The Doctor’s Opinion – Dawn Farm Ed Series

silkworthResearch continues to shed light on the neurobiology of alcohol/other drug addiction. Modern research supports much of what was intuitively and experientially believed by the medical specialists who supported the Alcoholics Anonymous program in its earliest days.  This program will describe a physician’s view of alcoholism, as presented in the literature of Alcoholics Anonymous and updated with the modern neurobiology of addictive illness. It will include a discussion of Dr. Silkworth’s explanation of alcoholism as a twofold disease affecting mind and body, how Dr. Silkworth’s opinion relates to the modern neurobiology of addictive illness, identification of therapy for alcoholism as promoted by Alcoholics Anonymous, and the relationship of this therapy to Dr. Silkworth’s opinion.

Handouts and other goodies:

Handouts and slides:

Related reading suggestions:

Video

The Doctor’s Opinion on Alcoholism from Dawn Farm on Vimeo.

Slidecast:

View more webinars from Jason Schwartz.

About the presenter

Dr. Herbert MalinoffHerbert Malinoff, MD, FACP, FASAM, is a specialist in chronic pain and addictive illness. He is the Medical Director of Pain Recovery Solutions, PC; and an attending physician at Saint Joseph Mercy Hospital in Ypsilanti, Michigan. Dr. Malinoff is a clinical faculty member of the University of Michigan Medical Center in the Department of Anesthesiology, and a consultant to Michigan Pain Specialists in Ann Arbor, Michigan. He is also a past President of the Michigan Society of Addiction Medicine. Dr. Malinoff received his M.D. degree from the University of Michigan Medical School.

Tribes of the recovering community – Calix Society

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This week’s tribe is the Calix Society.

Calix is an association of Catholic alcoholics who are maintaining their sobriety through affiliation with and participation in the Fellowship of Alcoholics Anonymous. Our first concern is to interest Catholics with an alcoholic problem in the virtue of total abstinence. Our second stated purpose is to promote the spiritual development of our membership. Our gathering today is an effort in this direction. Our conversation and our association together should be a source of inspiration and encouragement to each other, geared to our growth toward spiritual maturity. Our participation in all other spiritual activities of Calix, such as the frequent celebration of the Liturgy, reception of the Sacraments, personal prayer and meditation, Holy Hours, Days of Recollection and retreats, aid us in our third objective, namely, to strive for the sanctification of the whole personality of each member. We welcome other alcoholics, not members of our faith, or any others, non-alcoholics, who are concerned with the illness of alcoholism and wish to join with us in prayer for our stated purposes.

(The “Tribes of the recovering community” series is intended to demonstrate the diversity within the recovering community.I have no first hand knowledge of most of the tribes, so inclusion in this series should not be considered an endorsement.)

Living on the bottom

NMLG-cover300-201x300Debra Jay addresses the belief that families should let an addicted family member hit bottom:

Hitting bottom is an old idea, still imposed upon families as if it were an absolute. Many families sadly believe that they must wait for alcoholics to hit bottom before there is any hope for recovery. They rarely stop to consider that this belief sentences them to years of unhappiness and devastation. No one ever mentions the fact that alcoholics and addicts don’t take the trip to the bottom alone–the family goes with them. Families are never warned that the journey to the bottom takes even the smallest children.

. . .

“Bottoms” can be temporary. Alcoholics resist getting sober even when things are going badly in their lives. They are good at weathering storms. Perhaps they’ll swear off alcohol for a while, but as soon as things cool down, they begin drinking again. The addicted brain can’t make lasting connections between alcohol and the problems it causes. Once the problems go away, alcohol is their best friend again. Addiction is both invisible and sacred to alcoholics: they deny its existence yet sacrifice everything to it.

Addicts don’t want to cause trouble or hurt the people they love. Quite the contrary: they struggle to be the person they think they still are, the person they were before the addiction took hold. They can’t make sense of their own actions. As their addiction progresses and troubles mount, they work harder to manage their lives, but addiction never lets anyone lead a life free of trouble. There are always problems, big and small. Bad behavior, poor decisions and emotional upheaval are all symptoms of this disease that affects both the brain and soul. Families are confused, too. Not understanding what is happening to their loved ones, they mutter: “When will she learn?” But addicts can’t learn because addiction keeps tightening its grip, demanding complete allegiance.

