WHY TREATMENT FAILS
More often than not, treatment has become just another extension in the maze of addiction. After thirty years of working in the field of addiction as a therapist, educator, consultant, and (former) co-owner of an outpatient treatment program, I have been repeatedly disheartened by the all-too-often relapse rate for those people who struggle to recover from addiction. The current models for treating addiction do not work. The reason is that the most utilized treatment strategies focus on stopping the addiction (the symptom), not healing the cause, create a temporary dependency on the facility, and then fail to develop an adequate plan for continued abstinence after discharge. Thanks for your tens of thousands of dollars and now just go to some twelve-step meetings with a room full of strangers and when you relapse time and time again, we'll keep charging you for the same program or a different version of the same program for even more money or a longer stay"
Abstinence will stop the behavior but not the addiction. In fact, all willful attempts to stop or reduce the addictive behavior only intensify the obsession. Studies have shown that for heavy drinkers, parts of the brain that can help control a drinking habit are damaged, which makes the pursuit of moderation not just a matter of will but a physical impossibility.
Please note that any reference I make to treatment for substances applies to all flavors of addiction because they are all expressions of the same disease, which I will explain later. The treatment models are pretty much the same alsoyou give up the thing to which you are addicted. There are exceptions. Obviously, for food, you would abstain from the foods you are addicted tousually wheat and sugarand learn to eat healthily. For sex, you would abstain from harmful sexual behaviors and replace those with healthy sexual intimacy. I'd also like to note that even though not all compulsive behaviors have to be medically detoxed, all do have components of emotional and physical withdrawalthe jonesing effect that shows up across any manifestation of addictionand is always painful.
Medication
The medical community has three ways they use medications to treat addictions: detox, psychiatric medications, and harm reduction.
Detox: Hospitals, mental health facilities, and detox centers are available for detoxification from excessive amounts of alcohol or drugs. "Getting clean" is the first step of the recovery process, though not every patient intends to stop using; some just want to "dry out." Detox typically occurs in a confined setting; however, some outpatient clinics will detox patients if they have a proper caregiver at home to administer meds and watch the patient carefully. One of the disadvantages of this approach is that the recovering person does not connect with other people in detox or treatment and remains isolated, thus being less likely to attend recovery meetings and make new friends.
There are several medications prescribed for detoxification. Benzodiazepines (sedatives) and anticonvulsants are administered to reduce withdrawal symptoms and the chance of seizures. Benzodiazepines can cause severe depression, psychosis, and suicidal ideology, and can be deadly when mixed with alcohol. Naltrexone blocks the euphoric effect of opiates and reduces cravings during withdrawal. Suboxone and methadone are used to treat withdrawal from opioids, but both are highly addictive. All detox drugs are prescribed on a temporary basis to help the addict wean off the drug to which they are addicted.
One problem with detox is that many programs do not provide the therapy necessary for long-term remission. Many patients use detox centers to medically withdraw then start drinking or drugging again. A physician at a local hospital recently referred a patient to me who had detoxed five times within a few months. When I met with the patient, it was clear she had no intention of doing the work necessary to stay sober, especially since she was able to use the hospital as her legal drug dealer. When she couldn't stop drinking, the patient would get detoxed on massive doses of benzodiazepines then go on to stay sober for a week or two and repeat the patterns all over again. She simply used the detox medication to get high while she wasn't drinking.
I believe that detox centers could expand to address all manifestations of addiction. Since withdrawal from any addictive behavior has the same symptoms of anger, irritability, depression, and craving, a one- or two-week stay in a facility could ease the withdrawal. Temporary emotional support, safety, and self-care could stabilize a person, reduce chances of relapse, and prepare the person for intensive outpatient therapy and adequate support upon dischargesomething that is currently lacking.
Prevention: Antabuse is a medication that is given to alcoholics after they are detoxed to prevent relapse. The patient is responsible for taking a pill that when mixed with alcohol causes nausea, dizziness, chest pain, and other unpleasant effects. It only works if taken daily, and once alcoholics decide to drink, they set the pill aside.
Psychiatric Medications: Some medications are necessary if a person has a secondary mood or mental disorder such as anxiety, depression, personality disorder, or psychotic disorder. On the other hand, someone in emotional or physical withdrawal might exhibit all of the symptoms of mental illness, but given some time for the brain to regulate, these symptoms often subside. It is my opinion that in the past twenty years, the trend has been to prematurely render a dual diagnosis because many insurance companies will provide additional benefits for mental disorders.
Antidepressants: In the 1980s and early 1990s, unless a patient was severely impaired, it was customary to wait a year before prescribing antidepressant medication. At that time, depression was classified under two categories. Reactive depression was due to an environmental stress such as loss of a loved one and was typically treated with therapy. The other type was a neurochemical imbalance, which was treated with medication. If the environmentally induced stress was severe, such as the unexpected loss of a spouse or a child or being the victim of a violent crime, short-term medication was sometimes prescribed to stabilize the patient enough for them to benefit from therapy.
In 1980, when the third revision of the Diagnostic and Statistical Manual was released, there was an attempt to "re-medicalize" American psychiatry. The DSM-III elected to put all depressive and manic conditions under the category of "mood disorders," and this kicked off a slow shift toward prescribing more medication for these types of diagnoses. Now under the classification of mood disorders, depression due to environmental stress is regularly treated with medication, and in many cases, it is prescribed as an alternative to therapy. At the very least, a person should be given the opportunity to grieve a loss or process trauma before medicating the pain with an antidepressant.
These patients are prescribed serotonin reuptake inhibitors (SSRIs), which reduce symptoms by increasing serotonin levels in the brain. The most common drugs are Celexa, Lexapro, Paxil, Prozac, and Zoloft. These medications are not mood altering, but as I mentioned earlier, many patients who remain on these types of medications for a long period of time, then want to stop, go through a different kind of hell wrought with the symptoms of withdrawal experienced by any addict.
One patient, Jill, struggled with an eating disorder and depression and had been on an antidepressant medication for ten years. At the time, she was not happy in her marriage, her husband traveled, and she often was left alone at home with their two children. When her husband was home, he showed little interest in her, and she used food to soothe herself. Her medical doctor told her she was suffering from "clinical depression" and prescribed an antidepressant. (Jill should have been referred to a psychotherapist first.) Two of the side effects of the medication were weight gain and decreased sexual interest including the inability to have orgasms. During her therapy, we discussed getting to the bottom of her pain, so she could heal the feelings underneath her depression. She felt that the medication had made her emotionally numb, and she wanted to go off of it, so she could "get herself back." Under her physician's care, she was slowly weaned off the medication over a six-month period during which Jill suffered bouts of severe anxiety, clamminess, insomnia, nightmares, obsessive thoughts, and morbid feelings in the morning, all symptoms she'd never experienced before taking antidepressants. It took over a year for Jill to begin to feel back to her old self, and she often said had she known about the side effects, she never would have started the medication.
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