John M. Talmadge, M.D.

A Blog Covering Many Topics

Painkiller Overdoses On the Rise

In 2012, physicians wrote 259 million prescriptions for pain killers, enough to give a bottle of pills to every adult in the USA, Frieden said. More than 2 million Americans abuse prescription opiates, according to the National Institute on Drug Abuse. About 669,000 use heroin, to which many opiate users turn when they can no longer afford pain killers.

This news isn’t shocking to those of us who encounter addiction daily, but it’s in the headline today at USA Today. Other items of note from today’s paper:

With nearly 44,000 deaths a year, more Americans today die from drug overdoses than from car accidents or any other type of injury. Many of these deaths could be prevented if patients had better access to substance abuse therapy, experts say. Yet people battling addiction say that treatment often is unavailable or unaffordable.

Only 11% of the 22.7 million Americans who needed drug or alcohol treatment in 2013 actually got it, according to the Substance Abuse and Mental Health Services Administration. While some of those who went without care did so by choice, at least 316,000 tried and failed to get treatment.

"We know addiction treatment saves lives, reduces drug use, reduces criminal activity and improves employment," says Paul Samuels, president and director of the Legal Action Center, which advocates on behalf of people with HIV or addiction. "The data is there, the evidence is in, but our public policy has not caught up with the science."

Meanwhile, the crisis is getting worse, says Thomas Frieden, director of the Centers for Disease Control and Prevention. The death rate from drug overdoses more than doubled from 1999 to 2013, according to the CDC. The bulk of these deaths involve opiates, a class of pain killers that includes morphine and Oxycontin.

Injection drug use has fueled an outbreak of HIV in rural Indiana, a nationwide surge in hepatitis C infections, and an increase in the number of babies born addicted to drugs. States have responded to the surge in overdose deaths by expanding access to naloxone, a fast-acting rescue drug that can reverse the effects of an opiate overdose. Indiana lawmakers also voted to allow needle exchange programs in communities facing a public health crisis related to injection drug use. While those approaches are welcome, they don't treat the underlying addiction.

The wait for a spot in a detoxification program ranges from days to weeks, and it can be very expensive. As I say elsewhere here on my site, it's also true that not all treatment is really good treatment. Consumers are disadvantaged twice. Not only is treatment hard to find in the first place, but it's hard to know what constitutes a good treatment program. I have some comments about this on my FAQ page and on my Philosophy page.

Treatment: Know What to Ask


SEEKING TREATMENT: KNOW WHAT TO ASK

My goal in helping people includes educating them about what questions to ask.
Finding the right treatment for a person’s specific needs is critical. And finding the right treatment is not easy. Drug and alcohol addiction treatment is not “one size fits all.”

Treatment outcomes depend upon:
  • the extent and nature of the person’s problems;
    • the appropriateness of treatment;
  • the competence and skill of clinical staff;
    • the availability of additional services; and
    • the quality of interaction between the person and the treatment providers.


Family and friends play important roles in motivating people with drug problems to enter and remain in treatment. However, trying to identify the right treatment programs for a loved one can be a difficult process.

The National Institute on Drug Abuse (NIDA) has sound advice about the five questions to ask when searching for a treatment program:

1. Does the program use treatments backed by scientific evidence?
In the internet era, answering this question has become increasingly difficult. Many programs offer flashy "treatments" that are not scientific at all, despite claims made on beautiful web pages. According to Thomas McLellen, professor of psychiatry at the University of Pennsylvania, 90% of patients who enter addiction treatment programs don’t receive evidence-based treatment. Many current programs actually reject scientific evidence. For example, they prohibit the use of addiction medications, even though they’ve been shown to be more effective treating some addictions (specifically, the range of opiates like Oxycontin to heroin) than anything else. My concern is a bit different from Dr. McLellan's view (for example, he is not friendly toward 12 Step work). My major concern is that there are dozens of quack therapies, ranging from nutritional "cures" to "new age" approaches, to potentially harmful "trauma therapy."

