Chemical Dependence and Treatment Today
by Paul H. Earley, M.D.
& Michael L. Fishman, M.D.
BARRIERS TO RECOGNITION
It is no longer surprising when a movie star, a politician, or a sports hero, reveals to the news media a personal struggle with the perils of addiction. The disease is common; we now know that it afflicts an estimated 10% of the population. In Atlanta alone there are thousands of people in various stages of addiction and recovery. Alcoholics Anonymous, the oldest and largest self-help group for alcoholics in recovery, reports that more than one thousand AA meetings are held each week in the greater Atlanta area.
While these numbers are remarkable, the number of addicts who continue to suffer with their alcoholism or drug addiction remains much larger. The disease of addiction is still misunderstood, and the consequences of this misunderstanding are gravest for addicts themselves. The most formidable barrier to a rational understanding of the disease is the mental image people have of addicts, based on nothing more substantial than prejudice. When people think “alcoholic” or “addict,” they envision a down-and-out street person cradling his bottle in a torn brown paper bag. Despite the celebrity confessions and the odds that most of us have a family member, colleague, or neighbor with chemical dependence, this image persists in the back of our minds and interferes with awareness of our own addictive behavior. We struggle instead with the more palatable idea that next time, by handling our drinking or drug use differently, we will prove ourselves immune from this haunting mental image.
Dr. Paul Earley and Ridgeview alumni will be featured in a new five-part documentary on treatment and recovery by renowned journalist Bill Moyers. Close to Home: A Moyers Report on Addiction will air nationally on public television, March 29, 30, and 31, 1998, 9:00 P.M.
Reprinted from Insight Magazine, Vol. 18 No. 2 Fall 1997, a publication of Ridgeview Institute. For permission to reprint, call (770) 434-4568, Eat. 3006. For more information on Ridgeview’s programs and services, call (770) 434-4567, or 1 (800) 329-9775.
Some patients describe the increasingly unfamiliar way they were before, as if they had been looking at life from atop a strange mountain. To the individual entering this phase everything looks different, though it is in fact he who has changed.
Addiction to alcohol or drugs is the final common pathway. Many factors may propel an individual along the road to addiction; once there, however, one cannot go back to the days when drug use was voluntary or casual. One of the most powerful factors leading to addiction is a genetic tendency. This does not mean that people inherit addiction, but that they inherit the propensity for it. Whether they go on to develop an addiction depends not only on genetics but on the repeated consumption of addictive substances, and factors like family structure, personality, and environment. Children who have grown up in an atmosphere of shame experience a high incidence of addiction. People who tend to be anxious and driven or who have other psychological problems seem especially vulnerable to addiction. Childhood trauma-whether intentionally inflicted, like sexual abuse; or unintentionally inflicted, like the death of a parent-can result in an emotional injury that leaves us susceptible to becoming addicted. Stress can also lead a casual substance user along the road to compulsive use of chemicals. Each of these factors link in various combinations to reach the final common pathway: the disease of addiction. Regardless of the particular combination of contributing factors, once a person has developed an addiction, complex alterations in the brain’s chemistry make it impossible to return to an earlier phase of moderation and control. Unfortunately, people spend a lot of time and energy wishing to return to what is already irrevocable.
Another barrier to recognizing chemical dependence is that people addicted to drugs tend to misinterpret the source of the chaos in their lives. Alcoholics and addicts invariably define their problem as something external to themselves: a nagging spouse, hormones, a stressful job, or the drug itself, which they have come to both hate and crave. Research during the last decade has revealed that many individuals suffer from more than one addiction-6o% of people with bulimia nervosa are also alcoholic, 8o% of gambling addicts are addicted to chemical substances-that we now realize the problem of addiction occurs in the relationship between the brain of the addicted individual and the substance or behavior.
Whatever the addictive substance or behavior, symptoms of addiction are the same. One of the primary symptoms is denial, which makes it very difficult for the addict to seek help. Other manifestations of chemical dependence include physical dependence and increasing tolerance for the drug. Once the person is under the sway of addiction, what began as apparently harmless and voluntary social drinking or occasional drug use becomes the ruling passion of his life. Nothing–the entreaties of his wife, tears of his children, loss of a job, skirmishes with the law-is as important, or even appears to get through to him.
