modern treatments. Compared to these diseases, addiction has a much higher rate of recovery. It is ironic indeed that the chemical dependency treatment industry has been highly successful in convincing people that treatment outcomes are poor because they defined success as complete and permanent recovery. Meanwhile, the pharmaceutical industry and, yes, psychiatrists, convinced the public that success rates for treating depression, anxiety, bipolar disorder and schizophrenia are much higher than they are in practice.

MW

Benzos for Recovering People?

Recently, a colleague asked my opinion on the use of anti-anxiety medications called benzodiazepines in people either struggling with or recovering from an addiction (to something else of course.) Benzodiazepines (benzos for short) include common medications such as alprazolam (Xanax,) lorazepam (Ativan) and clonazepam (Klonapin.) Here is my reply:

First, I personally think that the idea that no-one who is in recovery from an addiction should ever ever be prescribed another potential intoxicant is a remnant of the all or none thinking in 12 step groups and programs. It's not based in fact. Yes, there may be a relative increase in risk, but the risk of true addiction to benzos (as opposed to development of tolerance and physical dependence) in an anxious pt is near zero in most people so the absolute risk is pretty low in someone with alcohol or opioid addiction, for example. The same holds true for pain medication in alcohol dependent people. I try to balance risks and benefits as I do with any patient or treatment. The science tells us for most people that an addiction is specific to a drug, not to "addiction" or intoxication of any type. There is no such thing as an "addictive personality." The other thing I'm impressed with is how poor any current pharmacotherapy is for chronic anxiety. The best treatment is good CBT, but it's hard to find and many pts aren't good candidates (although they might be for skillful psychodynamic therapy.) So I don't know about you, but I often find myself and the pt between a rock and a hard place.

An example patient is someone who had childhood onset of moderate to severe anxiety, often starting with separation anxiety and school refusal. Some patients report the onset of panic attack before the age of 10. Most of these people are extremely anxious all of their lives. I see them because they have became alcohol dependent. I generally prescribe an antidepressant, an SSRI or SNRI, but these seem to have poor efficacy in these primary anxiety patients, as opposed to people with depression and anxiety together. In one recent patient I  stopped benzos and the patient got to the point where I thought she would relapse to drinking w/o relief so I prescribed lorazepam and she almost immediately got much better, more stable, and with markedly reduced desire to drink. To my knowledge she hasn't used benzos in an addictive fashion, although the other problems of tolerance and lack of long-term efficacy haven't gone away. I usually try everything else I can: beta blockers, anticonvulsants, antidepressants, rarely antipsychotics if nothing else works. I always prescribe relaxation training and breathing exercises, give patients info about mindfulness approaches and also always recommend a CBT workbook for anxiety. I may recommend seeing a therapist. But sometimes it's only benzos that seem to help.

Some years ago a colleague of mine studied vets with severe chronic PTSD who were on benzos, expecting their outcomes to be worse than others. Theirs were better than others. Now that may simply be due to this group being more stable/adherent so therefore benzos were continued. But still, where is the evidence in the published lit that shows that long-term benzo use is often damaging? I worry that we prescribe truly toxic drugs like antipsychotics and depakote or lamotrigine to avoid benzos. And where is the evidence that many of these drugs actually help anxiety or are safe to treat it?

I think also there is a bias here: with very weak evidence of risk, we withhold benzos and with no evidence of efficacy or safety we prescribe toxic risky drugs instead. Make sense?

Also, underlying the bias is the pervasive idea, spread by 12 step treatment programs that 12 step treatment or groups are 100% effective if the person just does as they're told. You and I both know that's absurd and untrue. Medicine frequently involves compromise between ideal and pragmatic goals, and balancing various risks and benefits.

Finally, there is fairly strong evidence that untreated insomnia, pain and anxiety contribute substantially to increased relapse risk. It's easy to say "they should just tough it out or go to more meetings" but that seems pretty unreasonable and unsupportable to me.

In the end, I view it as all coming down to outcomes. Is the pt better off? Are their sxs less? Are they more functional? Does a rx for benzos help them recover more fully?

Be good to discuss some time....

Mark