Treatment
Treating Substance Use
We're at 30,000 feet flying around in circles.
Perhaps you recall this scene from the movie Traffic: Michael Douglas as the nation’s drug czar-designate has all his top people gathered around at 30 thousand feet on the return leg of a fact-finding mission. "I want you to think outside of the box," he implores his minions, to which he gets no ready takers. One by one, he calls on individuals representing the different aspects of drug policy, such as law enforcement and the military. "Treatment," he barks, grasping at straws, "what does Treatment think?"
Then the realization dawns. "Why isn’t Treatment on this plane?" he demands. Call it a golden film metaphor.
According to the Robert Wood Johnson Foundation, substance use is the number one health problem in the US: The economic cost is estimated at more than $414 billion in 1995. In the words of the Foundation: "Of the more than two million deaths each year in the US, one in four is attributable to alcohol, tobacco, and illicit drug use. In 1995, health care spending associated with alcohol, tobacco, and drug dependence was estimated at more than $114 billion."
Yet fewer than one-fourth of those in need get treatment. Most jurisdictions regard it as easier to lock away substance users and throw away the key. On the federal level, spending on criminal justice and interdiction takes up 60 percent of the federal drug control budget, while only 18 percent is devoted to treatment. According to the Mental Health Association, about 63 percent of jail detainees have a mental illness or substance use disorder.
In the meantime, metaphorically speaking, we’re up at 30,000 feet flying around in circles.
Dual Diagnosis Self-Help and Support
Twelve-step programs are an important component of substance use treatment, and there are dual diagnosis support groups modeled on AA. Those who do not have a dual diagnosis group (check out Dual Recovery Anonymous) in their area often have to make do attending a depression or bipolar support group one evening and an AA meeting another night. As a general rule, people in AA or similar programs do not want to hear about your depression or bipolar, and the reverse tends to apply in a mood disorders group. Some of you may find your needs being met by this split-personality approach to your problem. Others will find it far more logical to drive the extra distance to attend a group where you can put all of your concerns on the table.
One should be mindful of the fact that many substance use recovery programs and support groups stand in strong philosophical opposition to depression or bipolar treatment and support. For one, as opposed to most mood disorders groups which acknowledge there are many different ways of coping with illness and do not judge members of the group, various 12-step programs are oriented to a particular program or philosophy and tend not to look kindly on people not seen as fully committed.
Overzealous AA members sometimes tell those with mood disorders that they should throw away their medications, which they mistakenly regard as part of the chemical dependence mindset. Most AA groups are not this narrow-minded, so those with a bad experience in one group may want to seek out a more enlightened AA community or turn to other forms of support.
Alternative Recovery Models
Two articles in the New York Times report on a book by Anne Fletcher, "Sober for Good", which recounts the recoveries of 222 men and women who had serious problems with alcohol. Two-thirds of the group she describes as "masters" over alcohol, whose sobriety has lasted at least a decade.
More than half the people in the book quit without AA, many quit on their own, others through the help of therapists, especially those who practice cognitive-behavioral therapy, and others through non-AA groups such as Women for Sobriety and Smart Recovery.
The book quotes Rick N, sober for 21 years: "There are probably as many ways to defeat alcohol problems as there are people who want to recover. The more choices we can offer, the more people can be helped."
Surprisingly, many of the masters conquered their drinking problems without ever seeing themselves as "alcoholics" with a "disease." Many took control of their drinking before they hit rock bottom, often making a lifetime commitment to stop rather than go "one day at a time."
Their greatest initial difficulty tended to be the absence of a crutch to help "escape, hide or get momentary relief from painful situations, troubles and feelings." Instead of masking emotions with alcohol, the masters eventually learned to recognize what they were feeling, and to allow themselves to experience it and express it in a healthier way.
According to the Times: "Quite a few of the masters found that when alcohol no longer served as an emotional mask, they needed professional treatment for depression, anxiety or relationship issues that might have fed their drinking problems."
