Addiction, Alcohollism and Motivation to Change

Daily Reflections Dec. 21

Listen Share and Pray

‘When working with a man and his family, you should take care not to participate in their quarrels.  You may spoil you chance of being helpful if you do. »

When trying to help a fellow alcoholic, I’ve given in to an impulse to give advice, and perhaps that’s inevitable .  But allowing others the right to be wrong reaps its own benefits.  The best I can do ….and it sounds easier that it is put into practice….is to listen, share personal experiences, and pray for others. 

I remember well meaning individuals offering kind suggestions.  The difficulty is that they didn’t realize the depth of betrayal I’d experience of myself and with others. I simply did’t trust. I trusted God but those closest to me had abused my trust.  I was at that point quite frankly paranoid.  In the sense that schizophrenics are delusional because of the depth of their anxiety and alienation so are addicts and alcoholics however they appear normal at times and can hide the insaniety brewing beneath the surface.  

Motivational therapy is the treatment of choice today for addition. It first says listen. It says identify the ‘stage of change’ the addict or alcoholic is at .  The first stage is « precontemptlation’.  In precontemplation stage the individual is in such depth of denial they reject even the suggestion of a problem and become angry with anyone or any discussion of their ‘problem’.  Their problem is ‘you’.  They don’t see any reason to change, The problem is that others need to change.  Others need to cut them some slack, get off their backs, quit bugging them.  Others are the problem, not them.

Contemplation phase is different. In this phase the person might accept there is a problem and they might even consider they may be doing something wrong. They may think they drink too much or that drugs aren’t helping.  They aren’t ready to change but they are open minded enough to consider the possibility that their best friend and solutions, drugs and alcohol and those who use them might no longer be helpful.  Before Prochaska and others studied Motivation it was found that government funding and intervention immensely wasted and counterproductive because it was aimed at those in ‘precontemplation phase’.  This only entrenched alcoholics and addicts against change.  The timing of intervention is critical in addiction and when the person shows openness to the idea of their use of alcohol and drugs being part of the problem that’s the time when it’s good to simply off solutions.  Persons’ in the ‘contemplation phase’ welcome being given ‘literature’, ‘invited to come to a meeting’, offered a phone number, advised where rehab and detox centres are.  They are like people who say they were thinking of having their house painted so don’t mind hearing what’s out there but don’t want anything onerous or involved.  Just offer them information and be prepared to follow up at some time.,

Determination is a critical time and distinguished by the person admitting they have a problem and committing to making a change This is like the smoker who says they need to quit smoking and say they’re going to fo it in the spring.  This is the time to offer time and resources to assist the person in getting to the next and most critical phase. Unfortunately many alcoholic and addicts with talk ad infinitum about needing to quit and planning to quit but the rubber never seems to touch the road.  When it does that’s the time to pull out the stops.  In the past those who cared had wasted endless energy on those in the precontemplation phase they were angry by the time the person actually was determining to make a change.  Listening carefully to the alcoholic or addict is the key to identifying the fundamental changes

The Action Phase is evidenced not by talk but by action.  The key statement that came out of the AA experience was ‘if you talk the talk, walk the walk’.  Action is evidenced by a number key actions.  The first was attending a meeting of AA. Today people can attend a meeting of SMART or any of the faith based and secular ‘group therapy’ meetings. The corner stone of therapy for addiction is the group.  Social anxiety is central to addiction along with shame and dishonesty.  When a person is actually in the action phase they will literally leave their basement, pub, crack house, drinking and drugging friends and join a group of people who have and are leaving the old world for the new.  These are the people who don’t just talk about exercise but actually go into the gym and buy a membership.  In the action they admit they have a problem and need help.  Other major actions are going to a clinician and saying they have a problem with addiction or alcoholism and asking for help.  There’s going to a Detox centre. The action is picking up the phone or going to the building and asking for help. There’s calling the rehab centre and speaking to intake and then attending. 

This is where resources need to be focussed because this is what the person is truly ready and making an effort to change.  

The success of treatment for alcoholism and addiction is truly amazing if the person had a job and family in tact.  Too commonly people have looked at addicts that are homeless and on the street and not seen the success of treatment because of these few individuals who have end stage disease.  It would be like saying cancer can’t be cured.  Every day cancers are being cured if caught early.  Countless skin cancer and cervical cancer and breast cancer and even lung cancers and brain cancers are cured routinely because they are caught early and treatment is initiated.  In the past early diagnoses and treatment wasn’t available and people avoided seeking help for a lot of medical conditions, many of the worst known, because we screen for them and treat them early.  Pilots and doctors have a 90% success rate in treatment of alcoholism and addiction because their conditions are recognised early and treatment is initiated. 

