Substance Abuse, Dependence Becomes Substance Use Disorder

Substance use disorder, also known as drug use disorder, is a condition in which the use of one or more substances leads to a clinically significant impairment or distress. Although the termsubstance can refer to any physical matter, ‘substance‘ in this context is limited to psychoactive drugs.

 

 

DSM 5 changed our language from substance abuse to substance use disorder. Further, the diagnostic system requires that the substances be specified such that the DSM IV diagnosis of “poly substance abuse” has become “opiate use disorder, methamphetamine use disorder, tobacco use disorder and cannabis use disorder.”  More specificity in the diagnosis will help big data analyze “population health,” the new buzzword for focusing on trends and not on individuals. I wonder if there is a difference between “heroin use” and “heroin use disorder”.  Clearly, outlining the nature of the substances that the patient uses helps us understand the chemical feeling they are seeking. Yet, my experience in working in drug rehabilitation centers is that the majority of patients use all substances available to them including opiates, cannabis, alcohol, meth amphetamines and tobacco. I salute Lance Dodes MD http://www.lancedodes.com/ who says that substance abuse, like so many behaviors, are about self-sabotage, and not so much about the exact chemical that the patient is drawn to. He states, rightly so, that alcohol abuse is not qualitatively different from opiate abuse, but rather they are the result of self-hatred.This matches my clinical experience. If a patient goes from an alcohol use disorder to a gambling disorder, he does not have a new diagnosis, only a new symptom of an old diagnosis, which, in my mind would be a lost self. Rehabilitation centers need to help people love themselves, and how to do this is up for debate. Being tough, setting limits, or giving them understanding and compassion. Both approaches have successes and failures and both approaches do not know who to target and so most programs use a one-size fits all approach to a problem which uniquely develops in each person. In my mind, the diagnoses should be “escape disorder,” to group people together who need to escape from themselves, such that the major challenge is to find out what they are escaping. If they no longer have to escape, the substance will recede in importance. Is this oversimplifying a complex disorder? I do not think so. It is a hard job to find out what the patient is scared to face, and, of course, the pain they are avoiding is layered and often not obvious. Still, if the focus was on the escape and not the drug, there would be more hope. Our diagnostic system is important since it helps patients understand themselves and their family members. To speak in terms of “use disorders” misses the point.

 

 

Opiates, Race, and Public Health

 

http://www.theatlantic.com/politics/archive/2015/08/crack-heroin-and-race/401015/

 

“Heroin use has changed from an inner-city, minority-centered problem to one that has a more widespread geographical distribution, involving primarily white men and women in their late 20s living outside of large urban areas.”

What role should psychiatrists play in this changing epidemic? Is Opiate Use Disorder, (the new ICD 10 language), a psychiatric diagnosis? The issue of psychiatry and addiction has always been murky. Substance abuse as a disease is the common conception, and yet, little is known about what is diseased. What is the difference between substance abuse and criminal behavior? Is every armed robber in need of psychiatric treatment? Is there a difference between bad behavior and “sick” behavior. This Atlantic article highlights the issue that when the problem is predominantly in minorities, we tend to criminalize the behavior, but when the problem hits the middle class white folks then we see the need for rehabilitation.

Certainly the field is exploding, both because of the epidemic of opiate use disorders and the expanding health care coverage for drug problems. Yet, our understanding is very primitive. How do we help these people? Is it “tough love” or should we put them in a cocoon, feed them three square meals and tell them how to spend their time? Should we pamper them so they learn to love themselves or should we turn off the spigot of support so that they can “hit bottom”? Or, do we start with the loving, warm approach to treatment and slowly, as they “get better” diminish the support? Do they need group therapy, individual therapy and/or family therapy? How long does therapy take to prevent a relapse? On the other hand, if relapsing is part of the problem, then how do we hold providers accountable for their treatment?

Accidental overdoses are an all too common happening in this world. Who is responsible? Heroin use has grown in popularity in large measure because of prescription opioids. When the patient cannot get their “pills,” in order to prevent withdrawal, they have to switch to heroin. So, do we hold the prescribing doctor responsible for the addiction, or is this physician just trying to provide relief to needed suffering? What about the drug companies? Are they to be praised for creating a pill which diminishes pain, or are they the evil corporations which knowingly gets massive amounts of people addicted to drugs which  could lead to death?

Psychiatrists usually do not treat chronic pain, and yet we do have medications which diminish the cravings associated with substance abuse. Again, are we part of the problem or are we part of the solution? Diminishing cravings is helpful, but does it make sense to substitute one drug for another? Certainly if we can prevent the rise in accidental overdoses we are helping the world, but on an individual basis, the answer is less clear. In a simplistic sense, psychiatrists can be most helpful by trying to help the patient understand the escape. What is the patient trying to numb out about? Is it trauma? Usually, in my experience, the answer is yes. Metabolizing this trauma, helping to put it in perspective with a caring listener is, by my way of thinking, the best way for psychiatrists to help these patients. When the patient faces the childhood trauma with an adult, mature mind, the patient has less of a need to escape themselves. Can I prove that what I propose is true? Nope, but neither can anyone else. Given the lack of evidence in this field, intuition has to play a role, until otherwise notified.

