Fear and Education

Posted on February 1, 2012 by admin

It’s clear that more adults, including physicians, need further education about the causes and consequences of addiction, but it may be even more important to educate our children before they make decisions that can end up tearing apart their entire lives. Drug education in schools is mandatory and ongoing, but it’s clearly inadequate, for much the same reasons that health and sex education standards are inadequate.

The approach most schools take to drug education is a unilateral, completely straightforward “Just say no!” campaign. They struggle to paint all use of any substance, even one sip of alcohol or one cigarette, as a horrifying and potentially lethal act of self-destruction. While it’s true that beginning to drink or smoke at a young age can have horrible long-term effects on health, painting the situation with such a broad brush just sets the education program up for failure, because it creates an illusion that can’t be maintained. Kids — especially pre-teens and teenagers, who are the target of most drug education — are immature, but they aren’t stupid. They will see adults having a drink, or smoking, in their everyday lives. They may see their friends trying a beer or a cigarette, and when that adult or that friend doesn’t immediately crash a car, vomit, or suffer some other horrible comeuppance, the kid who has been through that style of drug education will conclude that they have been lied to. They will also realize, possibly just by going home in the afternoons, that not all people who are addicted to substances are bad, dirty people. By refusing to deal with any of the nuance or complication of addiction, much of drug education sets itself up as a lie — a lie that will be easily disproven. And the worst thing is that, once a kid has realized that official education sources may exaggerate or lie, that kid may never trust an official source of education again. Any future attempts to correct the bad drug education will fall on deaf ears.

If we are going to have any hope of reaching kids, we must show them the basic respect they deserve, and tell them the truth. They have to understand that a large number of people want to get high, or feel an altered state of consciousness, and that there are safe ways to do it — drinking in moderation with friends (without driving afterwards), for example. Kids need to know that some things, like marijuana, are almost infinitely safer than others — like the “legal” marijuana analogues that use things like toxic bath salts and tar, and can cause seizures.

The drug education standards prevalent today are not strictly “education”, in my opinion. Education is a process designed to give people true and useful information with which they can make decisions and keep themselves safe. The statistics and medical consequences discussed in drug education programs are certainly true, but they are not presented in the context of giving useful information; they are presented in the context of propaganda and scare tactics. While I understand the deep concern and fear for the safety of children that is behind this style of teaching, I also feel certain that it does not work, nor will it ever work, the way it was intended. Giving students information you swear is true, which will be contradicted by their real-world experience, will only set them up for lifetime distrust of education. It may also lead to them throwing out the legitimate warnings along with the trumped-up fear tactics, and put them in a worse position than before.

Drug education, like health and sex education and all other important topics, must be discussed with children in a way that is serious and straightforward, but it must also take into account the complexities that that child will face as they attempt to make their way in a nuanced adult world. “Just say no” has some valuable aspects to it as a campaign, and I would certainly rather that no one under legal age used any substances at all, but a lack of proper education will only lead to more addicted people living more self-destructive lives.

Interpretations of AA

Posted on January 19, 2012 by admin

I spend a lot of time on this blog discussing 12-step programs. But what exactly constitutes a “12-step program”? The term itself is rather vague.

I tend to use this as an umbrella term to describe the group-based, discussion-heavy, and non-medicated treatment style that claims to be the spiritual successor of AA. This approach has been expanded to treat narcotic addiction, nicotine addiction, and any number of other conditions. It has also been adopted very widely, and while it’s common for treatment providers to stay close to AA’s original 12 steps, they also tend to tweak and change and “put their own spin” on the program as much as they can. What this has led to is a huge variety of treatment approaches that, to an outsider with a critical eye, all appear to share a few core principles that they have taken from the founding tenets of AA. Usually this includes belief in a Higher Power; the righting of wrongs done to others in the past; establishing a social network with other ex-addicts; and a strong moral emphasis on being “clean” rather than “dirty”; and a refusal or demonization of medication.