A great website is not a guarantee that the advertised program is any good at all. Many programs today, using clever marketing, take advantage of opposition to Alcoholics Anonymous and 12 Step Programs by advertising that says, "We are NOT a 12 Step Program!" What these programs fail to do, in almost every example, is to state clearly what they actually do in their approach. Many other websites—and I have reviewed hundreds of them—claim to offer "evidence based treatment," when in fact the program is not evidence based at all. The average person has no idea whether or not claims of scientific evidence are true. Above all, beware of "testimonials" and celebrity endorsements. In selecting a treatment program, you have to use at least as much good judgment as you would use if you were buying a new car or having heart surgery.

Effective alcoholism and addiction treatments can include cognitive behavioral therapy, medications, or, ideally, the combination of both.

Key elements include:
• addressing a patient’s motivation to change;
• providing incentives to stop drinking or using drugs;
• building skills to resist alcohol/drug use;
• replacing addiction related activities with constructive and rewarding activities;
• improving problem-solving skills; and
• building better personal relationships.

Any and every good addiction treatment program will include competent assessment by a qualified addiction psychiatrist. Some programs will team an addiction medicine doctor with a well-qualified clinical psychologist, and that can work well. The point is that everything begins with getting the right assessment. Medications are an important part of treatment for many patients, especially when combined with counseling and other behavioral therapies. Different types of medications may be useful at different stages of treatment: to stop alcohol and drug abuse, to stay in treatment, and to avoid relapse.

2. Does the program tailor treatment to the needs of each patient?
No single treatment is right for everyone. The best treatment addresses a person’s various needs, not just his or her alcohol and drug abuse. Matching treatment settings, programs, and services to a person’s unique problems and level of need is key to his or her ultimate success in returning to a productive life. It is important for the treatment approach to be broad in scope, taking into account a person’s age, gender, ethnicity, and culture. The severity of addiction and previous efforts to stop using drugs can also influence a treatment approach.
The best programs provide a combination of therapies and other services to meet a patient’s needs. In addition to addiction treatment, a patient may require other medical services, family therapy, parenting support, job training, and social and legal services.
Finally, because addictive disorders and other mental disorders often occur together, a person with one of these conditions should be assessed for the other. And when these problems co-occur, treatment should address both (or all conditions), including use of medications, as appropriate.
Medical detoxification is a necessary first step in the treatment of certain addictions, but by itself does little to change long-term drug use.

3. Does the program adapt treatment as the patient’s needs change?
Individual treatment and service plans must be assessed and modified as needed to meet changing needs.
A person in treatment may require varying combinations of services during its course, including ongoing assessment. For instance, the program should build in drug monitoring so the treatment plan can be adjusted if relapse occurs. For most people, a continuing care approach provides the best results, with treatment level adapted to a person’s changing needs. A patient’s needs for support services, such as day care or transportation, should also be met during treatment.

4. Is the duration of treatment sufficient?
Remaining in treatment for the right period of time is critical. Appropriate time in treatment depends on the type and degree of a person’s problems and needs. People argue about this point all the time, and I don't have the patience or space on this blog to cite the references, but research tells us that most addicted people need at least three months in treatment to really reduce or stop their drug use and that longer treatment times result in better outcomes. The best programs will measure progress and suggest plans for maintaining recovery. Recovery from drug addiction is a long-term process that often requires several episodes of treatment and ongoing support from family or community. If you have read this far and are starving for the references, contact me.
Relapse does not mean treatment failure. The chronic nature of addiction means that relapsing to drug abuse is not only possible, but likely, similar to what happens with other chronic medical illnesses—such as diabetes, hypertension, and asthma—that have both physical and behavioral components. And like these illnesses, addiction also requires continual evaluation and treatment modification if necessary. A relapse to drug use indicates a need to re-instate or adjust treatment strategy; it does not mean treatment has failed.

5. How do 12-step or similar recovery programs fit into drug addiction treatment?
Self-help groups can complement and extend the effects of professional treatment. The most well-known programs are Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA), all of which are based on the 12-step model. This group therapy model draws on the social support offered by peer discussion to help promote and sustain drug-free lifestyles.
Most drug addiction treatment programs encourage patients to participate in supportive therapy during and after formal treatment. These groups offer an added layer of community-level social support to help people in recovery with abstinence and other healthy lifestyle goals.