The Gold Standard Navy pilot program involved 30 day in patient treatment followed by 3 AA meetings a week and monthly meeting with a psychiatrist and counselling as needed resulting in 80 to 85% of pilots remaining sober and clean and flying 5 years later.

That’s like the success with early detection and treatment for Tuberculosis and Diabetes. These used to be lethal diseases and still have major complications at end stage but the life expectancy in the past was at 20 to 30 years but now is 60 to 70 years. Alcoholics used to die 10 to 30 years younger but now are living out their lives.  Heart disease, lung disease, liver disease, hypertension and various cancers were all often caused by addiction and alcoholism but now are recognised as treatable life style diseases.  The longevity research show now that the greatest thing individuals can do to improve the length and quality of their lives is simply to quit drinking and smoking.  

People change,  Addiction and alcoholism are diseases that are curable.  Abstinence is the treatment of choice and AA remains a cornerstone of long terms success.  Not surprisingly it was called the ‘miracle of the 20th century’ because prior to the 1930’s alcoholism and addiction were a deadly scourge akin to the various infections that were treated by the introduction of sulfa and penicillin.  

Today we also have ‘harm reduction’ therapies for those in the determination phase of change but still ambivalent about abstinence.  I liken them to those who are told that surgery is the solution to their hip disease but want to do physiotherapy and exercise first.  If that works great.  In medicine clinicians want success and realize that scientifically there are superior treatments so that we describe efficacy of therapy as ‘primary’ , ‘secondary’ and tertiary.  

Because of the insaniety associated with addiction and compulsion and obsession often an addict will think that if only they don’t use heroin in the afternoon and limit their use to the morning all will be well.  It’s important for others to listen and not argue but to explain what indeed has been proven to be effective in the same way as we’d not agree with a dying man that using a salve on his bullet would will be sufficient.  We would recommend taking the bullet out and treating the would with antibiotics instead.  Of course if he wants to try his salve and lotion first that’s okay.  Insurance companies and governments and jobs won’t usually support these subjectively appealing but objectively questionable solutions yet it never helps to ‘argue’ with insanity.  

I prefer to pray myself.  

Recovery Today

“I never thought I’d end up here.” She said. Her clothes were torn.  Not in that fashionable way. But a sleeping outside and not having anything else to change in torn and worn way.  Her hair was matted. There was dirt on her hands and face. She was white at one time.  “I graduated college.  I had a husband and a child before social services took my baby.  I don’t know where she is now.”

She’d been sleeping in front of the bank because there was an overhang there that kept some of the rain off her sleeping bag and newspaper shelter.

“I drank first but then it got to harder stuff. I needed the drugs.  I didn’t like what I did for them.  Drug dealers are all disgusting pigs.  But I didn’t have any money. “. She was crying, shoulders shaking.  She did’t smell fresh either.

I didnt’ know if this was true or just a tale she’d picked up and used.  The stories are passed around and reworked for most impact. Especially the stories of abuse. They’re so polished that I’ve even heard the lawyers down here repeating them as their own.  Jungle tales.  But she sounded real.  What was sad is how the last thing blamed was the drugs. First the parents, then the men or women or the job or even the banks and government but finally one day if they’re lucky they look in the mirror and say, “It’s me. It’s the drugs. My drug dealer isn’t my friend.” 

AA considered calling the Big Book, the truly classic recovery read, “The Way Out”.

So many who develop drug and alcohol abuse had trauma that many think the subsequent self destructive lives are ‘identification with the aggressor’ and Stockholm Syndrome.  No one doubts that it becomes a disease.  The brain changes.  The amygdala and hypothalamus are altered. DNA and neurotransmitters are all altered.  The very thinking is high jacked like a worm in a computer. Addiction can be followed by public health like a viral epidemic.  It spreads in poverty and war from carrier to target.  There are well established vectors.  The enablers are the most interesting group.  A twisted form of narcissism.  Dr. Scott Peck described them in “People of the Lie’.  Without the enablers the natural history of the disease would be brief.

“I ran out of money and no one wanted me. That ‘s why I came in.” He said. He’d been a teacher at one time. 

I first met them in the detox ward I supervised nearly 40 years ago.  Back then the Delirium Tremens of the alcoholics challenged me. I’d be up all night trying to keep the patients alive as they crashed about screaming and hallucinating and I’d be afraid of how much medication I gave them because they’d have liver disease, heart disease and lung disease from smoking and drinking. Mostly they were older men then.

Today’s it’s children. Nobody realizes how many beautiful young women are addicts today. Female alcoholism has passed that of men.  Red Red Wine.! Poor ME. Poor Me . Poor Me Another Drink! The guys are coming in younger too.  

40 years ago it was alcohol or heroin but today it’s everything.  