I write about 12-step programs mostly from my own experience, because as a doctor advocating medication maintenance for addiction, I encounter a great deal of hostility and resistance from the staff of these programs. I also witness firsthand the effects that this style of treatment has on my patients, who refuse to stay healthy on maintenance because they believe they are still “dirty”. Most programs that fight against medication maintenance do so using a kind of authoritative hair-splitting; they claim that, since buprenorphine affects the opiate receptors, it takes away a patient’s right to be called “clean” or “in recovery”. I would just like to point out the irony of this panicked accusation, seeing as the founder of AA originally made it very plain that excluding anyone on such superficial grounds was very much against the spirit of the organization. You can read Bill W.’s opinion on who should be allowed to be a member of AA here.

Alcoholics Anonymous was founded in 1935 by Bill W. and Dr. Bob as a way to help alcoholics find strength and comfort in community. As part of my education in the field of addiction, I’ve read a large amount of AA literature, including the “Big Book”, considered the central text of the organization. I have reached the conclusion that the original spirit of AA was an unflinchingly inclusive one, and that the founders would not have approved of keeping an addict out of “recovery” based on what other medication they were taking, or what other measures they might be taking to control their alcoholism. Addiction is a disease, and taking regular medication for it should be no more problematic than taking regular blood pressure medication. It certainly shouldn’t be used as an excuse to keep stable and thriving patients out of the nebulous category of “in recovery”.

Yet a great deal of resistance to medication maintenance comes from a widely-held belief that medication somehow violates the principles of AA, and the 12-step programs that have descended from AA. I would argue that this belief is factually wrong, but the factual correctness of a statement like that doesn’t even matter, because every interpretation of the “principles” of AA is equally valid. AA (used here as the flagship example of the 12-step type of program) is a nebulous, widespread organization without a central authority capable of making policy decisions. It is based on a certain amount of written material, all of which is open to interpretation, and there is no one with the authority to call any interpretation right or wrong. It actually resembles many religions in this way.

I would argue that the belief that medication goes against the spirit of AA is widely-held, not because the texts support such an interpretation, but because it has become a sort of canon that has been mixed into the original philosophies of AA and passed on due to tradition and financial advantage. Thankfully, since all interpretations are equally valid, I will tell all my future patients that this ugly and discriminatory policy does not come from a place of authority and should have no power to prevent them from seeking the most effective treatment they can.

Inside the Anger

Posted on January 11, 2012 by admin

Last week, I wrote about how 12-step programs that hire exclusively from the small pool of “12-step successes” may be misleading their patients — and how patients are taken in by their own tendency to trust in anecdotes more than statistics and data. This week I want to write about a very similar trend among those who defend 12-step treatment programs against the advance of other, more scientific methods of treatment.

I spend a great deal of time on various forums online, debating the merits of different forms of addiction treatment with professionals and laypeople alike. I see it as a vital and valuable way to stay informed and relevant to the conversations going on in the community I am trying to serve. One thing I’ve noticed over the course of these discussions is that people who tend to support 12-step programs tend to be much more emotionally invested in their arguments, and often react to disagreement as though it were a personal attack.

I don’t think this has anything to do with these people in particular; I’ve gotten enraged, nearly hysterical responses from people who work at these programs, people who don’t, even people who relapsed after undergoing a 12-step treatment. I think a feeling of deep emotional attachment to the ideals of 12-step programs are a symptom of the way these programs are run. I mentioned last week that anecdotes, especially when they are highly emotionally charged and are coming from people in positions of authority, may well be the most powerful persuasive force that can act on a human mind. 12-step programs engineer situations that harness this force in their favor. They present sick, frightened, desperate patients with calm and reassuring counselors (remember, all drawn from a small percentage of addicts), and have those authority figures relate stories of how their lives were ruined and 12-step programs saved them.

The effect this has is very difficult to overstate. It is, as I said, very persuasive — but it’s persuasive on an emotional basis rather than an intellectual one. Emotional certainty can be very useful and necessary in our lives, but it can also cloud our judgement and make us miserable when we are confronted with facts that disprove the foundations of our emotional knowledge.