To order NIDA materials, please go to: http://drugpubs.drugabuse.gov.

Addictionary: Language of Addiction

The language of addiction is always evolving. Maybe we need an addictionary. See the full story on NPR here.

For example, when the word "alcohol" was written or spoken in early 19th-century America. it was often used in the chemical and medical sense. This is from an article about drawing out the essence of stramonium, or jimson weed: "The virtues of stramonium," the New England Journal of Medicine reported in January of 1818, "appear to be seated in an extractive principle, which dissolves in water and alcohol."

Image of words used in addiction work

The word "cocaine" had different connotations as well. In the 1860s, for instance, a substance termed "cocaine" was advertised by a Boston company as a topical treatment to prevent hair loss.

Over time these words – "alcohol", "cocaine" and others, including "drugs" and" intoxicated" – became more closely associated with substance use, abuse and addiction in American popular culture.

image of word alcoholism prevalence

"'Alcoholism' made its debut in the lexicon around 1900, associated almost exclusively with 'crime' and 'dreams' – coincidentally around the time that Sigmund Freud's The Interpretation of Dreams was published," Recovery.org notes. "However, the association with crime was soon eclipsed by concern over 'chronic' alcoholism and 'death'/'deaths' related to alcoholism, which ballooned in the 1920s during the height of the prohibition movement." Documentarian Ken Burns echoes this in his series, Prohibition. One of the tragic unintended consequences of the nationwide crackdown on alcohol was an increase in dangerous, unregulated spirits — leading to 1,000 deaths a year.

Mindfulness Based Relapse Prevention

Dr. Sarah Bowen has published a study on mindfulness and relapse prevention in JAMA Psychiatry, a specialty journal of the American Medical Association. According to Bowen, substance abuse is another example of that too-human automatic drive to move toward pleasure and away from pain—one that affects an estimated 24 million Americans, according to the National Survey on Drug Use and Health.

Traditional treatment for substance abuse often focuses on avoiding or controlling triggers that result in negative emotion or craving. While research has shown that this approach can help, substance abuse relapse remains a problem: about half of those who seek treatment are using again within a year.

Bowen has spent much of her career studying another approach: mindfulness, which involves cultivating moment-to-moment, nonjudgmental awareness of thoughts, feelings, and surroundings. She and her colleagues have developed a program called Mindfulness-Based Relapse Prevention (MBRP), which combines practices like sitting meditation with standard relapse prevention skills, such as identifying events that trigger relapse. Rather than fighting or avoiding the difficult states of mind that arise when withdrawing from a substance, this combination tries to help participants to name and tolerate craving and negative emotion.

But how do mindfulness-based approaches compare to traditional substance abuse treatments? And do mindfulness-based treatments work for everyone? Researchers like Bowen are beginning to answer these questions.

Here is the key to the success of the program: MBRP helps people to relate differently to their thoughts, and use tools to disengage from automatic, addictive behaviors.

The JAMA Psychiatry article describes how effective the Mindfulness-Based Relapse Prevention program is in comparison to a standard relapse-prevention program as well as a conventional 12-step program. Six months following the intervention, the mindfulness-based program and the standard relapse-prevention program were both more successful at reducing relapse than the 12-step program. One year later, the mindfulness-based program proved better than the other two in reducing drinking and drug use.

Bowen says that when people cultivate mindfulness, they’re developing a tool to become aware of that inclination to want only pleasurable things and escape uncomfortable things. Mindfulness also helps people learn to relate to discomfort differently. When an uncomfortable feeling like a craving or anxiety arises, people like Sophia are able to recognize their discomfort, and observe it with presence and compassion, instead of automatically reaching for a drug to make it go away. Bowen says that awareness of our experience and the ability to relate to our experience with compassion gives us more freedom to choose how we respond to discomfort, rather than defaulting to automatic behaviors.

More research is needed to determine why MBRP might be more successful than other programs in reducing substance abuse relapse, but Bowen speculates that MBRP holds an advantage because mindfulness is a tool that can be applied to all aspects of one’s life.

