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Evidence-Based Addiction Treatment Explained

This is an interesting article I found on: www.psychcentral.com

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12-step programs are an incomplete approach and do not meet the requirements for evidence-based treatment because they lack biomedical and psychological components, and they use a one-size-fits-all approach.

When looking for treatment for addiction, there is a lot of information out there and countless opinions. Friends, family, doctors, researchers, and people in recovery all have their own beliefs about what you need to do to get well.

Unlike in other areas of healthcare, addiction treatment is often deemed “effective” based on anecdotal reports. In fact, most people who seek or are forced into treatment do not receive health care that is aligned with evidence-based practice.

A frequently-cited definition comes from a 1996 article in the BMJ Medical Journal: evidence-based “means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” Other definitions also include the patient’s individual circumstances, preferences, expectations, and values.

These variables are not necessarily constant, and there is no one-size-fits-all solution; any list of evidence-based treatments is going to include a wide variety of approaches.

What Is Addiction?

In the United States, addiction is still treated more as a crime than as a chronic illness or disorder. Until that perspective changes, treatments will not meet their full potential and will not be as effective as they could be. Addiction, or substance use disorder (SUD), is a chronic medical condition that has remissions, relapses, and genetic components.

Are Relapses Normal?

A relapse is not a failure but a symptom. The brain of a person with SUD has gone through neurobiological changes that increase the risk of relapse because the damaged reward pathways stick around much longer than the substances stay in the body. Stressful events and other painful life experiences can trigger that maladaptive coping mechanism and cause a relapse.

For other chronic illnesses we would consider a relapse to be an unfortunate symptom of the disease, and we might call it a recurrence instead of a relapse. When successfully managed, the condition is considered to be in remission. Remission is a term that is relatively new in addition treatment; substance use disorder was not always believed to be a disease but rather a moral failing and a problem of willpower. We now understand that addiction is a chronic medical condition and that remission is the goal of treatment. Remission, as defined by the American Society of Addiction Medicine, is “a state of wellness where there is an abatement of signs and symptoms that characterize active addiction.”

What Is Successful Addiction Treatment?

Let’s take a look at what it means to have an effective treatment outcome in terms of addiction. The primary goal is usually abstinence or at least a “clinically meaningful reduction in substance use.” To measure effectiveness, we must look at how and if treatment improves the quality of life for the patient. Improving quality of life is the aim when treating all chronic conditions that have no cure.

Evidence-based therapies do not support the notion of “hitting bottom.” As with any chronic disease, early intervention is going to provide the best outcomes.

Even more effective than early intervention is prevention because SUDs are both preventable and treatable…

Find out more about evidence-based treatment — including different therapies, holistic care, and whether 12-step programs are evidence based — in the original article What Is Evidence-Based Addiction Treatment? at The Fix.

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Should Mental Health Determine Pain Treatment Options?

This is an interesting article I found on: www.psychcentral.com

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Patients with a mental health condition might have a hard time accessing opioids for pain relief, while patients with unexplained pain are often referred to psychiatric care, which does little to alleviate their symptoms. Finding treatment can be frustrating and humiliating.

Four years ago, Dez Nelson’s pain management clinic demanded that she complete a visit with a psychologist. Nelson was surprised, since she had no history of mental illness, but she didn’t feel that she could push back on the request.

“Of course I said okay — I didn’t want to lose my treatment,” Nelson told The Fix. “I was not happy about it, but I did it.”

Nelson, 38, went to the appointment and had a mixed experience with the psychologist. She hasn’t been back since and the pain clinic hasn’t asked her to visit a psychologist again. Still, Nelson said that the experience highlighted — yet again — the discrimination pain patients face.

“It was a condition of my continued care,” she said. “It seemed like they’re bringing it up in a beneficial light, as part of a multi-pronged approach to pain care. But I don’t think [mental health treatment] should be forced on a patient who doesn’t think they need it.”

Chronic pain and mental illness are among the most stigmatized conditions in modern medicine. The conditions frequently intersect and change the way that patients are cared for and treated. Patients who have a mental illness might have a hard time accessing opioids for pain relief, while patients with unexplained pain are often referred to psychiatric care, which does little to alleviate their physical symptoms. At the same time, research suggests there is a strong connection between mental health and pain: depression can cause painful physical symptoms, while living with chronic pain can cause people to become depressed.

All of this makes treating chronic pain and mental illness complex and frustrating for doctors and patients alike.

