Now What To Do: For The SUD Sufferer
Now That I Know About Substance Abuse, What Should I Do?
Gene Gilchrist
Louisville, KY
So far, we have discussed that the image of the alcohol or drug abuser as a street person is skewed. Hopefully, you now know that alcohol and other drug use issues occur over a continuum of unfortunate to tragic outcomes. You have made a good, personal, self-assessment or faced the reality about your loved one. There is a problem. Now what?
First, let’s take the case of your self-assessment. Congratulations. You have done the hardest part. According to a study by the National Institutes for Health [1], “Researchers frequently conceptualize drug and alcohol addictions as disorders of denial, dishonesty, and self-delusion, and believe effective treatment should confront these deceptive tendencies”. In lay terms, Very Well Mind [2] defines denial as, “a state where you deny or distort what is really happening and …. a powerful coping mechanism to delay facing the truth.” According to that source, denial takes the form of Minimizing (it's not that bad), Rationalizing (I earned a reward for … fill in the blank), and Self-Deception (convincing yourself that things are fine). Denial is very common (and not just in matters of substance abuse) and is the most frequent barrier to getting well. You have that part done. Now what?
To start, and most importantly, please know that substance use disorder is not a personal or moral failure but a treatable, medical condition. The National Institutes of Drug Abuse (NIDA) [3] notes that “research on the science of addiction and the treatment of substance use disorders has led to the development of research-based methods that help people to stop using drugs and resume productive lives, also known as being in “recovery”. People often want to know if substance use disorders can be cured. Again from NIDA, “like other chronic diseases such as heart disease or asthma, treatment for drug addiction usually isn't a cure. But addiction can be managed successfully.” Wading into this discussion is filled with conflicting views and treatment recommendations but substance use disorder, and the far end of the progression, addiction, can be treated.
There is a subtle but important point in this explanation. Substance use disorder, addiction included, is a disease listed as are heart disease, asthma or cancer. The American Medical Association defined addiction as a disease in 1956. Brain research has further defined addiction as a disease of the brain where physical connections are made in the pleasure centers. Further, like other chronic diseases including adult onset diabetes for example, addiction is subject to ongoing treatment not a one-time application. There are diseases that lend themselves to a one time treatment. Some cancers, prostate for example, can be treated by radiation or surgery. The disease state is removed, hopefully not to return. Other diseases like adult onsite diabetes do not lend themselves to a one time application but continuing treatment usually by pharmaceuticals and behavior changes. This is an important and buoying point. Too often addiction is treated as a penance for moral failure. You may take a better view in that addiction is a disease treatable like other, chronic diseases.
The popular view of treatment involves “rehab”. Such programs usually involve one to six months of residential treatment focused on abstinence, twelve step approaches, cognitive behavioral therapy, sometimes physical health assessments and treatment, nutrition, family interactions, and mental health assessments. These programs run a range from Medicaid or philanthropically supported programs often in urban areas, to very expensive, retreat-like programs, usually self-pay and often in suburban to rural areas. These facilities and programs were developed when the most severe cases were the only ones treated but have evolved to treat those who have not traversed so far down the addiction curve.
In the latter part of the twentieth century treatment began to recognize “high bottom” alcoholics and addicts who had not progressed so far down the curve but have had an experience that caused them to seek treatment. It is still often said that people don’t seek treatment when they “see the light” but when they “feel the heat”. Treatment professionals have evolved their thinking to consider a range of stages of substance use disorder that sought to treat people at a variety of points of progression of this disease. The point is that the popular perception of rehab as the first stage of treatment while still appropriate in many cases is dated and does not reflect a wide variety of circumstances.
The commonly held view is that the history of treatment in America started with associations mostly for Native Americans in 1750, with inebriate houses supplanted by mental hospitals, all being overshadowed by Alcoholics Anonymous in 1935. The Temperance Movement in the 19th century employed “The Pledge” where individuals vowed to refrain from alcohol usually done in a public setting. The Pledge evolved and, in some instances, became a private commitment to God, one’s spiritual advisor, and one’s self. Certainly, there are many who stopped consuming alcohol including getting through the initial withdrawal phase using The Pledge. Again, the point is that rehab is not always the first step to recovery in every circumstance although certainly appropriate in some circumstances.