Standard relapse-prevention programs teach tools specific to struggles with substance abuse—for instance, how to deal with cravings or how to say no when someone offers you drugs. A year after completing the program, a person may have a very different set of challenges that the relapse-prevention program did not equip them to deal with.
But because mindfulness is a tool that can be used in every part of a person’s life, practicing moment-to-moment awareness could continue to be an effective coping tool.

James Davis and his colleagues at Duke University are investigating mindfulness training as a way to help people quit smoking. Davis speculates that mindfulness is likely an effective tool in helping people with addiction because it’s a single, simple skill that a person can practice multiple times throughout their day, every day, regardless of the life challenges that arise. With so much opportunity for practice—rather than, say, only practicing when someone offers them a cigarette—people can learn that skill deeply.

Their intervention results showed a significant difference in smoking cessation for people who completed the intervention, as compared to people who were given nicotine patches and counseling from the Tobacco Quit Line.

Both Bowen and Davis emphasize that mindfulness is not a panacea; it doesn’t always work for everyone.

Dr. Zev Schuman-Olivier and his colleagues at the Massachusetts General Hospital Center for Addiction Medicine suggest that the type of therapy a person responds to may have something to do with their disposition. People who had the tendency to treat thoughts and behaviors with non-judgment and acceptance before the intervention began were more likely to be successful in reducing smoking following the mindfulness training. They write that if a person already has the skill to treat the self with non-judgment and acceptance, learning mindfulness practices likely comes easier to them than someone who has not previously practiced this skill.

Ultimately, the type of therapy that works best for a given person will likely capitalize on their pre-disposed strengths.Of course, as Bowen and Davis both note, the skills of mindfulness can be taught to everyone. But Schuman-Olivier’s finding suggests that people who are not oriented toward mindfulness may need a more vigorous or lengthy intervention, in order to more thoroughly learn mindfulness skills. It may be the case that people with less disposition toward mindfulness would fare better with a different therapy.

Another predictor of success in mindfulness-based treatment could be a person’s motivation to engage in the therapy. In Davis’ study, the people that started the intervention with the highest level of nicotine addiction were the most successful in reducing smoking by the end of the treatment. Davis said that this seemingly counterintuitive result likely reflects their motivation to quit; the people that were the most addicted had, at that point, tried everything, and were willing to try their hardest to make this therapy work. Meanwhile, people that were less addicted saw their addiction as less of a problem. They reasoned, “If this doesn’t work, I’ll be ok—something else will work, eventually.” As a result, they were likely less motivated to quit, and less engaged in the therapy.

Painkillers, Narcotic Abuse, and Addiction

The Texas Medical Association sent an alert today about a new study: About 25% Of Chronic Pain Patients May Abuse Prescriptions. Forbes (4/2) Contributor C.J. Arlotta writes that a new report, published in the journal PAIN, found that “20-30% of opioids prescribed for chronic pain are being misused,” and further concluded “that the rate of addiction is approximately 10%.” The opioid epidemic in the US, he writes, “puts chronic pain front and center,” and physicians and health experts “are routinely looking for ways to” lower the “risk of patients becoming dependent on” prescription medicines. An independent panel convened by the NIH came to the conclusion that “individualized, patient-centric care,” despite its challenges, “is one way to control opioid tolerance development in chronic pain patients.” Additionally, state governments have continued investing in prescription monitoring programs (PMP), even though “only 53% of primary care physicians” utilize PMPs.

Over the past twenty years, drugs like hydrocodone, oxycontin, and similar narcotics have become an epidemic problem.

Opioids -- also called opiates or narcotics -- are pain relievers made from opium, which comes from the poppy plant. Morphine and codeine are the two natural products of opium. Synthetic modifications or imitations of morphine produce the other opioids:

Heroin (street drug)
Dilaudid (hydromorphone)
Percocet, Percodan, OxyContin (oxycodone)
Vicodin, Lorcet, Lortab (hydrocodone)
Demerol (pethidine)
Methadone
Duragesic (fentanyl)
When people use narcotics only to control pain, they are unlikely to become addicted to the drugs. However, opioids provide an intoxicating high when injected or taken orally in high doses. Opioids are also powerful anxiety relievers. For these reasons, narcotic abuse is one of the most common forms of drug abuse in the U.S.

