The Addicted Brain (25 page)

These treatments focus on behavior and use plans and practices that will modify toxic behavior. Therapy sessions can be individual (one on one) with the counselor, in groups where many patients interact with a trained leader, or in family therapy where family members form the group.

In individual therapy, more time can be devoted to the patient’s specific needs. Group therapy, however, can be more economical because six to eight patients might share the cost of the therapist. Also, the more experienced members of the group can be mentors and models for newer patients, and the public nature of the process, where admissions of failures are open, and advice can come from many, can be powerful. Family therapy can be effective when the patient is either at home or have family nearby, and they can be recruited to assist in the treatment process.

Therapies that are proven are available and used in many centers. Although there are too many to summarize, here are some examples that give an idea of what might lie ahead for someone entering treatment. Cognitive Behavioral Therapy, pioneered by Dr. Aaron Beck and others, is designed to help the patient avoid relapse. It is a process where the patients describe high-risk situations, situations where they know they will be weak and perhaps fall back to drug use. Having identified these situations, the patient, along with the therapist, rehearses, role plays, and learns strategies including actions or thoughts that will help him or her survive these high-risk situations. This therapy uses the cognitive or thinking abilities of the patient. It might be especially useful for someone who is intellectually oriented.

Contingency management is another therapy that has been studied by Dr. Steve Higgins and others. It is a technique that uses a reward to divert the patient from dangerous behaviors. Getting the reward is
contingent
or dependent on carrying out specified, helpful behaviors or avoiding destructive behaviors. For example, if a patient has drug-free urine, which is obviously a goal in treatment programs, then he or she might be eligible for a voucher, which has some value. It might be tickets for a movie or credit for a meal. Getting healthy rewards that compete with drug use is effective.

Another treatment is simply exercise. It can be done alone, at one’s convenience, and it’s free. The Monitoring the Future survey shows that high school students who exercise regularly are less likely
to use cigarettes or marijuana than teens who are sedentary.
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It isn’t clear that the effect of exercise is a direct one, but this discovery could have implications for treatment.

Treatment is given in different settings and depends on the need of the patient and on the resources that are available. It can be simply given once a week with a school counselor in conjunction with family efforts. It can be given to an inpatient in a hospital or facility specifically designed to treat drug users. It can be given in prison, or it can be mandated by a judge for a non-violent offender as an alternative to prison.

Treatment and prevention can be facilitated in many ways. On March 16, 2011, the
USA Today
newspaper published an article describing how colleges and universities are devoting resources to help students in recovery. Parties in colleges and fraternities are legendary for their supply of drugs and dangerous to someone in recovery. But some students are in treatment and want a place on campus where they can be relatively free of alcohol and other substances and away from the people actively using them. In response to the need, some colleges are establishing drug-free residences and active treatment programs. What a great idea to help young people deal with addictions! After all, young people are among the more vulnerable.

Medications have proven to be an indispensable part of our repertoire for treatment. They are especially effective when used in conjunction with counseling and behavioral treatments. Because of their importance, there are major research programs aimed at developing newer and better medications. There are useful medications for users of some abused drugs, but not for all.
Table 13-1
shows examples of medications for three of the most commonly abused drugs.

Table 13-1. Some Medications for Treating Drug Abusers

Some medications are substitutes, which mean that they act in the same way as the abused substance and reduce craving. Others are blockers, which prevent the abused drugs from having an effect. And yet others act in ways that aren’t fully understood but might modify brain circuits involved with reward and addiction. An example of the latter type is naltrexone, which is an
opiate
blocker, but yet is very helpful in reducing
alcohol
intake. For example, one study showed that after 60 days of treatment, 60 percent of those taking naltrexone
had not relapsed to alcohol use whereas only 20 percent of those taking a sugar pill had not relapsed.
⁴
In any case, it is useful that we have different kinds of medications because some individuals might have bad reactions to certain medications.

A controversy usually surrounds the use of substitute medications like methadone, because their use is “just substituting one drug for another.” For example, it can be said that methadone is an opiate drug and using it in treatment is simply creating dependence on a different opiate. There is a black market for methadone (and other prescription opiates) where it is sold to active addicts for getting high, and this supports the idea that substitutes are problematic. Similarly, the nicotine patch still gives the user nicotine. The criticism is: what good can substitutes do? The addict is still an addict. This is an important question and confounds people at many levels in society—individuals, law enforcers, and legislators.

