John M. Talmadge, M.D.

A Blog Covering Many Topics

Never Underestimate the Power of a Single Intervention

For many years I have said to my medical students: "Never underestimate the power of a single intervention." Turns out this is true.

A few minutes of counseling in a primary care setting could go a long way toward steering people away from risky drug use -- and possibly full-fledged addiction, a UCLA-led study suggests. (Primary care refers to family physicians and other non-psychiatrists who provide most of our medical care.)

People who participated in the Quit Using Drugs Intervention Trial, or Project QUIT, which was a randomized controlled trial conducted in medical clinics, reduced their risky drug use by one-third when primary care doctors and health coaches provided them with brief interventions during a routine visit and follow-up phone calls.

Risky drug use is defined as the casual, frequent or binge use of illicit drugs such as cocaine, heroin and methamphetamine, or the misuse of prescription medications, without showing physiological or psychological signs of addiction. There are an estimated 68 million such drug users in the United States. These people are at risk not only for becoming addicts, but suffering attendant physical, mental health and social problems.

The study, published today in the peer-reviewed journal Addiction, is the first to demonstrate that a brief intervention led by a primary care physician can significantly reduce risky drug use among patients.

We Don't Plan to Become Addicts or Alcoholics

Most of the patients I (Dr. Talmadge) see in practice did not plan to become addicted to drugs. Casual use introduces powerful chemicals in the brain, and many of us then have our brains hijacked by these chemicals. As described in the HBO special on addictions, the human brain is an extraordinarily complex and fine-tuned communications network containing billions of specialized cells (neurons) that give origin to our thoughts, emotions, perceptions and drives. Often, a drug is taken the first time by choice to feel pleasure or to relieve depression or stress. But this notion of choice is short-lived. Why? Because repeated drug use disrupts well-balanced systems in the human brain in ways that persist, eventually replacing a person's normal needs and desires with a one-track mission to seek and use drugs. At this point, normal desires and motives will have a hard time competing with the desire to take a drug.

How Does the Brain Become Addicted?

As described in the HBO documentary, typically it happens like this:

-A person takes a drug of abuse, be it marijuana or cocaine or even alcohol, activating the same brain circuits as do behaviors linked to survival, such as eating, bonding and sex. The drug causes a surge in levels of a brain chemical called dopamine, which results in feelings of pleasure. The brain remembers this pleasure and wants it repeated.

-Just as food is linked to survival in day-to-day living, drugs begin to take on the same significance for the addict. The need to obtain and take drugs becomes more important than any other need, including truly vital behaviors like eating. The addict no longer seeks the drug for pleasure, but for relieving distress.

-Eventually, the drive to seek and use the drug is all that matters, despite devastating consequences.

-Finally, control and choice and everything that once held value in a person's life, such as family, job and community, are lost to the disease of addiction.

What brain changes are responsible for such a dramatic shift?

Research on addiction is helping us find out just how drugs change the way the brain works. These changes include the following:

Reduced dopamine activity. We depend on our brain's ability to release dopamine in order to experience pleasure and to motivate our responses to the natural rewards of everyday life, such as the sight or smell of food. Drugs produce very large and rapid dopamine surges and the brain responds by reducing normal dopamine activity. Eventually, the disrupted dopamine system renders the addict incapable of feeling any pleasure even from the drugs they seek to feed their addiction.

Altered brain regions that control decisionmaking and judgment. Drugs of abuse affect the regions of the brain that help us control our desires and emotions. The resulting lack of control leads addicted people to compulsively pursue drugs, even when the drugs have lost their power to reward.

Image of brain activity dopamine

The disease of addiction can develop in people despite their best intentions or strength of character. Drug addiction is insidious because it affects the very brain areas that people need to "think straight," apply good judgment and make good decisions for their lives. No one wants to grow up to be a drug addict, after all.

The addiction study cited above has some limitations. The results are based on participants' self-reporting, so the study may suffer from reporting bias. However, researchers found that based on urine testing, under-reporting of drug use was low. Additional limitations: not everyone in the clinic waiting rooms agreed to participate, which could impact the study's generalizability; there was some attrition during the study, though the 75 percent participation rate at follow-up compares to other studies of low income patients and drug use; and the three month follow up was relatively short.

There is a need for larger trials to gauge the QUIT program's effectiveness, but based on these findings the project appears to have the potential to fill an important gap in care for patients who use drugs, particularly in low-income communities, Gelberg said.

Read the entire report and article by clicking here.

One Nation, Under Sedation

In 2012, Medicare’s massive prescription drug program didn’t spend a penny on popular tranquilizers such as Valium, Xanax and Ativan. The following year, it doled out more than $377 million for the drugs.

Houston, we have a problem. For the full story, click here.