Terms like opioid abuse, drug abuse, drug dependence, and drug addiction are often used interchangeably, but experts define them as follows:

Drug abuse, including opioid abuse, is the deliberate use of a medicine beyond a doctor's prescription. In the case of opiates, the intention is generally to get high or to relieve anxiety.
Dependence occurs when the body develops tolerance to the drug, meaning higher doses are needed for the same effect. In addition, stopping the drug produces drug withdrawal symptoms.
Drug addiction occurs when the person has drug dependence, but also displays psychological effects. These include compulsive behavior to get the drug; craving for the drug; and continued use despite negative consequences, like legal problems or losing a job.

Symptoms of Narcotic Abuse
Signs and symptoms of opioid abuse include:
  • Analgesia (feeling no pain)
  • Sedation
  • Euphoria (feeling high)
  • Respiratory depression (shallow or slow breathing)
  • Small pupils
  • Nausea, vomiting
  • Itching or flushed skin
  • Constipation
  • Slurred speech
  • Confusion or poor judgment

Symptoms of Opioid Drug Withdrawal
If a person uses opioids for a long time, they develop physical dependence and tolerance. Usually, opioid abusers will then take more of the drug, to continue to get high. If a person stops using opioids after they become physically dependent on the drug, they will experience drug withdrawal symptoms which can include:
Anxiety
Irritability
Craving for the drug
Rapid breathing
Yawning
Runny nose
Salivation
Gooseflesh
Nasal stuffiness
Muscle aches
Vomiting
Abdominal cramping
Diarrhea
Sweating
Confusion
Enlarged pupils
Tremors
Loss of appetite

I tell patients that withdrawal from drugs like painkillers and heroin is like the worst case of the flu you've ever experienced. The symptoms of opioid drug withdrawal can be agonizing and intolerable, contributing to continued drug abuse. In general, how severe opioid drug withdrawal symptoms are, and how long they last, depends on how long the person has been abusing opioids and how much they have been taking.

Medicines like methadone, buprenorphine (sometimes combined with naloxone), and naltrexone can be taken in various forms and are used to prevent withdrawal symptoms after a person stops using, a process called detoxification ("detox"). After drug withdrawal is complete, the person is no longer physically dependent on the drug. But psychological dependence can continue. Some people with drug addiction may relapse in response to stress or other powerful triggers.

Dependence vs. Addiction

Controlling pain is the goal when opioids are used medically. Patients or health care professionals should not let fear of addiction prevent them from using opioids for effective pain relief. Knowing the difference between dependence and addiction is important.

People who take opioids for pain relief for extended periods of time may need higher doses to ease their pain. They may develop tolerance to the drug and experience withdrawal symptoms if the medication is abruptly stopped. They become physically dependent on the drug.
Addiction occurs when narcotic abuse becomes compulsive and self-destructive, especially concerning an opioid user's need to use the drug for reasons other than pain relief.
To prevent withdrawal symptoms in people who have become physically dependent on opioids for pain relief, the dose may be slowly lowered over a few weeks. People who are weaned off opioids and are pain free usually don't start taking the drug again or become abusers of narcotics. Opioids used for short-term medical conditions rarely require weaning. In those cases, stopping the medication after a brief period usually doesn't cause withdrawal symptoms.
Other Abused Drugs
Strictly speaking, most drugs referred to informally as narcotics really aren't. However, two drug classes have some similar effects to opioids, when abused:

Benzodiazepines include Valium, Ativan, and Xanax. Benzodiazepine abuse results in sedation and calm, but tolerance develops rapidly. Withdrawal can result in seizures, unlike opioid withdrawal.
Barbiturates include Seconal, Amytal, Nembutal, and Luminal. Barbiturates are also sedating and calming. Withdrawal after continued barbiturate abuse, like benzodiazepine abuse, is medically serious.
In general, benzodiazepines and barbiturates have less pain-relieving effects than opioids. All three drug classes are sedating and anxiety-relieving. Benzodiazepine abuse, barbiturate abuse, and narcotic abuse all produce tolerance and physical dependence over time, and withdrawal symptoms after sudden discontinuation.