“I don’t want the methadone or suboxone. I was just told I had to see you and fail your program before they’d give me the free heroin.”  He was 18 years old. He’d started using drugs when he was 6 years old. His mother was a prostitute and his father a career criminal.  “I”m pretty sure he’s my father. I visited him in jail. The guy my mother said was him. He acted okay and said we’d get to gether when he got out. He’s in for another 20 years. Manslaughter. I didn’t go back.” 

There’s lots of solutions. All the options are available here for treatment. The management of these options has been described as the worst managed in the western world.  The problem is communication and coordination.  The administration though is always playing their favourite game of divide and conquer and self aggrandizement. The emperors and empire building in beurocracy is rife.  

“I’d feel badly but when I see how incompetent the legal system is following known terrorists and dealing with criminals who use guns what is done in health care is genius by comparison.  Politics is just messy everywhere.” She said. A wise nurse teacher now working on the frontlines after leaving a cushy university position for reality.  

The housing crisis doesn’t help.  The bed bug stories and rats in 21st Century Canada frighten me.  Typhus outbreaks in Democrat California. Won’t be long before that spreads up there.  We still get syphilis cases and we’ve done everything to wipe out these diseases but as the government devolves the danger increases. We’ve got TB again but so far no Plague in Canada. The breeding grounds are growing though.  The anti vaccers don’t help either but who wouldn’t believe conspiracy theories with the lies coming out of Ottawa and Brussels about scientific ‘predictions’ that are just modern day political ‘prophecies’ .  

If the person has a job and family in tact as Dr. Ray Baker literally preaches, “We can get 80% or better outcomes at 5 year follow up with early intervention.  We do better with addiction that any of the other specialities in this regard but we are no better than they are treating end stage illness’.  Dr. Baker was the one who started the first medical school addiction education program when the authorities were in complete denial and blaming the victims like the courts and judges and too many politicians still do.  

The treatment of choice has been around since the Navy Pilot program. When AA began in 1935 there was no ‘cure’ but 50 men in Akron found that abstinence and accountability groups, 12 steps and broad based ‘spiritual’ focus rather than narrow focus resulted in 5 year cures for what was an otherwise deadly disease.  Unfortunately until people understood immunity, partial immunity and genetics of disease and disease spread little more progress was made for decades .But now, thanks to AA that millions of alcoholics were surviving and then Addicts too there were test subjects and money to continue the research that has lead to a broader based approach to the disease. The Navy Pilot program was 80% successful with early identification in the workplace, referral to a psychiatrist trained and experienced with addiction , seeing them monthly, seeing a drug and alcohol counselors weekly and attending three AA meetings a week after an initial 4 to 6 week (proverbial 28 day) inpatient treatment.  

There’s little change in that winning formula today except that there’s now ‘outpatient’ ‘DAYTOX’ and “SMART” Recovery groups alternative to the 12 step programs and a variety of faith based ‘accountability groups’ more appealing to particular religious affiliation.  Psychologists and psychiatrists have begun to treat the trauma that is usually associated with addiction at 3 to 6 months abstience.  Motivation Therapy and DBT groups are now psychological advances over the CBT developed in the 80’s .  Recovery Capital work is the foundation of modern psychosocial therapies. 

In addition a variety of drugs like Revia 50 mg a day have been developed to reduce craving and assist recovery much like the highly successful Chiantix used for quitting smoking. 

Harm reduction strategies have expanded the applicability from the original , ‘take it or leave it ‘ approach so that a number of approaches have been established to get people into the now generically termed ‘RECOVERY’ process. It’s becn said ‘you’re either on the up elevator or the down elevator.” Once it was believed that you couldn’t be ‘forced’ into recovery but functional MRI studies show that people who have been using drugs are literally ‘not in their right minds’ for at least 90 days or 3 months.  Intervention and rescue models and treatment Centers offering 3 month initial programs have followed this learning. The old ‘tough love’ AA program is still likely best practice for ‘relapse prevention’. 

 These harm reduction procedures include replacement models, like methadone, suboxone, and now morphine and injectable morphine. Internationally the highly successful injectable long acting antagonist treatments have been used though Canada and the US often because of the long delays haven’t  haven’t caught up with the Russian and Australian approaches to chronic relapsing disease. . Mostly the local  courts and beurocrats cause delays because of their lack of  scientific education in face of  crisis.  When I worked with the AIDS epidemic the courts and individual judges and beuroccrats by their delaying tactics and self aggrandizement accounted for thousands of passive aggressive deaths.  That said hundreds  of judges and thousands of beurocrats along with the front line workers turned that disease around as they are now grappling with this fentanyl epidemic.