Anger-management was a new skill they had to learn, using techniques from punching pillows to meditation and breathing to changing stressful situations. About a quarter of the masters had to abandon drinking buddies or find new friends. Ultimately, they all learned new ways to find joy in their lives without abusing alcohol, from reading to travel to outdoor activities. Becky H said she wove "a tapestry of sobriety: I notice things, positive things, and revel in them - a raindrop sliding down a leaf, my baby's giggle, the cat's paws twitching in her sleep, the smell of the gardenia."
From SAMHSA's Report
Meds: Co-occurring disorders pose special meds challenges. A 2001 study suggests antidepressants may have only a limited effect on those with co-occurring depression and cocaine use. Benzodiazepines (presumably because of their potential for addiction) are not recommended for those with co-occurring disorders, and MAOIs should not be prescribed to alcohol or cocaine users. Benzodiazepines used to treat alcohol withdrawal can produce significant adverse reactions if administered with Clozaril. A number of case reports indicate that Zyprexa with alcohol may result in dizziness and lightheadedness secondary to orthostatic hypotension. Methadone with desipramine may raise desipramine levels while Prozac may increase methadone levels.
Medications that have heart rhythm risk (SAMHSA mentions thioridazine but Geodon can probably be included here) may produce complications for users of cocaine (which can also worsen heart rhythms).
The FDA recently approved Subutex (buprenorphine) to treat opioid use. SAMHSA laconically states: “Physicians treating anxiety disorders with benzodiazpines need to be aware of the severe drug interaction between benzodiazepines and buprenorphine - sudden death..”
Therapies: Motivational techniques for abstinence include instilling the patient with the notion that he or she has the ability to change. Cognitive-behavioral therapy (CBT) involves changing an individual’s irrational beliefs such as “I’m only comfortable when I’m high” to rational ones. CBT has been applied successfully to both mental illness and substance use. Therapeutic communities focus on positive change through residential environments. Assertive community treatment is an aggressive (and some would say coercive) outreach of community-based services. For kids, family therapy works to educate family members and involve them in the treatment.
Housing and Employment: SAMHSA notes that people with co-occurring disorders often have special housing and employment needs, and that treatment providers must be prepared to help their clients across a broad array of services to sustain their recovery. For the homeless, many who are resistant to treatment, a “housing first” approach may be appropriate.
Patient Involvement: According to SAMHSA, “consumers and recovering persons may well be their own best advocates. They bring special characteristics that support the recovery of individuals from both substance use and mental disorders: subjective knowledge of the service delivery system, empathy for the struggles related to the process of recovery, a capacity to build rapport, and fundamental respect for the integrity of each person.”
Self-Help: Includes 12-Step programs such as AA. A 2000 study of 300 members of Double Trouble in Recovery found consistent participation was associated with better meds adherence. Although SAMHSA briefly alluded to Schizophrenics Anonymous, no mention was made of the hundreds of depression and bipolar support groups such as those sponsored by the Depression and Bipolar Support Alliance, the Mental Health Association, or NAMI.
HIV/AIDS: As many as 15 percent of those with serious mental illness and 13 percent of those treated for substance use may have HIV. In SAMHSA’s words: “The combined stigma of the three illnesses, separate and inadequate funding streams, and professional norms that differ among programs serving those with HIV/AIDS, substance use and mental disorders, make it difficult for individuals with all three illnesses to obtain a full range of needed and appropriate help.”
Other Medical Illnesses: Nicotine dependence is two to three times more common among the mentally ill and substance users, with greater numbers of smoking-related health consequences. Hypertension, chronic liver disease, and hepatitis C are also dangers.
Women: Women are more likely to suffer from affective disorders while men have more antisocial disorders, Women are also more likely to suffer from three or more disorders simultaneously. Substance use treatment, often featuring a confrontational approach, is geared to men and pays little attention to women’s special needs, according to SAMHSA. Women involved with the child welfare system may resist seeking treatment out of fear of losing custody of their children.
Published 2002, reviewed Feb 10, 2008
A Famous Bipolar Who Drank Himself to Death
Beethoven's life could fill a segment on Oprah.
Knowledge is Necessity
Copyright 2008 John McManamy Contact
My Book
“The perfect book for those of us living with mood disorders.”
Sue Bergeson, president DBSA
Order nowStay Informed: McMan's Report