This post includes material from WebMD Medical Reference.
SOURCES:
Van den Brink, W. Canadian Journal of Psychiatry, 2006.
WebMD Medical Reference: "Narcotic Abuse."
Bateson, A.N. Current Pharmaceutical Design, January 2002.
eMedicine.com: "Toxicity, Barbiturate."
Reviewed by Arefa Cassoobhoy, MD, MPH on August 01, 2013

Do 12-Step Programs Work?

Do mutual help organizations like Alcoholics Anonymous really work? Last year, The Carlat Report on Addiction Treatment reviewed the research on AA and reported positive findings. I've summarized that report and included the references here. AA and other 12 Step programs provide many of the elements found in formal treatment. More importantly, the recovering fellowship creates a framework for support over the long term, helping individuals stay sober longer, have fewer drinking days, and have shorter periods of relapse. Twelve Step Facilitation (TSF) has been found as effective as cognitive behavioral therapy in addressing alcohol-related issues.

Since the 1930's when Bill W. and Dr. Bob started Alcoholics Anonymous (AA) the fellowship has grown to over two million members. Meeting in rented rooms, school halls, hospitals, and the storied church basement, AA and similar 12-step organizations (eg, Narcotics Anonymous [NA]) remain the most commonly sought sources of help for substance-related problems in the United States (Substance Abuse and Mental Health Services Administration. Results from the 2007 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies; 2008).

Research has shown that attending AA, either alone or during and following professional treatment, enhances outcomes. One naturalistic study, for example, followed 466 previously untreated individuals with problem drinking for eight years. Participants self-selected into one of four groups: no treatment, AA alone, formal treatment alone, and formal treatment plus AA. Those who received some sort of help—AA, formal treatment, or both—had higher rates of abstinence at all time points. At eight years, 26% of patients in the no treatment group were abstinent from alcohol compared to 49% who received AA alone, 46% who received formal treatment alone, and 58% who received the combination of treatment plus AA (Timko C et al, J Stud Alcohol 2000;61(4):529–540).

A systematic Cochrane review of the best scientific studies on AA and TSF found that they were as effective as any of the interventions to which they were compared for some factors, such as retention in treatment, but found that no studies unequivocally proved AA and TSF were superior to other treatments (Ferri M et al, Cochrane Database Syst Rev 2006;(3):CD005032).

Other studies have found a linear dose-response relationship between AA attendance and favorable drinking outcomes (Kaskutas LA, J Addict Dis 2009;28(2):145–157). Attending one meeting per week, on average, appears to be the minimum threshold to realize benefit and increasing meeting frequency is associated with progressively greater rates of abstinence. In addition, research has shown that women engage with AA as much as men, become more involved with the 12 Steps, and derive similar benefit. In 1990, the Institute of Medicine called for more research on how AA works. Since then, research has revealed that AA aids recovery through multiple mechanisms, many of which are also activated by professional behavioral treatments (Kelly J et al, Addict Res Theory 2009:17(3):236–259).

Most consistently and strongly, AA appears to work by helping people make positive changes in their social networks (eg, by dropping heavy drinkers/drug users and increasing abstainers/low risk drinkers), and by enhancing coping skills and self-efficacy for abstinence when encountering high-risk social situations (see for example, Kelly JF et al, Drug Alcohol Depend 2011;114(2–3):119–126).

Among more severely addicted people, AA also appears to work by enhancing spiritual practices, reducing depression, and increasing individuals’ confidence in their ability to cope with negative emotion (Kelly JF et al, Addiction 2012;107(2)289–299). Thus, AA appears to work through diverse mechanisms and may work differently for different people. Stated another way: individuals may use AA differently, depending on their unique needs and challenges.

Research has shown that involvement in 12-step work can reduce the need for more costly treatments while simultaneously improving outcomes. A large multicenter study of over 1,700 patients found those treated in professional 12-step treatment went on to participate in community-based AA and NA meetings at a higher rate than those from professional cognitive behavioral therapy (CBT) programs, who relied more heavily on professional services. This translated into a two-year savings of over $8,000 per patient among 12-step treated patients, without compromising outcomes. In fact, those treated in the 12-step treatment programs had one-third higher rates of abstinence across follow-up (Humphreys K & Moos R, Clin Exp Res 2001;25(5):711–716; Humphreys & Moos, Alcohol Clin Exp Res 2007;31(1):64–68).