WHAT HAPPENS TO THE BRAIN IN ADDICTION
Understanding how addiction affects the brain helps explain these perplexing symptoms. To appreciate the process that goes haywire in the addict, it is helpful to visualize the basic structure of the brain. The cortex is the part of our brain in which conscious thought occurs, and the part of the brain that makes us distinctly human. The cortex is also called the “new brain” because from an evolutionary point of view, it appears in more highly evolved species such as lower primates and humans. The cortex houses the superior mental faculties-memory, learning, and judgment-of which we are understandably proud; it is, in fact, the part on which all conscious thought is based.
Despite its amazing properties, however, the human cortex is baffled by addiction. To see why, we must look at another part of the brain, the midbrain. The midbrain is the seat of the basic drives: hunger, thirst, the fight or flight reaction, sex, and the pain regulator. No conscious thought occurs in the midbrain; instead, pressure from the midbrain is transmitted to the cortex, where it registers as conscious thought (“I’m hungry.”). Although the cortex may appear to be running the show, the midbrain wields deceptive power. Several times in life-at puberty, for instance-the midbrain totally rearranges the way we see the world
From the perspective of addiction, the midbrain is where the action is. In people who become addicted-to alcohol, other drugs, compulsive behaviors-the midbrain takes on a sixth activity in addition to the five basic drives. This sixth activity is a primitive push for the addictive substance or behavior, which feels to the individual exactly like a basic drive. But there are two fundamental differences between this sixth function and the basic drives. The sixth (addictive) function eventually grows so powerful that it eclipses all the drives. And whereas the drives push the individual toward self-preservation, the sixth “drive,” the pressure to get drunk or high, leads ultimately to self-annihilation.
The midbrain sends its signals to the cortex through the motor cortex, which controls movement. First there is the pressure from the midbrain followed by a motor event. For example, the midbrain transmits pressure for alcohol. The alcoholic turns into the liquor store parking lot. Only then does what cortical neurophysiologists have dubbed the interpreter in the brain kick in to analyze the action: “You deserve a drink.” The interpreter tries, in retrospect, to make sense of the action triggered by the midbrain and carried out by the motor cortex.
Such an assessment mechanism is doomed to fail because of the discrepancy between the raw drive for a drug and the individual’s rational functioning. Errors in interpretation multiply, entrenching the person in denial. These misperceptions and rationalizations are the hallmark of addictive thinking.
IMPLICATIONS FOR TREATMENT
For treatment to be effective, the brain must be educated about the errors in circuitry by which it has been baffled. From our current understanding of the subtle changes in chemistry that occur in the brain during addiction, two important corollaries emerge:
You Can’t Think Your Way Out of Addiction. PAUL H. EARLEY, M.D., specializes in long term psychotherapy with individuals in recovery. Dr. Earley is the author of The Cocaine Recovery Book and The Cocaine Recovery Workbook. He serves on the Board of Directors and is a Fellow of the American Society of Addiction Medicine.
Treatment helps the addicted person reconcile the basic conflict between the cortex and the midbrain, or the old brain and the new brain. The critical role of the midbrain shows why even the most sophisticated analytical thinking cannot lead a person out of his addiction. Professionals often seem to have an especially difficult time in coming to terms with addiction. They may have achieved brilliantly in their careers and highly value their analytic abilities and reasoning powers. The mental capacity that has served them so well and distinguished them from their peers, however, is unreliable as an ally in this struggle. To recover, one needs the cooperation and integration of the midbrain, which is the common denominator not only of our humanity but also our relation with the other animal species.
A tragic error in treatment for addiction early in the century was the mistaken belief that if the addict could develop enough insight into his problems and come to feel better about himself through psychoanalysis or another form of psychotherapy, he could stop the addictive behavior. Sadly, the relapse histories of countless patients proved this a critical and often fatal error. To the addict, no amount of insight about underlying causes is enough to overcome the craving for chemical relief that occurs when one is actively using drugs and alcohol.