This is what I believe is going on today in the ongoing war between 12-step supporters and medical professionals who advocate maintenance therapy for addiction. 12-step programs have become almost a kind of religion; they introduce their patients to an entire moral worldview, one based on willpower and a “Higher Power”, complete with narratives of sin and redemption. They introduce this system in very stressful and vulnerable situations, and encourage their patients to rebuild their lives on this foundation. There would be nothing wrong with this, if the foundation itself wasn’t fundamentally, factually flawed. It turns out that addiction is not solely a moral failing, and often cannot be overcome by willpower alone, the same way that willpower can’t overcome diabetes. But statistics and science that try to make that point are rejected and even attacked, because they threaten the deep emotional foundation on which 12-step patients have constructed their world. Because it’s an emotional threat, the reaction is emotional as well; I, as a physician, don’t have a particular emotional attachment to any one mode of treatment, and I’m willing to debate them all on intellectual grounds. That’s why I’m often caught off-guard by the intensity of the anger that I find when talking to those who have been through this 12-step persuasive process.

I want to say again that I don’t think these people are “stupid”, or weak, or that they have some kind of innate problem. I believe they have been taken advantage of by a system that, wittingly or not, has been fine-tuned over decades to make its patients believe that no other method or provider can be trusted.

It is my hope that, through education and continual refinement of the science behind addiction treatment, we can replace this manipulative system with one based in factual reality, which will hopefully help more patients to live healthier lives.

12-Step Statistics

Posted on January 2, 2012 by admin

It’s common for addiction treatment centers and 28-day rehabs to advertise that their staff is made up only of ex-addicts. They treat it as a selling point that patients won’t talk to anyone who hasn’t found success fighting addiction — if not at that particular center, then almost certainly through similar methods of abstinence, willpower, roleplaying, and lectures.

There’s a valuable element of encouragement for patients to see and talk to role models who have overcome the problems they’re facing. It is completely natural and commendable for people who have struggled with addiction to want to help others who are currently struggling. But by hiring only one subset of people, these treatment programs end up spreading a deeply misleading and harmful idea of addiction, which can delay or even stop their patients who are on their own “roads to recovery”.

First of all, hiring only those who have “succeeded” on 12-step programs is playing a statistics game. Out of all comers — anyone who considers themselves an addict or alcoholic and attends at least one 12-step meeting — between 90 and 95% find the program doesn’t work, and leave. Success rates given by 12-step treatment centers are often framed with the understanding that these 90% of people don’t count — the program has an “80% success rate”, which means “successes” are 80% of those who were in the 10% who stayed. While this might be a good argument that the 12-step treatment works well for a certain kind of people who find the program helpful, it is not a compelling reason to say the treatment will work for all addicts. When you further narrow the field by choosing an arbitrary definition of “success” — three years clean, or five, or ten — the end result is that the program works for a very, very small percentage of the total addicted population. 12-step centers then go on to hire exclusively from this very small pool. What this means is that, although the whole point is to show patients that they, too, can become “successful” like the staff has, the reality is that it is very unlikely any particular patient will be part of the same tiny percentage of the population that all of the staff are drawn from. (It is also worth noting that when I say “very small”, I don’t mean that the total number of successes is small. It might be several million; that doesn’t matter. All that matters is that, for every success, there are many millions more addicts who 12-step programs would call a failure.)

So the “inspiring” message that patients can become like the staff is likely very misleading. What can make it harmful, though, is a fact of human psychology; human beings tend to find anecdotes more convincing than data. Especially to patients in a treatment center, who are often sick and frightened, a personal story of redemption told by an authority figure (a counselor or administrator) is much more powerful than a presentation on statistics of the kind I’ve discussed.

This is a very well-known fact of how human brains work, and there’s no getting around it. It’s the reason people buy lottery tickets, or refuse to fly on airplanes, or do any number of things that don’t make much sense from a statistical point of view. It can sometimes be very helpful to our survival, but it can also do us a great deal of harm. I personally have had patients leave my practice because I have statistics, data, FDA reports and medical science behind me, but I can’t offer a personal anecdote of having been at “rock bottom”. This emphasis on personal stories means that, not only are patients in 12-step treatment centers being told stories that are unlikely to apply to them, they are being taught to trust those stories more than any hard data they might see in the future. For the vast majority of people who won’t turn out to succeed in 12-step programs, the anecdotes they heard from ex-addict staff may prevent them from seeking other methods of treatment that might work better for them. It sends them back into ineffective 12-step programs again and again, utterly convinced that they can overcome all odds, projections,and medical facts, just because they heard that some other person once did (or thought they did).