The distinguished addiction specialist Charles O'Brien, M.D., authored a paper in 2005 discussing the risks of benzodiazepine abuse. The summary of his article states: "Although benzodiazepines are invaluable in the treatment of anxiety disorders, they have some potential for abuse and may cause dependence or addiction. It is important to distinguish between addiction to and normal physical dependence on benzodiazepines. Intentional abusers of benzodiazepines usually have other substance abuse problems. Benzodiazepines are usually a secondary drug of abuse-used mainly to augment the high received from another drug or to offset the adverse effects of other drugs. Few cases of addiction arise from legitimate use of benzodiazepines. Pharmacologic dependence, a predictable and natural adaptation of a body system long accustomed to the presence of a drug, may occur in patients taking therapeutic doses of benzodiazepines. However, this dependence, which generally manifests itself in withdrawal symptoms upon the abrupt discontinuation of the medication, may be controlled and ended through dose tapering, medication switching, and/or medication augmentation. Due to the chronic nature of anxiety, long-term low-dose benzodiazepine treatment may be necessary for some patients; this continuation of treatment should not be considered abuse or addiction."

Image of poster dangers of benzodiazepines

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.

Science on Will and Willpower - Part II

Although he is not known for work in the addictions, Roy F. Baumeister, Ph.D., a social psychologist at Florida State University, writes and does research on willpower, one of the most important issues in alcoholism, drug addiction, and other dependencies. In Willpower: Rediscovering the Greatest Human Strength, makes the case that willpower is a limited resource subject to being used up. In simple terms, we get up in the morning with a certain amount of gas in the tank, and by the end of the day we can be running on empty.

An excellent video of one of Roy's lectures is on my media page.

We try to control ourselves in all sorts of ways: eating right, exercising, avoiding drugs and alcohol, studying more, working harder, spending less. Baumeister says that the practical significance of all this is enormous. He says: "Most of the problems that plague modern individuals in our society — addiction, overeating, crime, domestic violence, sexually transmitted diseases, prejudice, debt, unwanted pregnancy, educational failure, underperformance at school and work, lack of savings, failure to exercise — have some degree of self control failure as a central aspect."

Baumeister goes on to say that two main traits that seem to produce an immensely broad range of benefits: intelligence and self-control. However, psychology has not found much one can do to produce lasting increases in intelligence. On the other hand, self-control can be strengthened, and the study of self-control is a rare and powerful opportunity for psychology to make a palpable and highly beneficial difference in the lives of ordinary people.

Image of Roy Baumeister

For example, in his research he has found that people perform relatively poorly on tests of self-control when they have engaged in a previous, seemingly unrelated act of self-control: "For instance, in a study in my lab, we invited some students to eat fresh-baked chocolate-chip cookies, and asked others to resist the cookies and munch on radishes instead. Then we gave them impossible geometry puzzles to solve. The students who ate the cookies worked on the puzzles for 20 minutes, on average. But the students who had resisted the tempting cookies gave up after an average of eight minutes."

"Such studies suggest," he continues, "that some willpower was used up by the first task, leaving less for the second. The pattern is opposite to what one would expect based on priming or activating a response mode. So we began to think that some kind of limited resource is at work: It gets depleted as people perform various acts of self-control. Over time, we have begun to link this resource to the folk notion of willpower."

Making decisions seems to use up our willpower. After making decisions, people perform worse at self-control. Conversely, after exerting self-control, decision-making shifts toward simpler and easier processes. That can lead people to make poorer decisions, or to avoid making choices at all. Apparently, decision making depletes the same resource as self-control.

One of Baumeister's examples of willpower depletion: "A dieter may easily avoid a doughnut for breakfast, but after a long day of making difficult decisions at work, he has a much harder time resisting that piece of cake for dessert. Another example might be losing your temper. Normally, you refrain from responding negatively to unpleasant things your romantic partner says. But if one day you’re especially depleted — maybe you’re trying to meet a stressful work deadline — and the person says precisely the wrong thing, you erupt and say the words you would have stifled if your self-control strength was at full capacity. What do you call this process? My collaborators and I use the term “ego depletion” to refer to the state of depleted willpower. Initially, we called it “regulatory depletion” because the first findings focused purely on acts of self-regulation. When it emerged that the same resource was also used for decision-making, we wanted a broader term that would suggest some core aspect of the self was depleted. We borrowed the term “ego” from Freudian theory because Freud had spoken about the self as being partly composed of energy and of processes involving energy."

In his book, Baumeister explains that some people imagine that self-control or willpower is something you only use once in a while, such as when you are tempted to do something wrong. The opposite is true. Research indicates that the average person spends three to four hours a day resisting desires. Self-control is used for other things as well: controlling thoughts and emotions, regulating task performance and making decisions. Most people use their willpower many times a day, all day. And toward the end of the day, there is less gas in the tank.

We now know that people can improve their self-control even as adults. As with a muscle, it gets stronger from regular exercise. So engaging in some extra self-control activities for a couple weeks produces improvement in self-control, even on tasks that have no relation to the exercise activities. The exercises can be arbitrary, such as using your left hand instead of your right hand to open doors and brush your teeth. Or they can be meaningful, such as working to manage money better and save more. The important thing is to practice overriding habitual ways of doing things and exerting deliberate control over your actions. Over time, that practice improves self-control. As people deplete willpower, they became increasingly likely to give in to desires they might otherwise have resisted. This was true for all manner of desires: desires to sleep, to eat, to have sex, to play games, to spend money, to drink alcohol or smoke cigarettes.

One of the best features of Roy Baumeister's work, particularly his book on willpower, is that he is easy to read, accessible to those of us not trained in clinical research or adept at deciphering scientific papers.