Dr. Jordan Peterson though, always one to avoid the political correct language of deceit, confronts the problem directly but saying that today 10% of the population are ill equipped to have any work. Work and the family are the cornerstone of community and without community the gangs and drugs take over.  Work has been a key component in limiting the spread of addiction.   It literally keeps people in contact with positive associations however as Dr. Peterson points out in the past there were all kinds of work that didn’t require intellect or computer knowledge or even reading and writing. But these kinds of jobs have been mostly taken over by machines. Society must come to terms with this problem. Some countries have brought back conscription while others are moving to a similar non military but public health peace corp type approach for those young people who are not going to make it to college or trade schools.  Anything is better than leaving these marginalized people to gang predators.  Some 75% of those in jail are there for crimes to obtain drugs.  The enablers are often those with a conflict of interest in maintaining the antiquated punishment jail based legal system which has much value but not in this arena.  The drug court is just one of the very best solutions to the problem but recovery houses and work must follow.  

The good news is recovery is working. A week doesn’t go by that I don’t meet someone who says they remember me , like others,  who were along the way in their recovery journey. They stop me and say ‘thank you’ .  I don’t remember them. I’ve seen so many thousands of patients struggling and recovering from the disease.  They never look like they did when I met them in their addiction or early in recovery. 6 month, a year or 10 years later the big difference to me is the ‘eyes’.  They look alive’. “Dead eyes’ is a well known term among those who care and know.  

What’s even better is the ‘life’ the people in recovery have.  They tell me about their new jobs, their education, the trips to exotic places, their reunions with family, their church or temples.  It still remains that those who are 20 years or more recovered tend to be going to AA groups or involved in some spiritual organization.  

It’s a tough field to work in especially with the alcoholism and addiction rampant in the authorities  and the denial in high places where the desire is to expand the tax base and hope that the 90% of people who can play with fire safely are not destroyed by the 10% of people who turn out to be arsonists.  Despite that it’s still rewarding in time to see the lives gained.  Those young people who I knew who had so much potential but died premature unnecessary undignified deaths still remain with me.  But the woman who lost her children and family is now 2 years clean and sober . That’s thanks to methadone, her drug and alcohol counselors, AA,  a smart psychologist, her local church, an enlightened social worker and family who were glad to have their daughter back. She has a job working as a secretary for a housing authority, a government beurocrat going out of his way to help her get work without stigmatizing her for the other non life she’d lived before recovery. That’s the new normal story in this work.  I’m thankful to have been a part of the recovery process.

Harm Reduction Good; Harm Reduction Bad

Harm Reduction Treatment is a term which is used commonly in Addiction Medicine. It followed “abstinence based’ treatment.  In other areas of medicine the term ‘palliative care’ is an equivalent expression.

The positive aspect of “Harm Reduction’ was that it provided care specifically for those who were not ready to embrace ‘abstinence based’ treatment or for those who had failed, even repeatedly failed, conventional abstinence based therapies.  

Historically ‘abstinence based’ therapy for alcoholism was exemplified by the Gold Standard , Navy Pilot program. Navy pilots cost millions to train and flew jets worth even more millions.  When they developed addiction as they did, grounding them caused  a major loss, often involving suicide, while letting them fly, was obviously dangerous. The treatment which followed included a 30 day inpatient treatment, followed by 3 meetings a week of AA (Alcoholics Anonymous), weekly drug and alcohol counselling and monthly visits to see a psychiatrist. At 5 years 80% of pilots were abstinent and flying.  A major success.  

This treatment with some variations is the treatment principally used for judges, doctors, other professionals, union members and all those ‘contributing citizens’ who individually or by insurance can afford the ‘best’.  It is well known by the advocacy of such distinquished treatment programs as Betty Ford, Talbot, Homewood, Edgewood, Orchard etc.  Often patients begin with a period of detox and follow up today can include SMART, a cognitive behavioural group therapy.  Group therapy is the cornerstone of abstinence based therapy.  A fundamental principle of addiction treatment in this model is that substance abuse compensates for relationship deficits.  Accountability and support come through fellowship and community.  Isolation begets addiction, participation treats addiction.

By contrast Harm Reduction Treatment has tended towards maintaining the substance use with a view to control. Originally the World Health Organization validated the Harm Reduction Programs only as they ‘lead to abstinence’. Abstinence is the ‘cure’ per se for addiction.  To this end methadone, suboxone, Kadian and now Heroin are used as Opiate Replacement Therapy.  Eventually patients were weaned off opiates however where in the abstinence models this occurred in weeks, in the Harm Reduction Model this might well take years.  

Alcohol is provided in a controlled fashion on the hour for chronic alcoholics, maintaining the steady state alcohol level and avoiding withdrawal as well as the revolving door detox, hospital and jail scenarios.