While it may seem heartless to say that people shouldn’t try to beat the odds, the fact is that the odds are there for a reason. Moreover, acknowledging the facts and acting accordingly will almost always lead to a healthier and happier life for the larger number of patients.

We at the Bel Air Center for Addictions hope that all of you have a healthy and happy New Year.

Pain and Addiction

Posted on December 27, 2011 by admin

This week, an excellent article on the American Pain Foundation (APF) was brought to my attention. In it, the APF’s stance that “the risk of [opioid] addiction is overblown” is examined in light of the fact that the APF receives a great deal of its funding from companies that produce addictive painkillers. I highly recommend you click that link; the article is thorough and well-researched, and provides a valuable perspective on the kind of misinformation that can harm patients when medical issues become overly profit-driven. The companies producing and promoting the use of addictive painkillers clearly have financial motives to conceal their potentially harmful effects, and they also have clear motives for funding institutions such as the APF, which can lend credibility to research that might otherwise appear “scant or disputed”. Whether or not the people working at APF believe what they say about the “low risk” of opiate addiction — and despite the real good that APF may have done in the realm of patient advocacy — maintaining that prescription of opiates should be uncontrolled is severely irresponsible.

Will Rowe, the chief executive of the APF, is quoted in the linked article as saying that “The problem isn’t opioids… It’s poorly trained doctors who prescribe them too easily or in excess.” That is certainly true. No drug in and of itself is “good” or “bad”; all treatments are appropriate in some situations while being inappropriate in others. But Rowe and others similarly associated with the foundation also express fears that regulation of physicians will “scare them away” from prescribing opiates, and induce “opiophobia” that will harm patients.

Even if the fear of “opiophobia” is legitimate, I have a hard time believing that encouraging doctors to be more conservative in prescribing highly addictive drugs will cause more harm than it will prevent. What pain management doctors don’t seem to realize is that addiction is a distinct disease, and that some symptoms of what they think is “chronic pain” are, in fact, symptoms of addiction. Some patients absolutely do have chronic pain that requires long-term opiate treatment, but I would argue that many more patients have “chronic pain” which is actually chronic withdrawal. I have had more patients than I can count who, after a few days on buprenorphine, tell me that the underlying cause of their opiate use (back pain, joint pain, or other common pain conditions) has disappeared. In these patients, the initial problem that caused them to seek treatment for pain probably cleared up long ago, and that the pain they had been self-medicating was in fact withdrawal.

Patients who are addicted without knowing it, and who self-medicate for withdrawal, are among those most harmed by the APF’s insistence that opioids have “low risk” and must be protected from regulation. These substances are absolutely, unequivocally addictive, and downplaying that risk is an appalling betrayal of trust on the part of the APF and all similar institutions. Whether patients are willing to take that risk is a matter to be decided with their physicians, but that decision cannot be made well if both physicians and patients are assured that there is no risk.

I’ve written before about how more regulation on the prescription of pain pills could very easily decrease addiction (and its associated costs), choke off the supply of narcotics being sold illegally, and improve pain management by not compounding pain with further addiction-related problems. The APF’s stance against such regulation seems to me to be blatantly self-serving, which undercuts their claim to be focused entirely on patient welfare.

The Gold Standard

Posted on December 7, 2011 by admin

On this blog I tend to talk about opiate addiction more than any other kind, mostly because opiate-addicted patients are the ones I most often see and treat. Of course, we can still learn from other kinds of addiction — in fact, if we really want to look at a powerful model for the disease of addiction, we need to look back at the gold standard: smoking.

There is very little actual advantage to smoking a cigarette, not in the way that there is for other drugs. It does not give you a lasting or euphoric high; it is not a great way to party or relax after hard week at work; it does not have nearly the psychoactive effect of any other typically abused drug. It can be a social activity, but more and more restaurants, hotels, and even public parks and bars have been banning smoking in recent years; smoking is becoming less and less feasible as a means of social connection, like alcohol is. The nicotine itself, apart from its addictive effects, provides a minimal amount of relaxation or stimulation (depending on how it is smoked) that literally lasts only for seconds.