In Race for Boston Mayor, Former Addicts Back Candidate With a Past

A colleague who specializes in working with at-risk youth was fond of saying that we could look at those kids as predators, victims or resources. Too often we fail to see them as resources.

The same could be said of addicts and alcoholics. The

NY Times shines a light on a recovering mayoral candidate who is using his peers as a resource to get himself elected.

Tom White, who says he used to swig two six-packs of beer while driving home from work, has been sober for 25 years. Now, his Toyota Corolla has a vanity plate that reads “ONEDAY,” a reference to the Alcoholics Anonymous slogan “one day at a time.” On the rear windshield is a sticker for Martin J. Walsh, a candidate for mayor of Boston.

Many people in recovery stay anonymous and protect the anonymity of others, and A.A. itself does not get involved in politics.  But here, a candidate for the city’s highest office is himself a recovering alcoholic. This has moved many former addicts — drinkers and drug users — to step out from the shadows and publicly support Mr. Walsh, 46, a state representative who still attends A.A. meetings after 18 years of sobriety.

But what is especially unusual about his story is how his candidacy has motivated others in the wide universe of recovery to shed their anonymity to support him.

Former alcoholics and drug addicts are not typical voting blocs. Most do not want to be identified. Because of privacy issues, they are hard to recruit. Campaigns do not target them with clever messaging. Some have never voted.

But those who have stepped forward for Mr. Walsh bring an evangelical fervor to their mission. It is the least they can do, some say, for a man who saved their lives.

Some of these supporters try to imagine a day when their potential for political muscle will be harnessed and organized, and they see the Walsh campaign as a step toward empowerment.

“With Marty, we don’t have to hide it anymore,” said Peter Barbuto, 33, who once thought he had ruined his life by stealing money to maintain his drug habit. He said Mr. Walsh, who had coached him in Little League, “called my family and said: ‘This isn’t the end of the world. We’ll take care of him.’ ” Now, Mr. Barbuto is an addiction treatment consultant. Over the weekend, he was distributing campaign literature for Mr. Walsh in South Boston.

“We have a voice, and it’s going to be heard,” Mr. Barbuto said between houses. “Like the blacks and gays are now — they didn’t have any power and then they came out, and now politicians say, ‘We have to get the blacks and the gays.’ One of these days they’re going to be saying, ‘We’ve got to get the recovery community.’ ”

Tribes of the recovering community

From the Fifth Chapter MC Rochester Charter
From the Fifth Chapter MC Rochester Charter

I remember getting sober and learning about the Sober Riders and Fifth Chapter. This recovery stuff was a whole new world, and I never imagined there’d be tribes like them. There are sober MCs (motorcycle clubs) all over the country.

Our local Sober Riders describe the MC this way:

The Sober Riders is a fellowship of Men and Women who live by the principles of the 12 step program of recovery, and promote, through attraction, the creation and preservation of a brotherhood for motorcyclists in a sober, drug free and safe environment.

 

Addiction and quality of life

 

photo credit: davegray
photo credit: davegray

David Best recently wrote a piece on addiction and quality of life.

On the role of community in recovery:

At the heart of the recovery movement is a shift of emphasis away from “treatment” as a model reliant on professionally delivered interventions. Rather, the movement sees the recovery journey an intrinsically social process and seeks to create the conditions that allow those with addiction problems to achieve a sense of connection in their community, including with peers who are further along in the path of recovery.

On the evidence for the positive impact of social connectedness:

From the United States, we know that only around 10% of those who complete alcohol or drug treatment receive community-based ongoing help. Yet, when this is received, it improves the person’s outcomes by 30 to 40%.

Similarly, a 2009 trial of support for problem drinkers found that adding one person in recovery to the social networks of a newly detoxified drinker improved the chances of them staying sober for a year by 27%. This is a huge impact that results from changing not only social networks but the underlying values, attitudes, beliefs and expectations.

Scottish study of recovering alcoholics and heroin users in the deprived housing estates of Glasgow found that the more time people spent with other people in recovery, the greater the levels of well-being reported.

It also found that people who were active in their families and communities – by parenting, volunteering, being members of social networks, by working and training – had the best quality of life.

1 in 5 Russian men die of alcohol-related causes

foreignThe scale of the alcohol problem in Russia is stunning:

Today, according to the World Health Organization, one in five men in the Russia Federation die due to alcohol-related causes, compared with 6.2 percent of all men globally. In 2000, in her article “First Steps: AA and Alcoholism in Russia,”Patricia Critchlow estimated that some 20 million Russians are alcoholics in a nation of just 144 million.