There is no doubt that harm reduction is good Community Medicine. 30 years ago when I was doing a Community Medicine Residency I studied the Swiss Methadone Maintenance programs of the day, showing then as they do today, that providing methadone, reduces the spread of diseases associated with needles, like infections, most importantly hepatitis and HIV.  They also dramatically reduce the cost of revolving door hospital, detox and jail scenarios. The legal cost alone for the theft associated with heroin use is horrendous and methadone simply dramatically reduces this.  

Harm Reduction Treatment is very good for the community when it is approached responsibly and it’s fiscal benefits are understood.

 Locally the Portland Hotel Society was a scandal with all manner of corruption and devastating failure as their Harm Reduction Model became dominated by crime and a ‘better living through chemistry’ attitude which indeed promoted drug abuse as opposed to treating it. The Portland Hotel Society has since modified it’s approach. 

For individuals as opposed to the community, harm reduction can be very good.  Methadone and suboxone specifically impressively reduce the use of needles and help individuals get free from the life of servitude supporting the criminal drug dealer factions and associated crime.  Eventually patients who might otherwise have died often have the time to move on to abstinence based therapies.  When the patients come for methadone or suboxone their other physical and mental health needs can be addressed.  Otherwise they might well avoid health care.  Housing, food, health care are all available as part of the a good methadone program.  Certainly we encourage participation and provided biopsychosocial interventions to the patients on methadone. The College of Physicians and Surgeons of BC like other College programs across Canada and similarly in other civilized first world countries,  historically managed the methadone programs and encouraged they take a wholistic approach to the patient.  Opiate programs required a federal government waiver given that the laws against drugs like heroin were nation wide. Locally the addiction treatment has been transferred mostly to Province or State and University care. 

Harm Reduction Therapy could well be seen as bad if all the doctor was doing was being a ‘drug pusher for the multinationals’ rather than using motivation therapy,   12 step facilitation therapy and cognitive behaviour therapy to move patients along the spectrum of motivation to change as laid out by Prochaska.  The preventative medicine aim was through relationship therapy with the physician , psychiatrist, pharmacist and overall treatment team aiming to ensure the patient’s self esteem and health indices  improved.  These indeed do and for many individuals the methadone and suboxone treatment have been life saving.  Heroin and other ‘needle maintenance programs’ are early ‘add ons’ whose value is not nearly as evident given that the key feature of methadone was that it moved patients off needles with the community risk inherent to methadone or suboxone, oral medications.

The alcohol therapy has been an end stage treatment model for chronic alcoholics who have failed all other programs and whose lives are more manageable without the drunk then withdrawal roller coaster broken by relationship with health care and managed hourly alcohol intake.

Champix  and bupropion, nicotine replacement gums and patches, and vapes are all Harm Reduction Therapies which have had proven success in helping people become abstinent for nicotine and smoking.

Revia (naltrexone) is a medication which reduces craving for alcohol and empirically reduces alcohol intake in those who abuse.  Acamprosate is another such medication. 

Narcan kits which reverse overdose are definitely a harm reduction strategy especially when put into the hands of first responders.  They are a simple preventative medicine strategy for those of my patients who I encourage to have on hand when they are using with family or friends trained to know how to use them. 

The safe injection site is obviously another  harm reduction strategy.

Needle Exchange programs are proven harm reduction therapy where the patient exchanges a dirty needle for a clean needle. Unfortunately locally the needle exchange program devolved into a ‘free needle’ program with needles being tossed out of a basket in the local park. 

A variety of medications have been used along with diets to treat obesity and overeating, sometimes call food addiction. At the extreme, when behavioural change fails, surgical interventions such as stomach stapling have been long acknowledged as life saving.

So why is Harm Reduction Bad?  Obviously it isn’t of itself.  Reducing harm is good and the use of this marketing term is very seductive indeed. Unfortunately it can be ‘enabling’ and can cause the disease to persist given the huge element of denial involved in addiction.  Further the Harm Reduction Therapies tend to be pharmaceutical or medicalized  and costly compared to the low cost equivalence of the more labour intensive approaches of treatment centres and frankly almost cost free community support programs.  Often all the high cost and front end approaches are used and use up the patients resources while in the end the recommendation is to continue in AA/NA or SMART as this is a chronic disease process and unfortunately the real issue is prevention of relapse.

When patients have work and family and community relationships still in tact they are most likely to benefit and succeed with the conventional abstinence based programs, detox, treatment centre, and group therapy. In traditional medicine this is considered the ‘primary’ care model and harm reduction therapy is considered ‘secondary’ or ‘tertiary care’.

Harm Reduction becomes ‘bad’ when judges and doctors and the wealthy are given the abstinence based approach while the poor are ‘maintained’ on their drugs without giving them the opportunity of ‘cure’ which comes with abstinence based models.