So why do people smoke, and why do they continue to smoke after it becomes costly, inconvenient, and even life-threatening? The answer, of course, is because of nicotine’s addictive effect on the brain’s reward system. People become so addicted to this short-lived effect that they find it necessary to reproduce it hundreds of times per day. A one-pack-per-day smoker is smoking 20 cigarettes each day, perhaps taking between 10 to 15 puffs per cigarette. That equals 200 to 300 hits per day. The effect on the brain of a single hit of nicotine lasts about 4 seconds. 250 hits per day gives 1000 seconds, or slightly less than 17 minutes of nicotine-stimulated brain activity per day. If someone smokes their one pack a day over a typical 16 hours of being awake, each day they are providing nicotine to the brain for only 2% of their waking hours.

Now think about the cost that society and individuals pay for this addiction in years of life lost due to cancers, chronic lung disease, premature heart disease, etc. On average, smokers die 13 to 14 years earlier than nonsmokers. (You can check out some of the tobacco statistics here.)

Smokers are exactly like anyone addicted to any other drug. They aren’t weak, and they aren’t bad people. To non-addicts, it looks like they are constantly, continuously making an irrational choice, but that’s not the case. Their brains have simply become so dependent on those little bursts of nicotine that it is incapable of putting any long-term health or financial consequences before getting the next hit. The very fact that it’s not so obviously harmful, and that it generally takes years to start showing negative health consequences, allows smoking to escape a great deal of the stigma of other addictive drugs. While it’s true that no addict should be stigmatized for their illness, that also doesn’t mean that smoking should get a pass, or be considered ‘not a problem’, when it can be just as powerful a controlling force in an addict’s life as a stronger opiate.

Cigarette smoking is less extravagantly destructive than heroin or methamphetamine, but it follows the same pattern of all other addiction. These are all different forms of a single disease. Our current scientific advances in the treatment of addiction notwithstanding, the best way of dealing with addictions is still with education and prevention, so that they never start in the first place.

Thanksgiving Thoughts

Posted on November 25, 2011 by admin

The blog is updating a little late this week because of the holiday. I hope that you all had wonderful Thanksgivings, and that you got the opportunity to spend time with your families and think about the things in life you’re thankful for. Though eating and shopping have become large traditional parts of this weekend, it’s always worthwhile to stop and reflect on what we are grateful for in our lives.

It’s always difficult to feel thankful when you’re suffering from a long-term illness, and the disease of addiction has a uniquely destructive effect on the lives of those it afflicts. The behavioral and psychological aspects of the disease often lead to broken families, as theft, lies, and betrayal take their toll on relationships with parents, spouses, and children. The financial drain of drugs and treatment can prevent addiction patients from being able to provide a large Thanksgiving feast. It’s a long, hard road to emerge from this disease, and it’s difficult at any point to feel particularly thankful for the troubles it brings.

But there are still reasons to be grateful. We now live in one of the few decades in history where an effective treatment for addiction is generally available. That treatment is not a cure, and it is not as widely available as I would like, but there is more hope of a normal life for addicted patients than there has ever been before. With more understanding of and education about this disease, the family members of addicted patients can learn to help their suffering loved ones and make treatment easier. And it is my sincere hope that understanding and treatment will only continue to improve.

Thanksgiving is now over, but I think it is worthwhile to remember what we have to be thankful for every day of the year. I am thankful for the ability to help my patients, and I will continue to reflect on that opportunity on Monday. Until then, I wish you all happy holidays.

Good Drugs and Bad

Posted on October 25, 2011 by admin

I’ve talked before on this blog about the fear patients and physicians often have that treating addiction with buprenorphine is “only trading one addiction for another”. While this might technically be true, it’s a phrase that ignores the huge material and medical improvements to patients’ lives that buprenorphine gives by eliminating the high-withdrawal cycle of active drug abuse. (Not to mention putting a stop to the destruction of the brain and other organs by toxic substances.)

The problem here is that there are a lot of fine distinctions between the normal course of the disease of addiction and the controlled, symptomless “addiction” of buprenorphine, but people who don’t know a lot about the field of addiction medicine aren’t likely to see that. And it’s mostly people who don’t know about addiction medicine — voters, lobbyists, abstinence care providers — who control the way it is seen by the public and dealt with by the law.