There are several ways to look at this controversy. One goal of treatment is to get the addict off the drug, which unfortunately can produce withdrawal. Any way that we can make withdrawal from drug use easier is helpful. Using substitutes in the short term can reduce craving and withdrawal, and gives the addicts time so that they can break up old toxic habits and behavioral patterns. They can also reduce harm and hazard to the user. For example, using nicotine gum or a patch eliminates craving for smoking, which is toxic to the lungs. Another example is the use of oral methadone for IV drug users. Intravenous heroin users are susceptible to a variety of problems including dirty and infectious needles and ignorance of what exactly is injected. Methadone administered orally by a reliable source eliminates those threats. Another practical help is that an approved substitute medication is not illegal; this eliminates the threat of breaking the law, which is confounding and adds yet another problem to the drug problem.

There are other, somewhat more complex, advantages to some substitutes in that they might have different time courses of action, which can be helpful. For example, substitute medications that have a
long life in the blood can keep the users more stable than drugs whose blood levels rise and fall rapidly. It must be emphasized that treatment with substitute medications such as methadone works effectively in that addicts stabilized on methadone are more healthy, sociable, and stable, and can hold down a job. Some individuals have been on methadone for decades without any severe side effects. From these perspectives, substitute medications are just fine. Is the problem the medication or is it the way we think about it?

In spite of these advantages, many still feel that substitutes are not the answer, or that they are short-term solutions at best. Can we justify long-term use of substitutes like methadone in methadone-maintenance programs? Most knowledgeable people say that methadone-maintenance is helpful, and this might be an example of where we need to challenge our traditional thinking about the evil of substitutes. In the 1960s, Drs. Vincent Dole and Marie Nyswander saw that addicts compulsively sought out heroin as though they really needed it to function normally. Said another way, drug addiction can be like diabetes in that diabetics require an external source of insulin, which is deficient or not working properly in the bodies of diabetics. This is the notion that addicts, even though perhaps a small fraction of our total population, are seeking to correct a metabolic deficiency in their brains by taking drugs. Dole and Nyswander examined the idea and selected methadone for testing because it was active when taken by mouth, lasted 24 hours, and was reasonably nontoxic. They found that opiate addicts did stabilize on methadone and stopped their out-of-control search for drugs.
⁵
The drug users were able to focus on rehabilitation because they weren’t distracted and driven by their drug-deficient brains. These results have been confirmed in thousands of centers and trials, and methadone-maintenance has been a great success medically and socially. Patients maintained on methadone do not appear any different from others, and the courts have established that patients may not be barred from any kind of
employment solely because they are taking methadone. From this perspective, our attitudes and the stigma we put on drug abuse is the problem, not the use of substitutes. It will be interesting to see how the thinking of our society evolves on this topic.

Prevention includes the policies and actions taken to prevent new or continuing drug abuse in a target population. If we can prevent the non-drug-using population from becoming drug users, then we can greatly reduce the burden of drug abuse. The idea is to prevent the damage before it occurs. Anti-tobacco and antidrug advertising are examples of prevention efforts. Prevention works! For example, two educational programs in schools, Life Skills Training (LST) and the Strengthening Families Program (SFP),
⁶
that are aimed at prevention of drug use have reduced marijuana smoking and alcohol use. The cost of these programs can be just one tenth of a year of outpatient treatment. The youth of this country are not stupid. When told about the problems with drugs, many listen.
Figure 13-1
shows a reduction in drug use by youths after being told about the dangers of drugs.

Figure 13-1
Providing information about the dangers of drug use to adolescents reduces drug use. (From NSDUH, SAMHSA, September 2008, and
http://www.whitehousedrugpolicy.gov/mediacampaign/about.html
, accessed March 23, 2011.)

A young drug addict has been surveying his life. He is in his early thirties, has lost his job and family, some of his health, and almost all of his wealth. His family and friends barely talk to him, and he doesn’t seem to have anywhere to go. He knows it can still get worse, but he makes a decision to get help. Where does he start?

There are several ways to find help. Family doctors are likely to know how to help, or at least how to begin. There are also several kinds of professionals that specialize in treating drug abusers. This group is the top of the heap in that they have the special training that it takes to assess and address drug problems. School counselors and clergy usually can be counted on to be knowledgeable and keep conversations confidential. They are often among the first to notice drug problems. School officials, in particular, who observe students’ performance, often know whether someone is having problems, and they try to help.

Although friends and family are not professionals, they often play a critical role in the search for help. They can offer emotional support, and sometimes practical help such as making phone calls or making some financial commitment to treatment. They are more likely to be committed to someone’s well-being than strangers. Moreover, they know the person well and might have insights to the problem, which might be due to a circle of drug-using acquaintances, or an illness, and so on. But family and friends might be an excellent place to start. Maybe someone who is in treatment can be a guide. Maybe they can sponsor friends in Alcoholics Anonymous meetings or in Narcotics Anonymous, if relevant. If someone can’t find help through friends and family, or if they make it worse, like assuming the drug user is an irretrievable failure, then they should move on. Go elsewhere to get help.