A Mental Health Diagnosis Affects the Way Your Doctor Treats You

Elizabeth* is a professor in her mid-thirties who had undiagnosed Lyme disease for eight years. Her Lyme contributed to the development of an autoimmune disease that has led to widespread inflammatory and nerve pain throughout her body. Elizabeth also has bipolar disorder. Despite the fact that she has been stable on medication for a decade, her mental health diagnosis complicates her pain treatment.

“Doctors’ demeanor changes when I tell them my medications. When I say I have bipolar disorder, it’s a whole different ballpark. To them that’s clearly a risk factor and red flag for drug abuse,” Elizabeth said.

Opioids are one of the few treatments Elizabeth has found that works to alleviate her pain. But she also takes benzodiazepines on an as-needed basis to control her anxiety (usually once a week). Even though Elizabeth is well aware of the risk of combining the two medications and knows better than to take the two pills together, doctors refuse to prescribe both. They don’t seem to trust her not to abuse them.

“I could tell them that I wouldn’t take them together. But that’s not a valid choice,” Elizabeth said.

While doctors were extremely cautious about this drug interaction, they didn’t focus on another drug-related risk: medications that are used to treat nerve pain can cause adverse reactions in patients with bipolar disorder. No one warned Elizabeth of this danger, and she ended up being hospitalized for psychosis after a long stretch of stability.

“The doctors didn’t talk about it because it’s just a side effect, not a liability concern,” she said.

On the flip-side, Elizabeth has experienced psychiatric providers who were skeptical of her pain diagnosis.

“They wrote in my chart that I had a delusion that I had Lyme disease,” she said…

Find out more about the complications of treating pain in patients with mental illness, the dangers of confusing one’s body with one’s psyche, and the “time bomb” of untreated pain in the original article Should Your Mental Health Determine How Your Pain Is Treated? at The Fix.

Should Mental Health Determine Pain Treatment Options?

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Pregnancy and Addiction: Overlooked and Undertreated

This is an interesting article I found on: www.psychcentral.com

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If one needs proof that addiction is a disease and not a moral failing, look into the eyes of a woman who knows her behavior is harming her baby but still can’t stop.

With one in three individuals with opioid use disorder passing through the criminal justice system annually, court dockets across the country are overflowing with cases of illegal behavior fueled by addiction. Though such cases wrangle with the complexities of punishing individuals afflicted with what is increasingly seen as a disease that erodes free will, they are the bread and butter of the legal system.

However, the recent Pennsylvania Supreme Court case known as In the Interest of L.J.B. adds another level of intricacy to the court’s decision-making process. The question asked in the case—Does drug use during pregnancy constitute child abuse?—is unpleasant to contemplate, but it is one of absolute importance.

The defendant in the case, a woman referred to as A.A.R., tested positive for illicit opioids, benzodiazepines, and marijuana when she gave birth to her infant, L.J.B., in January 2017. L.J.B. then required 19 days of inpatient treatment for drug withdrawal and was placed in the custody of Children and Youth Services, which alleged that her mother’s drug use during pregnancy was child abuse. On December 28, in a 5-2 decision, Pennsylvania’s Supreme Court ruled in favor of L.J.B.’s mother, stating that Pennsylvania’s child abuse law clearly excludes fetuses in its definition of a child. While the issue may be settled in Pennsylvania, there is little doubt that similar cases will be heard across the country amidst the opioid epidemic.

Pregnant Women with Opioid Addiction—Overlooked and Undertreated

The case of L.J.B. and her mother has drawn national attention to women who simultaneously carry a child and the burden of an addiction—a group that has often been overlooked or ignored in the national discussions about the opioid epidemic. Few individuals in our society bear such a stigma as these women. As an addiction psychiatrist, I’ve heard harsher judgment passed on these patients—even from fellow healthcare workers—than on any others. This stigma permeates our medical and legal systems, creating dire consequences not only for these women, but also for their unborn children.

Pregnancy is unparalleled in its ability to motivate women towards healthier behavior, but approximately four percent of pregnant women still use addictive drugs. When I’m asked to evaluate a woman who is pregnant, I know her disease is severe before I’ve even laid eyes on her. If one needs proof that addiction is a disease and not a moral failing, look into the eyes of a woman who knows her behavior is harming her baby but still can’t stop. There is no better example of the ability of a chemical to overpower the deepest-rooted human instincts.

