Saturday, February 21, 2009

Clean and Sober

It's not rocket science. First you must want to stop doing drugs and alcohol. Abstinence is the treatment of choice for alcohol and drug abuse. If you think you need to do 'something' about your drug and alcohol use, that's a pretty good sign it's abuse. If others say you should do something about it, then that's also a good sign. People who don't 'abuse' alcohol or drugs are not surprisingly rarely told they should do anything about it. Miller and Prochaska, in their now classic stages of Motivation for Change suggest others who think you should do something about your 'use' should first consider whether you're ready. People in 'precontemplation' phase would rather 'argue' with you about alcohol and drugs than stop them. Arguing, talking about, doing them is all one to them. When you're ready you're in the 'action' phase. Setting a date to stop and making a plan to stay stopped are good 'actions'.
For a lot of care givers the diagnosis of alcohol and drug abuse was generally, 'if the person drinks or uses more than you." Hence, alcohol and drug abuse is least commonly diagnosed by the often supposedly most trained. There are however people who specialize in the treatment of drug and alcohol abuse. They're called addictionists or addictionologists. In Canada the doctors have certification with the Canadian Society of Addiction Medicine and in the US it's the American Society of Addiction Medicine. There's an academic sub group of psychiatry in the US called Addiction Psychiatry as there are counsellors who are called Drug and Alcohol Counsellors. Psychologists and social workers may claim to have 'training' but alot of 'claimed' training in drug and alcohol is done by people who say they're 'researching' when they are really just getting drunk or stoned. It's good to ask for some paper and question the experience before you trust just anyone who claims to be able to help you with your alcohol and drug problem.
A treatment centre is a place where one can go for weeks to a month or two. They're often expensive. It costs alot to house and feed anyone and the higher costing treatment centres don't usually have better treatment per se but rather much more attractive facilities and services. The Salvation Army has a treatment centre but it doesn't have a jacuzzi. Edgewood and Orchard are two of the local leading treatment centres in British Columbia Canada , equivalent in many ways to the famous Homewood of Quelph Ontario or the Betty Ford Clinic of Palm Springs. Talbot Campus or the Hazelton Treatment Centre in the states are considered standard prototypes for treatment. They've been around for decades and successfully treated thousands. In Vancouver, Pacifica Treatment Centre has the advantage of having government subsidy. Some very fine treatment centres are run by different religious groups or cultural groups and usually have very good success if they incorporate the main components of, say, the Minnesota Model. The principle role of a treatment centre is to separate you from your toxic environment and give you an intensive education in living clean and sober while confronting the main components in personality and behaviour that are most likely to cause early relapse.
The detox unit in contrast may be combined with a treatment centre or run separately and exist in a hospital or even as a clinic outreach. Detox is simply getting the drugs and alcohol physically out of your body safely. Delirium tremens is a life threatening condition that can easily arise from stopping alcohol cold turkey. Dr. Doug Coleman in New Westminister runs a Rapid Detox Service for opiate addiction. These facilities address the initial pain of acute withdrawal and are aimed at making one as comfortable as possible while separating you and your acquired brain parasite, otherwise known as your drugs of choice. . When I've been in charge of detox units I've sedated my patients as much as possible in the first 48 hours. I like the idea of having people 'sleep it off' and use ironically pharmacology to do this safely. Drug abuse and alcohol abuse is "not natural' and there is no 'natural way' to detox from serious abuse. There are only 'safe' and 'unsafe' ways. I prefer using the safe ways. The key to safe detox is really good nursing. I've been fortunate in working with the best. Indeed I have done home detox as well but only if I have had excellent family and nursing support. It's akin to the home delivery I used to do and as serious. Personally hospitals and detox units are simply really great facilities for what they do best.
Recovery houses are drug free living accomodations which provide group living facilities for people who have the advantage of partaking in an ongoing accountability program while returning to work and life in the community. They increase the long term success of treatment centres and are the treatment of choice for those who still relapse after having been in treatment centres.
Once one is drug free and can think about changing one's life ,what keeps one clean and sober. The key is group therapy or community. All long term follow up of success is associated with a group of non judgemental, non using friends. Alcoholics Anonymous and Narcotics Anonymous are the gold standard for long term abstinence. SMART Recovery is a new group with good success in the first year using cognitive behavioural approaches as opposed to a 'spiritual' program. CELEBRATE, the Christian program and other 'faith based' programs of group therapy and community have also been successful. Individual therapy has the least success, not surprising given that perhaps the greatest therapist of all time, Freud, said that Alcoholics were untreatable. It's been summarized that 'you can't think your way out of bad actions but must act your way out of bad thinking'. It takes at least a year (four seasons) of continuous sobriety before the major cognitive distortions and triggers associated with addiction have been addressed. Vaillant, the leading Harvard researcher, said it was 5 years before people returned to the normals of the community of origin in behaviour and thinking. Not surprising, given that addiction has been called the 'cancer of the brain'. Thankfully today it is treatable. Abstinence is that treatment of choice.