Specialty Certifications

 

Addiction Medicine, eating disorders, geriatric, child, psychoanalysis all suggest additional psychiatric training and yet the meaning of each certification is very different. There is an addiction medicine board which requires one year in an addiction medicine fellowship, followed by an examination with an 87% pass rate, and if you have worked in the field, that can count as your fellowship. With eating disorders, there is no board examination, but there are letters one can get after one’s name which says they are “certified” to treat eating disorders. Geriatric and child boards both imply a 1-2 year fellowship program along with a board examination. Yet, how much of this extra training is necessary, versus learning about these areas on the job? I am a board certified psychiatrist and I am a psychoanalyst. I do carry a bias that these two areas of extra training has widened my scope of practice and has given me the tools and the confidence to treat all patients, from cradle to grave. At the same time, I now work in the addiction world, and I also feel confident that my skill set is very useful there, and that I could sit for the addiction boards, but I am not sure I see the point. Would my colleagues respect me for it? Maybe. Is this worth the time and expense for board preparation? Maybe. Would my work with my substance abuse patients be more insightful, if I disciplined myself to study for this exam? Maybe. Typically, I am up for the challenge of a new certificate. I enjoy learning new things and I appreciate the neuronal stimulation this activity would give me. On the other hand, after 25 years in practice, I feel confident in my skill set and I see addiction, as with all of the human condition, as part of the self-destructive behaviors which in the short-term alleviate pain, but in the long-term create misery and hopelessness for the patient and for those around him. That argument is not very compelling. Knowledge is helpful and deepening my understanding of addiction is crucial to helping my patients. I think I should go for it.

Where Have I Been?

 

I went dark there for a bit, compelling me to talk about my professional transitions. First, I am slowly working on making my office an electronic, moving into our digital world, with all the associated fears and excitement. My first goal is to e-prescribe, giving my patients the freedom to go directly to the pharmacy without the hassle of dropping off a prescription. My hesitation thus far has been that scheduled drugs, meaning stimulants and sleeping medications, require more sophisticated software to e-prescribe and so that limits me considerably. Still, I am going to take the baby step of e-prescribing to those who do not take regulated medications. This will give me mobile access to more information and it will make information management simpler. On the other hand, privacy concerns are huge, as is the dependence on connectivity. I can still write prescriptions, but with each baby step, I get more and more dependent on the internet.

Second, I am expanding my clinical practice to include an emphasis on “recovery” patients, meaning those people who find themselves wanting (and usually needing) to clean themselves from dangerous substances. This is an exciting expansion for me, as I am curious to drill down into the psychological underpinnings of self-harm. Self-harm, in big ways and small ways, has always been a major emphasis of my practice, but adding a focus of substance abuse expands my understanding of the human mind. My inquiry, my passion, for hearing a person’s narrative fits well with helping those who are seeking to start a new chapter. My understanding of psychotropic drugs both helps me understand some of the consequences of their addiction as well as helping me use prescription drugs to decrease their suffering while they transition from substance dependence to sober living.

These two areas of expansion have consumed the part of my brain which allows me to post often. As I settle into my new routines, while maintaining my previous focus on private practice and teaching, I hope to resume frequent postings. Thank you, readers, for your patience.

Does ‘Ecstasy’ Live Up To It’s Name?

http://www.latimes.com/local/la-me-mdma-20140316,0,4729638.story#axzz2wFf3Afb4

“By some estimates, as many as 4,000 therapists were using MDMA in their practices before federal authorities banned the drug.”