There is a similar confusion I often hear about “prescription drugs”. Lots of people know that misuse and overdose on prescription narcotics cause a huge number of deaths every year. There’s a general sense that we have to reduce the number of drugs being prescribed, because more drugs leads to more death. So when physicians like me who realize the need for medication treatment of addiction try to push for the power to prescribe more medication, we are met with resistance from the belief that prescription drugs kill people, and are bad.

While this is an understandable response to the amount of drug deaths we see yearly in the U.S., it is also an overgeneralization that actually does a great deal of harm to everyone involved. It’s true that many kinds of prescription medication, especially narcotics, can be and are abused. It’s true that patients often scam multiple doctors to get prescriptions for these kinds of medications, and that the best way to cut down on their abuse would be to keep a stricter watch on prescriptions and reduce the number of prescriptions given out. So how can I advocate for wider prescription?

There are several very important distinctions that “prescription drugs” fails to acknowledge. The first, and maybe most important, is that it’s virtually impossible for a patient who is already addicted to opiates to lethally overdose on buprenorphine. Once the opiate receptors are fully saturated, taking more buprenorphine will have no appreciable effect. So while it can certainly be diverted to the street and shouldn’t be given out indiscriminately, buprenorphine is infinitely less dangerous than ordinary prescription narcotics and benzodiazepenes. It also carries fewer health risks in and of itself than many stronger opiates.

Secondly, buprenorphine by definition is a medication used to treat addiction, and therefore would only be prescribed by physicians who are knowledgeable about treating the disease of addiction. It’s my opinion that the root of our prescription painkiller problem today is physicians who don’t know or don’t understand the addictive effects of the medications they prescribe, and aren’t willing to deal with the addictions of their patients. Over-prescribing of opiates and narcotics has led to a rise in the incidence of the disease of addiction, and now new, different medications are required to treat this disease that we created.

A good way to think about this problem is by analogy to viruses and vaccines. It seems non-intuitive at first that exposure to a virus could help you avoid the problems caused by that virus, but that’s exactly how vaccines work. It’s also how buprenorphine works; by introducing a safer, more predictable, more controllable version of the problematic prescription drugs, we can prevent and alleviate the problems they cause, from crime rate spikes to the deaths of celebrities.

There is no such thing as a “good drug” or a “bad drug” — all drugs can be good when they’re given and taken in the right circumstances, and all drugs can be bad when they’re abused. Saying that all prescription drugs are bad is a shortsighted assumption that can do long-lasting damage to patients and physicians alike.

Simple Truths

Posted on October 11, 2011 by admin

The truth is never simple.

This week, I discovered that one of the patients in my office is a drug dealer. While she is seeing me for her opioid addiction and getting buprenorphine prescriptions, she continues to see her regular doctor to get prescriptions for her narcotic pain pills. She then sells the narcotics on the street. She is defrauding her insurance company, lying to multiple doctors, and enabling other addicts by illegally making prescription narcotics available to them.

She is also a 76-year-old grandmother, widowed, and barely able to walk due to scoliosis — the reason she was taking addictive prescription narcotics in the first place. She lives with her son, who helps to take care of her. Both this woman and her son are on Medicare and disability, and her profits from selling narcotics are a significant part of their income and is absolutely essential for them to make ends meet.

Selling drugs is criminal and morally wrong; in addition to harming those who buy the drugs, it has long-lasting consequences on the entire healthcare system. “Diversion” — when prescription drugs are sold on the street rather than being taken as prescribed — is a major issue in pain management and addiction right now, and it’s one of the reasons that many physicians are so reluctant to treat addicted patients.

The selling of drugs illegally also reinforces the connection between substance addiction and crime; it familiarizes younger addicts with criminal behaviors, but also casts undeserved shame on people who have never committed a crime but are addicted to prescription narcotics due to illness and injury, like this woman herself.