In historic perspective the most successful approach, Alcoholics Anonymous and its various offspring, make it quite simple. Their treatment is based on abstinence, and it certainly would seem clear that abstinence will avoid getting high and/or drunk. Abstinence is under much pressure as the treatment approach today because it is said that this barrier is too high to get people into recovery. Given that the twelve step approach (often combined with cognitive behavioral therapy) is estimated to have been successful for under 10% of the target population there seems compelling cause for critique. However, abstinence is not the social death sentence many assume. In America at least 30% of adults do not use alcohol, roughly 16% of Americans use marijuana recreationally, and less than 8% use other narcotics. Abstinence from alcohol is hardly unusual and abstinence from narcotics is the norm not the exception. If those numbers surprise, perhaps you may reflect that your drinking or drug behavior has led you to spend time with those people who do the same rather than those who do not.
One must grant that the twelve steps and the abstinence model were developed in 1935 and focused on people who had “hit bottom”; those so desperate, so far down the scale, that abstinence was the only logical approach. In order to start down the road to abstinence, AA proposes the first three “steps” (you can substitute drugs for alcohol):
1. Admitted that we were powerless over alcohol (drugs), that our lives had become unmanageable.
2. Came to believe that a power greater than ourselves could restore us to sanity.
3. Turned our will and our lives over to the care of God as we understood Him.
There are all kinds of issues here, especially as societal views have evolved since 1935. In a nation that is now approximately 25% secular the use of God is a challenge for many. Referring to God as masculine is an issue for others. Powerlessness runs counter to rugged self determination that underpinned the country perhaps more so for men. Some balk at the implications of being restored to sanity though anyone who practiced self-deception might have scant claim to this complaint. These are all opportunities for avoidance of the most successful approach to date. At its core, the steps say, “I can’t handle this obviously, others have, I’ll try what they have done.” In these terms the first three steps seem natural and manageable.
The core of the twelve step approach is, of course, group or community, mutual support. For those who have reached this place of self-assessment, that there is a problem, this approach has the benefit of 85 years of testing and a cohort of an estimated 3 million Americans who will attend a twelve step meeting today as a support network. Community mutual support, usually practiced through meetings of voluntary adherents, has been adapted to many circumstances from addiction to weight management to breaking unhealthy habits and includes programs for the codependents such as Al-Anon. It is increasingly common for people to use twelve step programs in conjunction with treatment by alcohol and drug clinicians. In very recent years certification has been extended to Peer Counselors. Peer Counselors are people in long term recovery who share their experience, strength and hope after clinical training. This combination has shown early promise. Most of this approach, twelve step communities perhaps combined with professional counseling, can be and often is done on an outpatient basis.
SMART Recovery (Self Management and Recovery Training) was established in the U.S. in 1994 to meet the increasing demand for evidenced based and secular alternatives. In some ways similar to twelve step programs, SMART Recovery strives to be an evidenced-informed method grounded in Rational Emotive Behavior and Cognitive Behavioral Therapy designed to:
· Build and maintain motivation
· Cope with urges and cravings
· Manage thoughts, behaviors and feelings especially as related to substance abuse
· Live a balanced life
SMART programs and groups typically come into play after clinical treatment (residential or outpatient) and focus on abstinence.
Although there have been practicing, private counselors with a range of training for decades, recently there is increased interest in research applied to various approaches for substance use disorder. The NIDA article cited previously lists several such approaches including:
Cognitive-behavioral therapy often helps clients recognize, avoid, and cope with the situations in which they are most likely to use alcohol or drugs (this has been in use for some time)
Contingency management uses positive reinforcement for remaining drug free and for persisting in foundational behaviors such as twelve step meeting attendance
Motivational enhancement therapy uses strategies to make the most of people's readiness to change their behavior
Family therapy helps people with drug use problems, as well as their families, address influences on drug use patterns and overall family functioning
Twelve-step facilitation (TSF) is individual therapy to prepare people to become engaged in 12-step mutual support programs.