A recent report released by the CDC revealed that opioid addiction among women in labor quadrupled from 1999 to 2014, signifying the need for immediate action. Opioid addiction during pregnancy can create many problems for mother and child, including preterm labor, neonatal abstinence syndrome, and even fetal death. Tragically, pregnant women with addictions are less likely to receive prenatal care.

Aware of society’s disdain, many don’t want to be stigmatized at the doctor’s office. Some mothers-to-be can’t even find a physician willing to treat them, and others are afraid of being reported to authorities due to laws that have arisen out of prejudice and misinformation…

Find out more about what Dr. Barnett has to say about how harsh laws can harm the mother and child, how we can help pregnant women with their addictions, and more in the original article Pregnant and Scared to Get Treatment: When Conception Meets Addiction at The Fix.

Pregnancy and Addiction: Overlooked and Undertreated

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Which Should We Treat First: Mental Illness or Addiction?

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Substance use can alter behaviors, moods, and personalities so severely for people with addiction that without specialized knowledge and experience, it’s difficult to determine underlying causes such as mental illness or trauma.

I credit psychological intervention for pushing me into recovery from alcoholism.

Addiction is a mental illness, but is it one that needs to be treated before anything else? Or should we be stopping people from hitting their addiction bottom and helping them recover from their comorbid conditions concurrently?

What Is Addiction?

Before we can discuss treatment, we need to understand what addiction is and how it is defined. The two major guidelines for diagnosing mental health conditions around the world are the DSM and the ICD. The DSM (Diagnostic and Statistical Manual of Mental Disorders) is the standard diagnostic tool for mental health conditions in the United States and often used in North America. The ICD (International Classification of Diseases) is endorsed by the World Health Organization and often used in Europe.

In the DSM-5, substance abuse and substance dependence are combined under the same name of substance use disorder, which is diagnosed on a continuum. Each substance has its own sub-category, but behavioral addiction is also in the DSM-5, with gambling disorder listed as a diagnosable condition. Other similar entries, such as internet gaming disorder, are listed as needing further research before being formally added as a diagnosis. In the ICD-11 there is a subset of mood disorders called “substance-induced mood disorders,” which are conditions caused by substance use. To qualify for this category, one must not have experienced the mood disorder symptoms prior to substance use.

Hypothetically, a person who has alcohol-induced mood disorder might find health with abstinence alone, but substance use disorders do not occur in a vacuum and no one can go through the experience of addiction without it altering their mind and body, sometimes irreversibly. With enough time, substance-induced disorders change the function of the brain and alter emotion regulation. That doesn’t mean that addiction will cause another mental disorder; addiction is a mental disorder.

Not everyone with an addiction is concurrently experiencing another mental disorder. Substance use can alter behaviors, moods, and personalities so severely for people who are addicted that without specialized knowledge and experience, it’s difficult to determine what, if any, underlying cause is responsible for the changes. Drugs, even those that are prescribed and used as directed, can have side effects that seem to mimic the symptoms of other diagnosable conditions. These effects can also appear if a person is in withdrawal. Because of this inability to isolate co-occurring conditions, there was a time when it was popular for doctors and clinicians to first treat substance use disorders before exploring the possibility of other mental illnesses.

That is no longer considered the best approach to care…

So, what is considered the best approach then? Keep reading for more information about therapy to recognize addiction, integrated treatment, the consequences of discriminating against people with substance abuse disorder, and more over at the original article Addiction or Mental Illness: Which Should You Treat First? at The Fix.

Which Should We Treat First: Mental Illness or Addiction?

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The Value of a Relapse

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Utter the seven-letter word relapse in recovery circles and the room grows silent. Why did it happen? How did it happen? How much sobriety did she have? How long did she stay out? If a person had years of sobriety accrued, it is expected that the clock be reset – as if they had never stopped drinking. Call me a rebel, but this is too black and white for my taste. While I realize the need to recognize and commemorate consecutive days of sobriety, recovery from addiction is rarely straightforward or neat. More often than not, it’s a messy, ongoing journey of learning and coping and healing that includes its share of falls. Relapses are a sometimes-necessary part of the adventure. In fact, I’m glad mine happened. Here’s why.