They have tried to address it several times, but their efforts have been political pressure to maintain alcohol tax revenues. (Is there a lesson to be learned for advocates of propping up state budgets with marijuana tax revenues?)

The Russian government has repeatedly tried to combat the problem, but to little avail: this includes four reforms prior to 1917, and larger scale measures taken during the Soviet period in 1958, 1972, and 1985. “After each drastically stepped-up anti-alcohol campaign, [Russian] society found itself faced with an even greater spread of drunkenness and alcoholism,” explains G.G. Zaigraev, professor of Sociological Sciences and Head Science Associate of the Institute of Sociology at the Russian Academy of Sciences. The Kremlin’s own addiction to liquor revenues has overturned many efforts to wean Russians from the snifter: Ivan the Terrible encouraged his subjects to drink their last kopecks away in state-owned taverns to help pad the emperor’s purse. Before Mikhail Gorbachev rose to power in the 1980s, Soviet leaders welcomed alcohol sales as a source of state revenue and did not view heavy drinking as a significant social problem. In 2010, Russia’s finance minister, Aleksei L. Kudrin, explained that the best thing Russians can do to help, “the country’s flaccid national economy was to smoke and drink more, thereby paying more in taxes.”

Let’s sensationalize recovery

It just so happens that Dawn Farm is co-sponsoring a screening of the film next week.

One Crafty Mother has a post responding to The Anonymous People.

That last bullet point is the one I want to focus on. [There are over 23 million people in long term recovery in America alone.] Changing the public’s perception of addiction by TALKING ABOUT RECOVERY. Because, everyone, RECOVERY WORKS. There are more people in recovery from addiction than there are suffering from it.

Here’s the rub, though. People don’t recover on their own. Every single recovery program focuses on community – on finding other addicts and alcoholics who understand where you are and can help you navigate life without alcohol or drugs.

It doesn’t matter what program of recovery you follow. Recovery advocacy is for EVERYONE.

You don’t have to talk about HOW you recovery, just THAT you recover.

For those of us in programs that have anonymity as a tradition and who are confused about breaking this tradition, this point is KEY. How you stay sober isn’t relevant. You do not have to be a mouthpiece for an individual program of recovery. You can talk about recovery without ever mentioning how you do it. When someone who is suffering asks you how you stay sober (and if you talk about recovery they will ask, I guarantee it), then you are free to share – in the sacredness of a one-on-one (or group) setting – how you do it.

But until the public understands that RECOVERY HAPPENS, people are going to stay stuck in addiction. People are going to misunderstand what addiction means. People aren’t going to know it is quite literally on every street in America. Every street has someone stuck in the darkness and isolation of addiction, and every street has someone thriving in recovery. We have enough coverage of the destruction of addiction. We sensationalize the stories of celebrities crashing cars, going in and out of rehab. We condemn the havoc alcoholism and addiction bring to society.

We are sensationalizing the wrong thing. Let’s sensationalize recovery.

She’s got a great message and very gracefully addresses a couple of potential pitfalls. I like encouraging advocacy while also respecting traditions of anonymity. I also like her emphasizes that there are lots of ways to be an advocate and each recovering person can find their own advocacy approach.

I love her passion and clarity. I’m going to have to watch this blog.

I’ve got one quibble with the statistic the film uses–23 million Americans in recovery. That is based on surveys asking people something to effect of, “Have you previously had a problem with drugs or alcohol and no longer have one?” That kind of question is going to get a lot of false-positives for what we think of as recovery.

The point, however, is there there are large numbers of people in long term recovery in the U.S. And, unfortunately, when people think of addiction, they don’t think of recovering people like me or friends who are doctors, nurses, lawyers, business owners, moms, dads, bothers, sisters, etc. Instead, they think of us as social parasites, or worse, scary people committing a violent or property crime.

Telling our stories is powerful. Dawn Farm often takes clients or alumni to speak to community groups like the Lions, Optimists, Rotary or school groups. The response is always the same–shock that the clients are just like their niece, nephew, neighbor, grandchild, etc.

Brain disease does not equal stigma reduction


Yesterday, I posted about The Anonymous People and Dawn Farm’s co-sponsorship of an upcoming screening of the film.

So…why is this message of recovery so important to stigma reduction?