Project MATCH was a large randomized trial comparing three individually-delivered psychosocial treatments for alcohol use disorder—TSF, CBT, and Motivational Enhancement Therapy (MET)—that was funded by NIAAA. It included 1,726 patients from nine clinical sites across the US (Project Match Research Group, J Stud Alcohol 1997;58(1):7–29). TSF was found to be as effective as the more empirically supported CBT and MET interventions at reducing the quantity and frequency of alcohol use post-treatment and at one- and three-year follow-ups. Moreover, TSF was superior to CBT and MET at increasing rates of continuous abstinence, such that 24 percent of the outpatients in the TSF condition were continuously abstinent at one year after treatment, compared with 15 percent and 14 percent in CBT and MET, respectively (Tonigan JS et al,Participation and involvement in Alcoholics Anonymous. In: Babor TF & Del Boca FK, eds. Treatment Matching in Alcoholism. New York: Cambridge University Press;2003:184–204).

Abstinence rates at three years continued to favor TSF, with 36 percet reporting complete abstinence, compared with 24 percent in CBT, and 27 percent in MET (Cooney N et al. Clinical and scientific implications of Project MATCH. In: Babor TF & Del Boca FK, eds. Treatment Matching in Alcoholism. New York: Cambridge University Press; 2003:222–237).

In light of findings from several such RCTs that demonstrated the efficacy of TSF, this therapy was added to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Practices and Programs (NREPP) in 2008.

The overwhelming majority of research has been conducted on AA. More research is needed on other MHOs, such as SMART Recovery, LifeRing, Celebrate Recovery, Women for Sobriety, Moderation Management, and others, so that more objective evidence is gathered on secular, religious, and non-abstinence-based AA alternatives (see the article "Alternatives to 12-Step Recovery" for more on these groups).

Treatment Philosophy

My work includes general psychiatric problems like anxiety, depression, attention deficit disorder, substance abuse, family conflict, childhood behavior, stress, and other issues. Many people know me through my work as a specialist in the treatment of alcoholism and other addictions or chemical dependencies.

My approach to psychiatric practice reflects many years studying human nature and working to help people who are having a hard time in life. By the time most people see a psychiatrist, they are worried, or they are sad, or they are very confused about something I will just call “the problem,” or “the complaint.” Let me make some general comments about my approach, and then I will discuss my thinking on the use of medications.

People seek psychiatric help for a variety of problems, but everyone wants the same result: to feel better, to think more clearly, to rediscover satisfaction and happiness, and to regain a sense of self control and personal freedom. The problem may be related to mood, energy level, motivation, sleep, worry, relationships, anger, troubled behavior, obsessions, compulsions -- it’s a long list. People who drink too much, use drugs, or misuse prescription medication are often using these chemicals to find relief. Alcoholism and substance abuse are widespread in our culture.

Dealing with life is never easy.

Most persons first try to solve the problem or deal with the complaint on their own. Frustrated that things aren’t improving, they may seek advice from others. Sometimes a person hides the problem or lives in silence with the complaint. They may read a book, go to a support group, consult the internet, or try a new religious practice. We all have problems and complaints, and we all do the best we can to solve the dilemmas of life. When someone calls me about consultation, I almost always hear them say that they have a problem, they have tried to solve the problem, and they are looking for someone who knows how to help make things better.

One of the individuals consulting with me said, “I feel like I’m in a box, and the directions for getting out of the box are printed -- on the outside of the box.”

A successful airline pilot, a Vietnam combat veteran, said, “Doc, I’m out of altitude, airspeed, and ideas.”

Often the person seeking help has waited so long that demoralization has begun to set in, and they are beginning to lose hope. This doesn’t mean that the individual is suicidal or, in fact, any more unhappy than many of the people at the workplace or in the neighborhood. It means that they are resigned to always feeling this way, never feeling any better than this. Demoralization means a state of mind in which a person considers accepting fate, giving up, and abandoning the idea that things can get better.