Recovery Takes Time
When a drug is introduced to the body of a person who will become addicted, it leads to a surge of euphoria that is quicker and more intense than any “high” the body can produce. This artificial activation of the brain’s reward system increases the release of certain chemical substances, or neurotransmitters; however, this surge of euphoria does not last. After the body develops tolerance, larger quantities are needed; the addict begins to need the drug not to feel high but to feel normal. This happens because the brain’s chemistry develops tolerance for the artificial surge produced by addictive drugs. When the addictive drug is withdrawn in treatment, it takes the body awhile to resume production of substances that make the person feel a sense of calm and well-being. This process of detoxification and normalization of thought takes time, usually months or years.
Once detoxified, the individual in recovery must hack through the thicket of excuses and rationalizations by which his brain has attempted to make sense of his bizarre behavior. This also takes time. When the addict finally and deeply understands the havoc wrought by drug use in the brain’s natural chemistry, the midbrain essentially gives up, and the individual feels set free from the compulsion to drink or use drugs.
THE NATURE OF TREATMENT TODAY
Based on our current scientific knowledge about addiction and treatment, the treatment process at Ridgeview Institute encompasses four distinct phases of recovery.
1. Behavioral Intervention The first step in treatment involves behavioral containment, stopping the drug from entering the body. Once the individual feels the tug of addiction as a primitive drive, no therapeutic change can occur until he stops taking the addictive drug. Acute detoxification usually takes several weeks; it may take months before the brain’s chemistry returns to normal. During this early phase, alcoholics and other addicts often feel like they have lost their best friend or lover and experience enormous grief and/or anger, as well as depression.
Among the most destructive cultural attitudes toward alcoholism and drug addiction is the notion that the addicted person is morally weak and lacks self-discipline.
2. Cognitive Insight The phase of cognitive insight is the “Aha!” phase, during which the recovering person begins to recognize and make sense of his formerly perplexing behavior. This usually occurs in a series of fits and starts over a period of about a week.
3. Emotional Integration During the phase of emotional integration, the recovering person begins to rediscover his feelings. This process takes weeks-feelings may have been buried for a long time, and they are usually covered in shame. Among the most destructive cultural attitudes toward alcoholism and drug addiction is the notion that the addicted person is morally weak and lacks self-discipline. When internalized, this attitude interferes with the alcoholic’s realization that he has a disease and with his understanding of the insidious disease process. We sometimes call the phase of emotional integration the “Ugh” phase because it is difficult work-work that requires courage. Most people who do not recover from chemical dependence give up or attempt to sidestep this painful phase.
4. Transformation Transformation is the last stage of change-the transition into recovery. Transformation does not mean changing one’s mind about using drugs. It means nothing less than seeing the world in a different way. The transformation phase is what recovering addicts often describe as a spiritual experience. Some patients describe the increasingly unfamiliar way they were before, as if they had been looking at life from atop a strange mountain. To the individual entering this phase everything and everybody looks different, though it is in fact he who has changed. People who make it to the transformation phase generally lock in their recovery and go on to live life free of drugs and filled with an inner peace that often surprises them and those around them.
WHO SEEKS TREATMENT?
The disease of addiction knows no demographic boundaries; it affects people of both sexes and all ages, races, lifestyles, job classifications, and income brackets. Recent years have witnessed some shifts in the patient groups seeking treatment for chemical dependence. Although Ridgeview Institute has always drawn a large proportion of alcoholic patients, the number of alcoholic professionals-physicians, nurses, pharmacists, attorneys, ministers-has increased considerably, with the steady growth of the Impaired Professionals Program. In the past, more chemically dependent patients at Ridgeview were men; at present, the numbers of men and women are nearly equal. People now tend to seek treatment at a greater range across the age spectrum. While the number of patients in treatment for cocaine addiction has declined during the past few years, there has been a resurgence in heroin addiction. The heroin-immersed popular music culture has unfortunately attracted a large crowd under 28; many of these young people have become addicted to the drug either by snorting, smoking, or injecting it. Whatever the addictive drug, the chemically dependent patients we see tend to be psychologically fragile and to experience great fluctuations in self-esteem.
THE IMPACT ON MANAGED CARE
The shift toward managed care has profoundly changed the American health care delivery landscape, and specifically the way treatment is provided at Ridgeview. Some of these changes have led to serious concerns among those responsible for offering effective treatment for addiction. Whereas addicted patients used to be admitted for an inpatient stay of 21 to 28 days followed by tapered care, today’s patients stay in inpatient treatment more than three days only in cases of severe medical problems or if the attending physician is concerned that drug withdrawal may lead to suicide or homicide.