NIDA also discusses the increasing use of several types of medications that may be useful at various stages of treatment to help a patient stop abusing drugs, stay in treatment, and avoid relapse. Methadone was discovered as a pain treatment in the 1930s and was adopted for use in treating opioid use disorder (then primarily heroin) in the United States in the 1950s. Since that time, the numbers and purposes of these drugs in Medical Assisted Therapy (MAT) has grown. Typically, the goals of MAT include:
Treating withdrawal. Managing various physical and emotional symptoms, including restlessness or sleeplessness, as well as depression, anxiety, and other mental health conditions and physical withdrawal symptoms that sometimes make it hard to stay off the drug of choice
Staying in treatment. Help the brain adapt gradually to the absence of the drug. These treatments act slowly to help prevent drug cravings and have a calming effect on body systems
Preventing relapse. Reducing relapse. Knowing that stress cues linked to the drug use (such as people, places, things, and moods), and contact with drugs are the most common triggers for relapse, MAT is focused on interfering with these triggers to help patients stay in recovery.
Harm Reduction is a very active discussion in America today. A full discussion of that topic will take much more time than appropriate or necessary here. The base notion is that there are those people abusing drugs and alcohol, and many addicted, for whom the goal of abstinence is simply unrealistic due to a wide range of circumstances and conditions. Certain branches of harm reduction suggest that traditional treatments have racial or gender biases that make illegitimate those activities that have been practiced for centuries such as drug use and sex work. The public health perspective might argue that the goal of getting every addict clean and sober is both unrealistic and beyond the available resources, and that reducing the instance of drug and alcohol use is a more realistic and achievable goal.
Applied to the individual, harm reduction may suggest that one can continue to use alcohol and drugs. No doubt there comes a point in the physical, emotional and psychological progression of substance abuse and addiction where this is, simply, not a realistic goal. However, there are approaches currently underway that suggest that those who have not reached this stage, and some of those who have, can manage their alcohol and drug use.
It is very common for people who struggle with alcohol or drug use to ask whether or not they really have to stop forever. Can they learn how to drink or use in moderation? For years, the answer was assumed to be no, there is no room for “just one drink.” Recently, however, programs usually called Moderation Management aim to allow for a certain level of controlled drinking and drug use. To be clear, the evidence is that these programs are not meant for everyone.
Moderation Management programs often involve a 30-day period of abstinence during which strategies for identifying and controlling triggers, adopting other healthy behaviors and activities to replace drinking, and managing future moderate drinking behaviors are developed.
Moderation Management has been found most successful for those who have experienced problems with drinking or drug use but who do not meet the criteria for substance use disorder. Many people who struggle with heavy or unhealthy alcohol or drug use or substance use disorder and who try moderate use come to realize that abstinence is the only option for them. Usually, they experience symptoms of withdrawal including typical psychological and physical symptoms. Successful Moderation Management is not done alone but with a professional clinician and most often involves a variety of strategies such as mindfulness and practicing ahead of time about various social circumstances.
The caution about Moderation Management is obvious. It is very common for people with a history of alcohol and drug use and abuse to want to continue. One must ask about the source of that desire. After recovery from extensive burns from a crack pipe incident Richard Pryor mused in a comedy routine about how his crack use went from him telling the pipe when to use to the pipe telling him when to use. In fact, on the AA Agnostica web site they tell “The Sad Tale of the Founder of Moderation Management”. That founder, Audrey Kishline was unable to control her drinking after founding Moderation Management, killed a young woman in a head-on auto crash while intoxicated, spent time in prison and never learned to control her drinking. Certainly, there are people who have learned to drink or use drugs successfully. However, given that abstinence is a certain treatment, achieved by millions since 1935, and not the social death sentence portrayed, one has to ask about the underlying motivation to pursue Moderation Management and why it would be a preferred course of action. Further, there is scant clinical research to support Moderation Management as a successful approach across the population of people with substance use disorders.
There are also MAT approaches that are being used to allow continued use. The Sinclair Method is being used for the treatment of alcohol use disorder to help people to continue to drink. In the 1960s, John Sinclair began research into the use of naltrexone to treat alcohol use disorder. Naltrexone is one of the drugs used in MAT often for opioid use disorder. This approach involves taking naltrexone before people drink. These medications minimize the endorphin release in the brain that usually accompanies drinking. Because this makes drinking less pleasurable, people are less likely to crave alcohol. There are reports from certain studies that at the end of four to six months of treatment with the Sinclair Method, 80% of people who had been overusing alcohol were either drinking moderately or abstaining entirely.
Caution is warranted here. First, it appears that the best review of clinical trials comes from Dr. Sinclair himself. In “Evidence about the use of naltrexone and for different ways of using it in the treatment of alcoholism” [4], Dr. Sinclair reviews several studies including preliminary clinical trials. This writing does not, per se, reflect self interest issues but one should be careful.