MDMA, the active ingredient in Ecstasy, heals the traumatized brain, or so some patients and therapists believe. No science exists, only anecdotes. Is it compassionate to try a compound in which the stories sound compelling, even though it is illegal? This is the dilemma posed by this article which grabbed my attention both because of the ethical dilemma, and the intriguing neurochemistry. Let me start with the latter. Can we imagine a chemical which makes traumatic memories, memories from war-torn environments, memories from childhood sexual abuse, somehow seem less shameful and more open to discussion? Yes, I can imagine that. I can see how if the amygdala is suppressed, then the sting, if you will, of the memory is diminished, and thereby a narrative can flow without the obstruction of judgment or horror. As to the ethical dilemma, this is more troubling to me. Both sides of the dilemma make sense. On the one hand, people who are suffering need relief, and sometimes we have to think out of the box to obtain that. On the other hand, science is critical to advancement and so we should advocate for meticulous research before walking into territory which could cause more harm than good. Yes, it is true, that my professors did LSD research on autistic children, to see if the LSD would help with social skills, and so using illicit drugs for medicinal purposes is not a new idea. Yet, these professors used government funding to explore, what turned out to be, a failed experiment. For the clinician to advise MDMA ingestion, without the rigors of a clinical trial strikes me as well-intention, but misguided. The seduction that a medicine or a diet can alleviate human suffering creates an industry of hope and opportunity. If there were no side effects, like our relatively new gluten-free fad, then I am happy to emphasize the lack of science and encourage people to have their own trial. However, in the case of MDMA, fooling around with brain chemistry is a very scary proposition. I am waiting for the science, even though, as the article reminds us, no one seems to want to fund this. Having said that, I would rather use our current tools than to step over that anecdotal line which says,  “well, it worked for me, and so it might work for you too.” Ecstasy, the drug, in my clinical experience, is a wish for some, true for others, and a nightmare for the rest of the folks. I repeat. I am waiting for good data.

See also ……

Flashback to the 1960s: LSD in the treatment of autism.

Sigafoos J1, Green VA, Edrisinha C, Lancioni GE.

Author information

Abstract

Between 1959 and 1974, several groups of researchers issued reports on the use of d-Lysergic Acid Diethylamide (LSD) in the treatment of children with autism. This paper reviews that literature to consider how the authors justified these studies, as well as their methods, results, and conclusions. The justification for using LSD was often based on the default logic that other treatment efforts had failed. Several positive outcomes were reported with the use of LSD, but most of these studies lacked proper experimental controls and presented largely narrative/descriptive data. Today there is renewed interest in the use of psychedelic drugs for therapeutic purposes. While this resurgence of research has not yet included children with autism, this review of the LSD studies from the 1960s and 1970s offers important lessons for future efforts to evaluate new or controversial treatments for children with autism.

PMID:

 

17608329

 

[PubMed – indexed for MEDLINE]

Doctor Rant

 

 

http://www.latimes.com/local/la-me-rx-source-20140304,0,3275352.story#axzz2v38ABubS

 

Doctors give pain pills to relieve suffering, avoid phone calls and to be liked by their patients. Many, as described in today’s LA Times article, do not seem to think about the public health hazard of prescription opiates, given to patients who might be abusing them. Oral surgery is a prime example. Many young adults get their wisdom teeth removed, followed by a prescription for 30 opiates, most of which are not necessary for pain relief. Most teenagers can use a Non-steroidal anti-inflammatory agent.Those who need stronger pain relief need one or two pills, not thirty. Then why are  there massive amounts of opiates being prescribed? Lot of  pain medications means the doctor won’t get called for more medication. This is a bad reason. Worse yet, are those doctors not considering that the patient is drug-seeking? Even before today’s environment where patient satisfaction is seen as a key indicator of physician quality, many doctors get a narcissistic high when patients are grateful, even if they are grateful for medication which they can use to hurt themselves. Gratitude is a seducer and as such, many physicians are vulnerable to losing good judgment in exchange for feeling important. Now that it is exposed that doctors are a key part of the prescription drug abuse problem, there will be better monitoring of a physician’s prescribing practice, and as such, there will be a better tracking system of the great offenders. This might help, but my suggestion is more training in medical school and residencies about how the power to prescribe, means the responsibility to say no, and in so doing, physicians need to learn to tolerate the ensuing rage associated with limit setting. This rage, in today’s world, often means scalding reports on social media sites, and again, physicians need to accept that drug addicts, incensed that they cannot get what they want, can then cause internet distress. This is the world we now live in. Doctors need to rise above. This begins with good training. We have a long way to go.

Addiction Therapy: Let’s Think About This

How do we treat addiction? Psychotherapy? Psychopharmacology? Rehabilitation Facilities? Yoga? Meditation? Twelve Step Programs? All of the above? None of the above? There are no answers to these questions, yet with the Affordable Care Act, every plan must include addiction treatment. We, taxpayers, will support treatment for which there are very few outcome measures of success. Am I saying that people with addiction should not get treatment? No, addiction is a symptom of an underlying disorder in one’s mental state, in which one sabotages oneself, and one’s family, and as such, treatment is indicated. At the same time, we need to be honest that although treatment is indicated, the field is in its infancy, and as such, the appropriate intervention is not known. Scientific studies are in progress, but we need to deal with the state of the art, at the moment. My solution is that every patient with self-sabotaging behavior, including addictions, should be evaluated by a psychiatrist and then the psychiatrist can determine the best plan of action. I do not think patients should self-refer to a rehabilitation facility, as this is an intervention that makes sense for some, but not all addicts. I return to the  building blocks of good medical care. A good history, an experienced and well-trained clinician, yields our best bet, given the limited science. The term “addiction treatment” should be re-framed to go under general psychiatric care, where patients are evaluated for mental distress and then referred on to a treatment program. “Addiction treatment” should not be separated from psychiatric care, in general. This division takes away from patient’s understanding of themselves, which is critical to their recovery. The psychiatrist needs to explain to patients, after the evaluation, his/her best guess as to the nature of his illness and the most appropriate intervention. Calling it “addiction coverage” is like saying all insurance plans should have “chemotherapy coverage”. Addiction coverage should be implied in mental health care. I state the obvious, but apparently, it needs to be said.