The compressed treatment schedule required by managed care is potentially dangerous because recovery takes time. In fact, time is the greatest ally in mobilizing the recovery reflex. Now patients are required to make important treatment decisions when their brains are still toxic from their drugs and lifestyle.
MICHAEL L. FISHMAN,M.D., specializes in chemical and nicotine dependence. Dr. Fishman is the author of “Treatment Centers: The Next Challenge,” published in the Journal of Substance Abuse Treatment. He is a member of the American Society of Addiction Medicine, and a medical review officer.
But there is a brighter side. The pressures of managed care have forced treatment to become more efficient and cost-effective. With the uniform, 28-day inpatient treatment model of the past, some patients may have been hospitalized longer than necessary. Today’s shorter inpatient stays tend to be less disruptive to patients’ lives. For some patients, inpatient detoxification is not necessary, and can be managed in partial hospitalization or intensive outpatient treatment. The advantage of outpatient detoxification is that limited care dollars can be spent at a time when patients are better able to comprehend the treatment process. Finally, payors have forced treatment programs to pay more attention to the particular outcomes of treatment. Those who have a basic and abiding interest in helping the addicted person recover are now challenged to accomplish as much as possible within a shorter time.
THE CONTINUUM OF CARE
Partly because of managed care, the standard treatment program of the past has been replaced by a continuum of care options. Before treatment begins, a team of addiction specialists assesses the patient’s condition, determines a treatment plan, and prescribes an appropriate level of care. The continuum of care ranges from outpatient detoxification to intensive inpatient treatment, with several intermediate levels, depending on the needs and circumstances of the individual.
Patients with severe drug dependence or other medical problems may require intensive inpatient care for medical stabilization, after which they will transition to one of the other levels of care to continue the recovery process.
Partial hospitalization or day treatment is an option for patients who need more support and structure than outpatient treatment can provide, but do not require 24-hour medical supervision. Recovering alcoholics and addicts in the partial hospitalization program typically spend 6-8 hours per day in treatment, and return home or to a recovery residence in the evening.
Intensive outpatient treatment, day or evening, offers a flexible schedule of treatment-usually 3 to 6 hours per day. This allows patients to live at home and maintain a work schedule. Some patients in partial hospitalization or intensive outpatient care live in Ridgeview’s on campus Recovery Residences, which provide a supportive living environment, and help the alcoholic or addict reconnect with their humanness.
Specialized treatment tracks and groups target the particular needs of recovering addicts. These include groups for African-Americans, for people who have struggled with relapses, and for those trying to overcome addiction as well as depression or other psychiatric disorders. In addition, family support groups and activities help husbands, wives, and children come to terms with the addict’s disease and attempt to integrate his or her recovery process into the fabric of family life.
THERAPY AND THE 12-STEP PROGRAMS
The 12-Step Programs are the backbone of recovery both in the initial treatment phase and in sustaining the benefits of treatment. Intensity of care has been shown to be less significant than duration of care in galvanizing successful recovery. Before they leave Ridgeview, patients make a commitment to participate in AA, Narcotics Anonymous (NA), Cocaine Anonymous (CA), or another 12-Step program as a lifelong part of their recovery. Twelve-Step programs offer the power of group support and collective life experience. In a safe setting, recovering alcoholics and addicts can continue to discover and explore a new way of life that involves expressing feelings rather than anesthetizing them.
For people who suffer with alcoholism and addiction, it’s not about will power; it’s too late for just saying no. In fact, acknowledging that your problem is beyond you and asking for help are the first steps toward recovery.
At Ridgeview Institute, we have helped thousands of people take the difficult first steps toward recovery and gain control of their lives. Our programs help you learn to live clean and sober, build self-awareness, heal family wounds and gain support from 12-Step meetings.
This kind of treatment is now available in day and evening programs that are less disruptive than in-patient treatment, yet are remarkably effective.
If you have reached a point where you are ready to accept help, take action now. Our counselors are available seven days a week, 24 hours a day. For more information and a free and confidential evaluation, call (770) 434-4567.