My five-day experiment

The summer before last I experimented with alcohol after 28 years of sobriety. Having quit drinking before I was legal, I always questioned whether or not I was truly an alcoholic. Maybe, I thought, my binge drinking between the ages of 15 and 18 were merely a form of high school rebellion. It seemed a valid question. I couldn’t relate to many of the testimonies in twelve-step group meetings because I hadn’t really lost anything as a result of my drinking, except for some pride after initiating a stupid cat fight under the influence.

One July evening after everyone had gone to bed, I stared at the Heinekens in the fridge. Maybe I am normal, I thought to myself. Maybe I can have the occasional cocktail and join the fun. So with shaking hands, I pulled one out of the fridge, opened the bottle, and reacquainted with my long lost friend.

Nothing terrible happened. I stopped at one. So the next night I tried it again. For the first 48 hours of my experiment it seemed as if I had joined the ranks of the social drinkers. Hallelujah! However, by day three, I began to obsess about my next drink. On day four, I smuggled a six-pack of Coors Light into a park to drink alone. On day five, I considered stopping by the liquor store to buy a bottle of vodka to keep in the trunk … you know, in case I needed a fix.

The next day, by coincidence or divine intervention, a friend who is a recovery alcoholic stopped by the house during his run. He has never done this before or since. I confessed to him the details of what I was up to and he told that he was picking me up for a meeting the next day.

A bathroom break, not a start over

“Is there anyone here with 24 hours of sobriety?” the meeting chair asked at the end. I wasn’t sure whether or not to raise my hand. As the folks in the room saw it, I had about 26 hours of sobriety. However, by my standards, I had been sober 28 years and one day. I went with their math and waltzed sheepishly to the front of the room to claim my chip.

That day was an important milestone for me. I haven’t drank since. However, I wasn’t celebrating a day of sobriety. I was commemorating all the wisdom and perseverance and courage that had kept me sober for over a quarter of a century. All the sweat and hard work of the 28 years of sobriety that preceded my 24-hour chip were on display in that moment. Nothing was lost. I don’t believe a person starts over if they pick up a drink. I view it more like a bathroom break, where you look at yourself in the mirror and ask, “What the hell am I doing?” and then resume your place in line to get a table.

Progress is uneven

Perhaps some people have linear recoveries. They drink. They stop. They find happiness and peace. But I have yet to meet such a person. The recovery patterns for most of us entail a dance of up-and-down movements, right-to-left adjustments, a pirouette and a plié – with the hope that we are moving forward. Much like a walking labyrinth that guides you out before in, recovery is typically more spiral or circular than it is square. Just when we think we’ve encroaching on home base, we are thrown out to left field.

“Progress, not perfection” rings true with all of my addictive behavior. I don’t have to get it down the first time, the second time, or even the 52nd time. Gradual baby steps towards the goal of serenity and peace are enough. On those days when I engage in codependent behavior or reach for something to relieve my pain, I remind myself that it’s not the fall but the rebound that counts. Healing consists of catching myself and trying over and over and over again, sometimes as many as 50 times a day. It’s the journey and effort that matter in recovery, not a perfect score card.

Lessons of a relapse

Relapses teach us invaluable lessons if we are open to learning. For example, before my experiment, I regarded my decision to stop drinking much like I did eliminating gluten and sugar from my diet. My relapse demonstrated the seriousness of addiction, that sobriety is a life-saving action, not a healthy choice. Abstaining from a cocktail isn’t in the same category as foregoing a brownie or piece of bread. For addicts, alcohol hijacks your brain, whispering false promises in your ears. If you’re not careful, the self-destruction can erode all aspects of your life.

My relapse also taught me that abstinence isn’t about willpower and discipline. It has nothing to do with personal character or emotional resilience. Recovery is about humility, about admitting powerlessness and relying on other people and a higher power for strength and guidance. The healing power is found in the shared experience of others, in tapping into a community of support.

The pain underneath the addiction

I dare say that my relapse was life-transforming in that it forced me to discover what was driving the addiction. I began intensive psychotherapy and probed more deeply into every aspect of my life, asking the question, What’s going on here? My soul-searching efforts resulted in a stronger sense of self. As a result I can better identify the pain that makes me susceptible to addictive behavior.

I’m certainly not saying relapse is all good. Some people can’t get clean again after they start drinking or reengage in an addiction. It is a risk, for sure. However, if you are able to end your addiction and return to recovery, relapse can open the door to a better understanding of your addiction and, therefore, to a stronger recovery. I don’t believe you start over if you pick up a drink. I believe you pause and begin again with a new perspective.

The Value of a Relapse

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