Second, the use of naltrexone is not risk free. The usual, listed side effects include:
Headache
Drowsiness
Nausea and vomiting
Dizziness
Reduced appetite
Joint pain
Cold symptoms
Sleep disturbances
Toothache
Pneumonia
Depression
Serious allergic reactions, such as trouble breathing, chest pain, or swelling of tongue, mouth, face, or eyes
Liver damage as indicated by severe stomach pain, yellowing of the whites of the eyes, extreme fatigue, or dark urine
Severe reactions at the injection site, such as lumps, blisters, or open wounds
Further, as naltrexone is metabolized in the liver with the potential for liver damage, as is alcohol indicating that some liver damage may have already occurred, there is ample reason to be concerned about their use together.
So, what does this all mean for you? If you recognized the symptoms of prostate or breast cancer and later received a diagnosis, you would visit a professional, most likely an oncology physician. That doctor may tell you that your case as diagnosed does not have options other than treatment. Your treatment options may be limited if the disease has progressed, or you may have a choice of surgery, recently gene therapy, radiation and/or chemotherapy. In the case of prostate cancer, you may have the option to wait and watch or even do nothing. Regardless of what you hear from the doctor, you may walk away and do nothing. If that is a conscious choice, then so be it. If it is denial, then that is a psychological issue and likely not a conscious choice. Regardless, the outcomes of inaction will be bad for you and your loved ones (and expensive for the rest of us who pay health insurance premiums).
The treatment for substance use disorder is similar. If you have considered the evidence and have a concern that you have an alcohol or drug problem, then you have options. You may see your spiritual advisor and take The Pledge. You may attend a twelve step meeting (AA and NA have online lists of their local meetings). If you choose one of these options, then be careful not to isolate yourself. It is easy to succumb to the stigma around addiction and think even wish that you can do it alone. There are those who do. They are likely few, and they are foregoing available support.
Far better to see a professional and honestly discuss what is going on for you. These professionals advertise and are easy to find. You might discuss this with your primary care physician (s/he knows about your issue already we promise you) who will have trusted referrals. Once working with a professional, be honest and thorough from the start. These professionals are bound by ethical and legal responsibilities to maintain your confidence. You may choose to arrange to pay the bill yourself in order to avoid billing your insurance company. This might be good advice if insurance is through your employer.
A few closing thoughts.
Inaction is no more called for here than in the case of cancer. They will both cause you and your loved ones great harm and decrease your life span. In the case of addiction, you may also endanger others such as through workplace or vehicular usage under the influence
Stigma is real but vastly diminished. Just check the TV for all the people who talk about their recovery publicly. Attend an AA or NA meeting. It is likely that there will be someone there you already know, like and respect
Sorry to burst your bubble, but lots of people know about your drinking and/or drug use already. Very few people who get to this self assessment successfully hide their behavior. Would you rather be known as the addict or a person in recovery who dealt with their disease? Better to get at this issue now
In a similar vein, it is very unlikely that people who ask themselves this question are simply suffering from hypochondria. If you are asking yourself this question it is highly recommended that you take some action even if that action does end up suggesting that you are overly concerned and there is no problem
While abstinence is considered unacceptable by far too many, the risk of continuing might be more unacceptable. By some estimates as many as 30% of Americans do not use alcohol and very few people care if you do or don’t. Less than 15% of Americans use any drug including cannabis. Estimates are that 7% of Americans use other Schedule I (street drugs) narcotics. Abstinence, once considered a penance for immoral behavior, is rather treatment for a disease and more the norm among Americans than an aberration. On the other hand, if you try to continue to use and are not successful, then the consequences are dramatic and not just for you but others and that is unacceptable.
What about those among us who have concerns about a loved one? Next, advice for the family.
Gene Gilchrist
[1] “Coming to Terms with Reality: Predictors of Self-Deception Within Substance Abuse Recovery, Jospeh Ferrari, Ph.D. et al
[2] “Addiction and the Power of Denial”, Elizabeth Hartney, BSc, MSc, MA, Ph.D., December 2020
[3] “Drugs, Brains and Behaviors: The Science of Addiction: Treatment and Recovery” National Institute for Drug Abuse, July 2020
[4] “Evidence about the use of naltrexone and for different ways of using it in treatment of alcoholism”, John David Sinclair, Alcohol and Alcoholism, Volume 36, Issue 1, January 2001