Further, the harm reduction models can contain an inherent negation of the patient’s capacity to change.  Seminal studies have shown that a patients capacity to change and get well depends strongly on the therapists belief in their capacity to do so.   If the therapist doesn’t believe the patient can overcome their addiction to heroin the therapist will indeed prove to be the rate limiting step. The success of AA and NA is that the rooms are simply full of individuals who have indeed climbed the Mount Everest of Recovery and encourage others to believe they too can succeed.  

Both models have their naysayers and both models have their glorious success stories. The social justice warriors often argue that the addict and alcoholic should have ‘free’ stuff , in this case ‘free drugs’.  Unfortunately the disease of addiction is one of ‘more’ and there simply isn’t enough of whatever to suit the active alcoholic or addict who will die or commit crimes to persist in his or her narcissistic hedonistic pursuits.  

Should society pay to increase the risk to itself.  Part of the difficulty today is that there are increasing numbers of those who feel society should allow them to ‘spread their disease’ , a group of HIV positive individuals having parties with ‘non infected’ but those seeking “solidarity”.  

In the best of possible worlds when physicians, psychiatrists and other care givers are seeking what is best for the patients ,understanding the severity of the disease, the limits of resources and looking at each case individually there is rarely any conflict between the models .as in the individual’s life and care both models are at different times and sometimes together  being used.  

Politically, Harm Reduction Therapy has, I believe, a great deal more potential for harm than traditional abstinence based therapies.  Naturally there is a concern that the rise in addiction and death has been parallel to the increase in Harm Reduction Programs. Is this an association or is some of this cause and effect.  Changing the ‘drug dealer’ from the street criminal to the State has sent a different message. Legitimizing drug and alcohol abuse can be problematic.  Promoting marijuana use for profit just like promoting alcohol for profit may cost individuals and communities while a few profit.  

What is best for the individual, what is best for the community and what is best for the State and treating services are great when they all work together. Historically, the individual has been lost in the demands of community and State and those that ‘profit’ from individuals with disabilities such as addiction.  

We have always done ‘Harm Reduction’ as doctors. My concern has principally been individuals get the best care. The group “Like Minded Doctors” developed in part to discuss these concerns. 