Clearly what my patient is doing is wrong — but saying she is “weak”, or a bad person, becomes difficult. Here we have a woman who is desperate and disabled, just trying to survive. The Occupy Wall Street movement which has recently spread throughout the country is teaching us just how much desperation and anger exists among people trapped in poverty and unemployment, and how desperate situations can lead to desperate acts. The Occupy movement has been ridiculed for not having a clear agenda or offering solutions to America’s financial problems, but this is foolish, and it’s a distraction from the really important thing; that it doesn’t matter whether Occupy Wall Street has a clear agenda. What matters is that it is happening. People are spontaneously gathering all over the country to express their frustration with the economy. That this is happening at all is a clear sign that this country’s social, economic, and medical systems are massively, disastrously broken.

My patient is not connected to the Occupy Wall Street movement, except for the fact that her situation is a symptom of a massively broken system. Just the fact that she is forced to sell her pain pills in order to make ends meet is a sign that something has gone terribly wrong in the Social Security systems meant to keep her out of poverty, and the medical systems that are meant to effectively manage her treatment.

Her terrible situation does not excuse her from the responsibility of the harm she’s caused by selling illegal drugs. All talking about it can do is help others understand the root of the problem, which is the only way we as a society might have a hope of solving it. And if nothing else, this goes to show just one more way in which the public, “commonsense” perception of drugs, drug addicts, and even drug dealers is far too simple, divided, and prejudiced to approach the deeply complicated truth.

Self-esteem and Treatment

Posted on October 4, 2011 by admin

Addiction treatment is often a very turbulent and even painful period in a patient’s life, for reasons that may or may not be directly connected to their treatment. Often patients are driven to seek treatment by a traumatic event in their lives — the death of a loved one, the “intervention” of friends and family, or legal troubles that require them to get “clean”. This
is one reason why my office will recommend counseling to those who want it, since pure medical treatment of the disease sometimes leaves behind emotional and interpersonal issues in a patient’s life that should be addressed.

Every patient’s life is different, but one problem that I see many of my patients wrestling with a lack of self-esteem. If it seems odd that self-esteem should be an issue in addiction treatment, keep in mind that, no matter what kind of treatment is used, overcoming addiction is often a long and arduous process. Even with medication — the kind of treatment that causes the least physical suffering — an addiction patient often has to
adjust their life in major ways; whether it’s finding a new drug-free social circle or dealing with the effects their illness and treatment are having on friends and family, the challenges of addiction treatment can be ongoing and severe. Without some belief in their own strength and ability to cope, some patients can find it next to impossible.

Unlike removing their cravings for addictive drugs, this isn’t a problem I can easily solve for my patients. But it’s clear to me that something needs to be done to help give addiction patients more faith in their own ability to manage their health and cope with the hardships of treatment, they need to be empowered — the same sort of general encouragement that is often available for people recovering from other diseases, like cancer, or from major surgery. It is recognized in these areas of medicine that optimism and self-esteem are valuable tools in recovery, and they are encouraged by medical personnel and by friends and family. In addiction this, like so many other aspects of care, is largely ignored, and many treatment providers still try to shame patients out of their desire to use, which only makes things worse. A person suffering from addiction will most likely try to eliminate feelings of shame and guilt by relapsing to their drug of choice, not by pulling themselves up by their bootstraps to do a better job.
Building self-esteem and self-empowerment in this patient population is a complicated and delicate process. It is best accomplished after patient’s cravings and withdrawal symptoms have been treated with medications as the relief of these symptoms will at least give patient the ability to refrain from using. Expecting patients to refrain from using in the face of intolerable withdrawal symptoms will only expose them to another potential
failed attempt at changing their lives and will continue to pile on the shame, guilt, and feelings of helplessness and worthlessness. The current most commonly relayed message to those suffering from the disease of addiction by most treatment programs based on 12 step phiolosphy is still shame, guilt, and helplessness. These messages to those who are addicted must stop before we can make significant progress in treatment. As I’ve said a thousand times before, addicts are sick, not evil; and sick people deserve
treatment, not punishment.
As a physician, I sometimes find it difficult to walk the thin line between encouraging my patients to think positively about the future and giving them false hopes about what addiction treatment is currently capable of. I am also mostly powerless to help them with the consequences of bad decisions in their lives, and the patterns of bad decision-making that may have accumulated over the years of their addiction. Nonetheless, as people with a serious medical condition, addiction patients deserve the same encouragement that cancer patients routinely receive; that they are stronger than their illness, that they can beat their condition and return to their normal, healthy lives.