http://www.whitehouse.gov/ondcp/healthcare

Rave Rant

http://www.latimes.com/nation/nationnow/la-na-nn-electric-zoo-rave-cancelled-20130901,0,3687215.story

http://graphics.latimes.com/towergraphic-coliseum-rave-deaths/

http://www.latimes.com/news/local/la-vn-playing-with-fire-20130125,0,7910386.premiumvideo

“Most of the dead were in their teens and early 20s, according to the records. The youngest was 15-year-old Sasha Rodriguez, who overdosed at Insomniac’s Electric Daisy Carnival in 2010 at the Los Angeles Memorial Coliseum.”

Thousands of people gather together for an all-night concert with dangerous drugs being passed around, like water, making the timbers there for a fire, but it seems to me children had to die to let people know this was dangerous. I have been anxious about raves for years, hearing about the crowded conditions, lack of sleep, and heavy drug use. I have worried about adolescent after adolescent who attends these events, knowing that the ingredients for disaster are there. Sure enough, children have died, heads have rolled, and raves continue. I know we live in a free country, and so we are not about to legislate the freedom to go to concerts, but having adolescents in a large crowded space, not having good impulse control, is a recipe for disaster. I am glad that New York and Los Angeles and Dallas have closed their venues for raves, but I am saddened that these young people had to die to make that happen. I think about Sasha Rodriguez, not knowing her, but imagining that she was a young kid who, quite accidentally, got into harm’s way, which in other venues would have given her a bad headache, or a close encounter with a toilet, but given the dangers of a rave, resulted in death. How sad this must be for her family, her friends, and for her.

Women And Opiates: My Rant

Pills of hydrocodone, also known as Vicodin, are shown. Drug overdose is one of the few causes of death in the United States that is worsening, eclipsing fatal traffic accidents in 2009. (Toby Talbot / Associated Press / February 19, 2013)

“About 15,300 women died from overdoses of all kinds in 2010, more than from car accidents or cervical cancer, according to the CDC.

Overdose deaths rose most rapidly among middle-aged women who, previous research has shown, are more likely to suffer from chronic pain and to be prescribed painkillers.

“Mothers, wives, sisters and daughters are dying at rates that we have never seen before,” Frieden said. ‘These are really troubling numbers.’ ”

http://www.latimes.com/news/local/la-me-rx-painkillers-20130703,0,916397.story

 

I highly suspect that many of these “middle-aged women” taking opiates, overdosing from opiates, complaining of chronic pain, are suffering from disappointments, psychic pain, and frustration with their lives, particularly their relationships. This “middle-age” for women, as we all know, is associated with launching children, coping with elderly and disabled parents, menopausal body changes, along with mid-life relationships which range from long-term marriages to being new to the dating scene to perpetuating a single life, which may or may not feel satisfying. Where do these women turn? The psychiatrist? Nope. For both social and financial reasons, these women, generally speaking,  turn to their trusted primary care physician. However,  complaining about their husbands, children or their parents, seems like a “waste of time,” so they focus on the very real pain of aging. Joints do not work as well. Injuries are more common. The fluidity of the body is slowly declining and so they complain. Exercise, of course, should be the first line of defense, but primary care physicians are usually coached to get rid of pain quickly, rather than telling patients to exercise, as primary care doctors often feel that the exercise  recommendation is unlikely to be understood as helpful, but rather the patient responds with  “yea, I know, but I won’t.” The culture of doctors wanting to please their patients, encourages physicians to give them opiates for pain that is not clearly understood, but complained about. “What is going on with your life, right now?” is the question that I wish happened in that eight minute office visit. Primary care doctors could venture an educated guess, that the pain of aging is exacerbated by disappointments in relationships. Middle-age is a hard time for women. The culture seems to understand the “mid-life crisis” of men, but women, too, examine their choices, sometimes with feelings of deep regret and despair. Maybe opiates numb that despair, and over time, as the feelings mount, so does the opiate use, leading to tragic and preventable death. My solution: Exercise and psychotherapy for these women who come complaining of body pain, while working them up to make sure that they do not have an underlying disease process which requires medical intervention. Opiates are wonderful drugs for those facing the end of their lives due to a debilitating disease. By contrast, opiates ruin the lives of those who could have a lot to look forward to, but who need to get over a major hurdle in their lives.  Physicians need to understand that. Women deserve it.