Fear, anger, resentment, feeling constantly wounded, feeling overwhelmed, feeling unappreciated, feeling worthless -- all of these emotions are part of our lives. But when we feel negative all the time, or most of the time, most days, then we need help. There are very few emotional problems that defy intelligent therapy and reasonable efforts toward a solution.

When I meet someone for the first time in consultation, I have three major concerns. First, I want to get to know the person and hear about the problem are the complaint. My first question usually is simply, “How can I help?” or “What brings you to see me?” Second, I want to explore the individual’s point of view or understanding of the problem, including what solutions have been attempted. Third, I want to consider what we can do, working together, to improve the situation. I tend to focus more on results than on reasons. I’m not always sure about why things happen, but I am very focused on what we can do now. Sometimes I explain in detail how the brain works, and sometimes I discuss how life works. The process of recovery involves growth, change, and even personal transformation.

Research shows that psychotherapy can help, medication can help, and intelligent problem solving helps. Psychotherapy is not for everyone, and medication is not for everyone, but the vast majority of people who want help can find it. One of my favorite expressions is, “You have to do it yourself, but you can’t do it alone.”

Over the years I have developed a style that I call “sober conversation.” The word “sober” does not apply just to alcohol and addictions. To be sober is to be serious, to focus on what is most important, and to try to get it right. I believe in the importance of what we care about, and in this regard I have seriously studied the specific problem of human will. I call it “the problem of human will” because we are often confused about what we will ourselves to do, or not to do. When I work as a psychotherapist, I am most interested in what people care about, how their beliefs and assumptions about life have been formed, and where they feel stuck or at odds with themselves. Sometimes we have conflicting feelings about the same thing. For example, someone wants to take life in a certain direction, but he or she feels conflicted about it. Or someone tries to solve a problem, not realizing that it’s part of a bigger problem, or a different kind of problem. My definition of psychotherapy is that it is a form of personal consultation, focused on the situation of the client, with the goal of solving problems and feeling better.

Not everyone is cut out for in-depth or long-term conversation. Some people like to come for a few visits, and some like to keep going for weeks, or even months on a weekly basis. Some people prefer to come two or three times a week because they want to do the work and get on with whatever is next. Some people come for an hour, and some come for an afternoon.

Psychotherapy does take time, because the process is basically two people getting to know each other in the context of a specific purpose. Psychotherapy at its best is about taking life seriously, getting it right, and feeling the satisfaction that comes from clarity of thought, commitment to integrity, and comfort with the complexity of one’s own emotions and ideas. Some say that psychotherapy is a dying art, and this may be true. Psychiatrists today (and perhaps psychologists as well) do not receive the extensive training in psychotherapy that we did thirty years ago. Many psychiatrists and psychologists are not interested in psychotherapy. And many psychotherapists are not really very good or very well trained. Today there are thousands of people who call themselves “life coaches,” and anyone can hang out a shingle and call himself a “life coach.” There are several private organizations that offer “certifications,” but there are no license requirements, there is no government regulation, and no educational standard that is generally accepted. For these reasons, I think the concept makes sense, but in practice let the buyer beware -- caveat emptor!

Medications can be very helpful in treating some specific psychiatric problems. Today we have excellent medications for anxiety, depression, moodswings, insomnia, attention deficit disorder, and other conditions. Bipolar disorder, for example, is a devastating condition that can be very effectively managed with medication, restoring individuals to a life of normalcy and stability. I have absolutely no doubt about the value of psychiatric medications. I also believe that what is most important is getting the right diagnosis and the correct strategy for intervention and treatment. I see many people who have been misdiagnosed, and even mistreated, because they have not been well assessed. Assessment can take time, and I never jump to conclusions about diagnosis. After knowing someone for a few weeks, together we may decide that we see the condition in a different way.

Psychiatric medications are powerful, effective tools when used properly, but they also have side-effects, and they are expensive. Getting the right medication for the right diagnosis is extremely important. And there is an old saying from Hippocrates, creator of The Hippocratic Oath: “It is more important to know what sort of person has a disease than to know what sort of disease a person has.“