Addiction is Isolation;Recovery is Participation

When someone is addicted it’s like they have separated themselves from the mainstream by their addiction activities.  Over time they become increasingly absorbed in these  activities, thinking about it, anticipating it, doing it, and recovering from it,  so that the addiction takes over more and more of their life.  At first friends who are not into the addiction are lost or avoided then family, and eventually recreation and jobs.  Normal people, successful people participate in life. They are involved in their family, work, community and their political and  spiritual life.
When doctors ‘fix’ a broken leg they don’t try to ‘set’t the leg according to the way it was previous to the break but rather set it according to the best functional possibility for the leg. This information has been acquired over hundreds of years especially from the studies of olympic athletes and obviously from healthy people.
Addiction isn’t just about the drug, the alcohol, the substance, the process. It’s like a virus that invades the whole body and can indeed be a total epidemic and public health crisis as we see today in many parts of our world.
If you consider addiction socially, really, it’s more like a religion than anything else. The addiction will have ‘no other gods’ before it. The dealer or promoter is like a priest. There are ‘places’ like crackhouses, casinos, bars where the addiction is practiced mostly.  There is a language and a particular way of thinking. “If you had my life, you’d do what I’m doing’ along with other popular cognitive distortions.  To healthy normal people people with addiction often sound like fanatics and sometimes frankly psychotic.
The most successful people in society belong. Freud said mental health is the ability to love and work.  The WHO extended this to what has been summarized as ‘love, work and play’.  In addiction the person finally have only  their addiction.  Addiction has been called the ‘great eraser’. The earlier one can intervene after the ‘it’s fun stage,’ to when it’s fun and trouble, before it’s just trouble, the more successful the outcome. Indeed those with intact family and jobs and still socially active in their communities are most likely to ‘kick the habit’.
In addition to medication, individual psychotherapy and social therapy I encourage people to ‘participate.  Studies have shown repeatedly that those who are abstinent from addiction at 5 years belong to some group that supports their recovery.
Vaillant’s work showed that those 20 years clean and sober were most likely still attending a 12 step program or some other spiritual based program.
But the cornerstone of recovery is participation. It doesn’t have to be a spiritual program.  The loner is at highest risk.  Addiction presents as a ‘friend’ just like the dealer is a ‘friend’.
I had one senior government worker  patient heavily addicted to marijuana and asked her if she had any friends. She insisted she had one friend. That friend was her dealer.  We used to joke in adolescent psychiatry that if your only friend was your social worker you were in trouble. Well, in addiction psychiatry, if your only friend is your dealer you really are in trouble.
When you drive into a town there are usually two large lists of clubs.  One is the so called ‘spiritual club’ so you’ll see a surprisingly long and wide list of churches, synagogues, mosques and temples. Also you will see another list of ‘social’ or ‘community clubs - Elks, Kiwanis, Odd Fellows, Masons etc.  In addition to these emotional and spiritual community clubs there’s a garden variety secular club commonly called a ‘gym’ but also called a dojo, a yoga studio or ‘running club.’  The majority of successful people without addictions belong. Addictions eventually like other major mental illnesses are increasingly isolated and alienated.
12 step programs and spiritual clubs and some physical activities don’t ‘cost’ an arm and a leg.  The Yacht Club or the Jockey Club by contrast are usually well beyond the means of the person in recovery.
12 step clubs and most spiritual clubs welcome people without expectation of any more than a ‘buck’ and please fill a chair.  There are specific recovery ‘clubs’ like the Alano Clubs, a kind of coffeehouse atmosphere hang out, or the similar Recovery Club. The Avalon Society hosts  houses specifically for women. There are a new set of ‘sheds’ for men and a wide variety of ‘drop in’ clubs for mentally ill patients which welcome people in recovery as well. Since addiction is so depressing it is common for people in recovery to come to a realization of their depression and benefit from attendance at the mood disorder clubs or anxiety disorder clubs which are increasingly part of the urban landscape. There are specific support activities commonly, fully or particially funded by government.
The self help or community based services usually have a higher functioning capacity.  The average synagogue, church, or temple or YMCA/YMHA/YWCA will have a wide spread of highly successful to marginal individuals. This is like the 12 step programs where those who have long term recovery and ‘are’ back on their feet again are encouraged to hang around to help the next person.
Society is generally set up like a membrane with only a few ‘gateways’ where the addict or alcoholic in recovery can ‘mix’ with those who don’t suffer.  Part of the function of the health care system has been ‘quarantine’.  The local golf club doesn’t advertise, ‘heroin addicts welcome’.  It may not be right but it is real.
So Im forever encouraging patients to participate. To this end I encourage all the standard ‘health care based resources ‘but then encourage what was part of the patients life before the addiction kicked in.  Just as the addiction stopped a person from working and contributing and in recovery we encourage a person to return to work I encourage a person to return to those activities that they did before the addiction isolated them.  Not those activities which contributed to their addiction but the other ones.
Over many decades of work I’ve been pleased to be a part of  real success stories. Patients who were in school but dropped out have returned to school, often starting with a night school course and often going on to completing trades, bachelors, master’s or phd programs.  Recovery is that amazing.  So many of my patients have joined gyms and this has been the take off to their return to health and self esteem.  Yoga, Tai chi, martial arts programs, swimming, YMCA are all amazing places for increasing what has been increasingly called ‘recovery capital’.  There’s a lot to be said for ‘healthy body, healthy mind’
Actual human longevity has been associated with ‘relationships’ , the more connections one has the better off one is. What a contrast to the crack addict sitting alone with pornography in a single room with the curtains drawn. What a contrast to the grossly obese person who sits alone at the smorgasbord.  Or consider the addicts whose only contact with a neighbour is sharing a needle or the alcoholic  nursing their bottle in the lonely drinking bar.