Medications that can assist in this process are used directly in the detox phase by clinicians but others have been found to assist motivation and recovery in the first months. Those who can avoid use of medications have been shown in some studies to have the greatest success as they apparently focus most on the relationship and emotional issues which have been most negatively affected by addiction. Given that "oral fixation" and 'wanting the breast' have been terms used by psychoanalysts for the developmental regression of alcoholics and addicts, this same group is very much at risk for looking to a 'pill' or 'drink' to solve their predominantly 'life' and 'love' and 'work' problems. Nonetheless, empirically the following drugs have been shown to have benefit in the inititial treatment of alcohol and drug abuse: gabapentin, topiramate, naltrexone, and even old fashioned antabuse used voluntarily. A simple rule of thumb for what drugs not to use in the treatment of alcoholic and addicts in recovery is to ask if that drug has a 'street value" mark up before prescribing it. Antidepressant medications such as buproprion, mirtazepine, and trazadone have been useful too but only as protection and baseline. Antipsychotics such as seroquel have been beneficial for lingering paranoid ideation and sleep problems but clearly if you've stopped drugs and still think you're Superman you might benefit from the Concurrent or Dual Diagnosis programs affiliated with the best university Psychiatric Hospitals. The problem that clinicians encounter is that addicts and alcoholics who have not 'learned' how to handle anxiety are likened to fighters who used the 'guns" of alcohol and drugs to answer all their emotional problems and now must learn new coping and mood modulation techniques that everyone else who learned martial arts, wrestling and such did while holding the 'gun' as last reserve. No 'oral' solution will take the place of the 12 step programs of recovery or learning meditation, cognitive therapy, non abusive communication, exercise and good habits of normal living. Changing playmates, playbox and play toys and learning new games is the harder but most rewarding part of recovery.
So called 'harm reduction' strategies are first and foremost usually 'cheaper' alternatives and commonly promoted by governments and funding agents as equivalent to 'abstinence approaches'. They aren't 'equivalent' Abstinence after abuse is the gold standard. Where the argument arises reasonably is whether one can return to drinking or drugging after an extended periold of abstinence. Clearly there are those in the minority who can with perhaps no further deterioration in heath. The best studies though show that 50 % of those with 5 years of abstinence when they attempt to control their drinking run the greatest risk of returning to their previous levels of abuse or worse. As one fellow put it, while I was staying sober, my disease was in the parking lot taking steroids and doing push ups. Further very impressive studies have shown that the mental and emotionally and social health of those who remain abstinent surpass those who return to drinking and indeed in a highly significant number surpass the projections of where they might well have been without ever having drunk or drugged. A dentist friend with long term abstinence and a member of AA said, "When I drank and used it was like living my life hauling a monkey around on my back that grew into a gorilla, now I'm like a guy working in a gravity free environment who grew up on a very heavy planet." Sadly there are also those who only stop after they have permanent brain damage, liver, lung, pancreas or heart disease or wake up as one fellow did to find a child on the grill of his car he'd not realized he'd hit in a black out driving home. Recent PET scan and functional MRI studies strongly suggest that the 'thrill' of addiction is indeed the 'playing with death' but unfortunately as everyone who knows an alcoholic or addict will attest there's tremendous collateral damage of the innocents. The organization Al Anon was developed to help those who had an alcoholic loved one.
That said, 'harm reduction' is still medically indicated. While surgery is the treatment of choice for appendicitis and has a 90 plus % success rate, the death rate of doing nothing is near universal so I was trained in wilderness medicine to put people who I couldn't get to surgery on antibiotics and that alone increased survival to 30%. Indeed if I didn't take out the infected inflamed appendix but used antibiotics and made an incision into the side of the person where I could put a drain to let the pus out I might indeed get as high as 50% survival rate. Abstinence may be the gold standard but 'harm reduction' is still a very good second choice and often the only way a person with limitted motivation makes his or her way to finally addressing their addiction problems 'once and for all'. Further programs such as methadone not only help the addict but they are a tremendous advantage to the community at large The standard line in AA and NA is that the door 'swings both way'. Like most chronic illnesses it's a disease with relapses. What diabetic hasn't had a chocolate cake and what heart patient hasn't run up the stairs with the natural negative consequences of such human and forgetful behaviour. The thing to remember is that the shorter the relapse the healthier the person so there are always people in the system in various stages of recovery and everyone who wants to quit or even thinks they should ought to be welcomed somewhere in the overall scheme of things. The real advantage of the 'illness' model is that nowadays no one can treat people with this often devastating disease as lepers. Alcoholism and drug abuse have only recently been shown to be the scourge of Lady's, Presidents, Premiers, Bankers and even the incredible Britney Spears. Many of the paparazzi who have been so cruel to people who have suffered with addiction have been so because of their own denial of their own addiction. I wasn't surprised to hear that the press 'coke machine' in the parliament of canada press gallery got jury rigged to dispense whiskey. When you work in the field of addictions it's not hard to recognise that alot of things in politics, sports and media are best explained by what people were smoking.
Dr. Ray Baker, an occupational medicine addiction specialist is fond of saying that what's so exciting about addiction today is that it is a wholly 'treatable" illness and that the earlier we can get people to the best treatments, the certain outcomes in health, work and marriage follow. Addicts or alcholics who say that they tried treatment and it failed are most often like pregnant teenagers who said that they had a birth control prescription however had never filled it at the pharmacy. It was less than 100 years ago that alcoholism was considered wholly untreatable and alcoholics were thought to have a worse disease than schizophrenia. Only as little as 3o years ago addiction was considered a 'curse' and likewise untreatable. Today we know better. Literally millions have left the religion of drugs and alcohol broken free of the cults of the marijuania or crack and left the shrines of the bar. The incredible success that has come all over this continent in regards to fighting the psychopaths and murderers of the tobacco industry with the release of all their prisoners is testimony to the treatability of addiction. The original 'big book' of alcoholics anonymous was called 'A way out'. Today that extraordinary beginning has blossomed into a myriad of solutions of hope and fulfillment bringing joy and life to millions.

1 comment:

Anonymous said...

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