Many of my patients have benefitted most from going to AA or NA or CA (Cocaine anonymous) or OA,  Overeaters Anonymous, or GA, Gamblers Anonymous, or Debtors Anonymous or Sexaholics Anonymous, Codepents Anonymous or Sex and Love Addicts Anonymous.   There are literally millions involved in the 12 step (or anonymous ) recovery programs. And now increasingly SMART another cognitive behavioural pseudo self help program is increasingly available.
Churches, temples, mosques and synagogues are a cornerstone for recovery. If you ever attended or your parents attended any then you’re really welcome back  Besides that being a ‘club tourists’ is always welcome and I encourage people to simply ‘drop in’ a few times to these ‘clubs’ in their neighbourhood, and put a ‘buck’ in the basket and go a few times to see if it ‘fits’. Anything is better for recovery and depression than being with ones self or one’s dealer.  We joke by saying that ‘I may not be much but I’m all I think about’ and “my brain is a bad neighbourhood, I shouldn’t go their alone.” It’s equally important to consider ‘volunteer activities’ and become involved in the countless volunteer clubs and activities increasingly available to get one outside of themselves. It’s old adage that if you haven’t shoes then you can still help a person without feet. So much of recovery is ‘perspective’.
I’ve had countless patients benefit from returning to the spiritual organizations that they attended as a child. Commonly addiction makes one critical of all those activities that don’t promoted addiction. These spiritual organizations are themselves reaching out to the recovery community with a local synagogue having a weekly group for people in recovery, countless churches of all denominations having weekly dinners and services and the various HIndu, Sikh and Muslim temples encouraging people to forsake their addictions and participate in community. In Malaysia the mosques have methadone clinics situated in their buildings with a combination of spiritual and medical personal available for people seeking help with addictions.  The local indigenous community has a variety of native healing communities involving sweat lodges, drumming societies and smudging.
A lot of my patients have been welcomed back open armed into the HIndu and Sikh temples where their extended families are so happy to see them engaging in their communities. Yoga is especially helpful in recovery while mindfulness meditation is increasingly recommended.  The taoist tai chi organizations are further ‘clubs’ where people can get healthy and learn a wholistic approach to their recovery.
Each ethnic and cultural group has it’s own ‘community’ clubs.  Where a person might have rejected their ‘catholic roots’ they might well find ‘participation’  and extended friendship in the local ‘buddhist’ temple.  The key is ‘participation’ .  Going from isolation to ‘participation’ is what works and where it begins isn’t necessarily where it ends. A number of my patients have gone on to leadership in community organizations that are at variance with where they began. A United Church minister left aetheism by joining the vaguely theistic unitarian church  to move onto anglicanism and eventually becoming a united church minister.  The key is movement.  Get out.   I have patients who have done exceptionally well in organizations like Kiwanis and Masons.  A number of women I had as patients in the country gave up drinking wine alone by joining the local quilting society.
The ‘meet up.com’ app is an amazing resource for activities for people to participate in.
I am also encouraging people to join political parties. To date 99% of those who have followed this advice have joined ones other than my own. The key is that political parties in Canada at least are ‘cheap’ to join and have a wide variety of community interests and activities.  It’s uplifting for people who once were the greatest ‘critics’ to be seen voting and participating in the political process.
Some of my patients have stayed sober in Toastmasters, others have overcome depressions and gained a whole variety of skills theres. Still others have joined a variety of dance organizations, including Salsa International, Arthur Murray’s, Fred Astaire, and all the different ethiic dance organizations including square dancing and high land dancing.  As much as we like to demonize leaders of the different parties individually they are truly amazingly accomplish social individuals.
Addiction is isolation.  It carries a large component of shame.  Recovery is participation.  Rather than a ‘phoney’ or ‘fake relationship’ with one’s substance of choice or addiction of choice, one moves out of being a mental wanker to being a part of community and participating in all the wide variety of activities that people do where addiction is frowned on and certainly isn’t a selling feature.
Some ‘clubs’ require ‘caution’.  For a while some Legions were glorified drinking clubs dominated by alcoholics though increasingly I hear that these organizations and other veterans organizations are working actively to identify and counter addictions that not surprisingly  follow combat experience. A third of those with ptsd and no other history of addiction vulnerability developed addiction. Underlying all addiction it can be said is anxiety, most commonly social anxiety and sadly ‘if you don’t use it you lose it’.  However, there's also a lot of 'yes, but' in addiction. Prochaska encouraged maximum resource input into those who were willing to be 'active' in their recovery. "Show me, don't tell me."  Many patients are indeed looking for someone to blame rather than wanting to 'change'.  It's not surprising that the phrase 'If you talk the talk, walk the walk' is so prevalent in treatment centres.  Many addicts want to say they are seeing a therapist only to 'appear' to be 'participating' and of course will get very angry if you don't 'collude' with their outright 'refusal to change'.  Not surprisingly 'drug testing' is common place in early recovery for those returning to work.
Dr. Paul O., famous for recovery, said “I can find a problem with a white wall and if you don’t see the problem, it’s an even greater problem.”  Addicts who would shoot up in a church basement without concern or get drunk at any church wedding or funeral would suddenly say they couldn’t attend AA or whatever because of the ‘god’ stuff. Thankfully SMART was developed and atheists can as well join ‘philosopher’s corner’ or ‘political parties’. Most commonly the ‘criticism’ reflects’ lack of willingness to change.  This is sadly indicative of high risk for relapse since commonly people’s previous life is adapted to support the addiction and people feel most comfortable with what they know. All change is anxiety provoking and initially discomforting. The obese are, in my experience, least likely to jump at the suggestion to join a gym.
It’s not rocket science.  It’s really very simple. Yet it’s not easy.  Those who want to change most will eventually make the effort or sadly die or end up in jails or hospitals as a consequence of their persisting addiction and isolation.  Now of course there are ‘exceptions’ and not all people with addiction are ‘isolated’ in this way. Some are merely ‘isolated’ in themselves . But that’s a specific sub group.  The generalization addiction is isolation and recovery is participation is just garden variety main stream.