We’ve spent 20 years trying to convince the public that addiction is a brain disease without too much attention to the potential for this message to backfire. Bill White outlines the potential pitfalls:

 My fears are captured in the following three propositions.  First, communicating the neuroscience of addiction without simultaneously communicating the neuroscience of recovery and the prevalence of long-term recovery will increase the stigma facing individuals and families experiencing severe alcohol and other drug problems.  Second, the longer the neurobiology of addiction is communicated to the public without conveying the corresponding recovery science, the greater the burden of stigma will be.  Third, the brain disease paradigm could create new obstacles for social inclusion of people in recovery and provide a rational for coercive, invasive and harmful interventions.

As I noted in my earlier paper, the vivid brain scans of the addicted person may make that person’s behavior more understandable, but they do not make this person more desirable as a friend, lover, spouse, neighbor, employee, or candidate for college entrance, military enrollment, or a car or home loan.  In fact, in the public’s eye, there is a very short distance between the diseased brain and the perception of a deranged and dangerous person. We should not forget that less than a century ago biological models of addiction provided the policy rationale for prolonged sequestration of addicted persons, their inclusion in mandatory sterilization laws and a host of other harmful interventions, including prefrontal lobotomies and chem- and electroconvulsive “therapies.” Further, christening addiction a CHRONIC brain disease without accompanying recovery messages, inadvertently risks further contributing to social stigma from a public that interprets “chronic” in terms of “forever and hopeless” (“once an addict, always an addict”)(See Brown, 1998 for an extended discussion of this danger).

Conveying that persons addicted to alcohol and drugs have a brain disease that alters emotional affect, compromises judgment, impairs memory, inhibits one’s capacity for new learning, and erodes behavioral impulse control are not communications likely to reduce the stigma attached to alcohol and other drug problems, UNLESS there are two companion communications: 1) With abstinence and proper care, addiction-induced brain impairments rapidly reverse themselves, and 2) millions of individuals have achieved complete long-term recovery from addiction and have gone on to experience healthy, meaningful, and productive lives.

If it wasn’t rational, they wouldn’t be doing it

mencken-complex-problem

Ugh.

The NY Times has another column promoting a rational addiction model.

“When they were given an alternative to crack, they made rational economic decisions.”

When methamphetamine replaced crack as the great drug scourge in the United States, Dr. Hart brought meth addicts into his laboratory for similar experiments — and the results showed similarly rational decisions.

“If you’re living in a poor neighborhood deprived of options, there’s a certain rationality to keep taking a drug that will give you some temporary pleasure,”

Here we go again. Their drug use by addicts is rational. A rational choice. If you had their lives, you’d be an addict too.

I’m not even clear that there’s a causal relationship from poverty to addiction. If so, how strong is that relationship?

In an article titled, “Taking Absurd Theories Seriously“, Ole Rogeberg walks through an extensive takedown of rational addiction theories. This video is great.

Why do people insist on framing addiction as rational?

For others, it’s assimilation into the monoculture:

To begin with, in the economic story, you are an individual.

The economic story also says that as a human being, you’re rational. In economic thought, being rational doesn’t mean that you’re sensible or that you’re a clear thinker. Being rational means that when you’re faced with a decision, you move through a three-stage process to decide what to do. Assuming you know what your goals are, you first lay out all the ways you could reach each goal and identify the costs and benefits of each possibility. Next, you analyze which option is most efficient — the one that most directly lets you get the most of what you want while costing you the least of your resources. Finally, you choose that most efficient option, because in the economic story, your best choice is always the most efficient choice.

In the economic story, you’re someone who is self-interested, in the most positive sense possible.

Being cast as someone who is rational and self-interested might sound relatively harmless, but that way of thinking has implications because it’s based on the assumptions that you know what condition you’re in, you know what your options are, and you know what you want, but those assumptions don’t necessarily hold. … The story says that you act as you do because you’re trying to get what you want, and the rest of us can tell what you want by watching how you act.

For others it’s philosophical:

Although addiction may be defined and operationalized in a number of different ways, the heart and core of the concept lies in its implication of the loss of the ability to choose – that is, the loss of free will.  Hence, and logically, the concept of addiction also implies the actual existence of free will.  And there lies the rub.

The addiction concept repackages one of the Big Questions – free will and determinism – into a new and seemingly more manageable form.   But should we be entirely comfortable with the tacit implication that ordinary, non-addictive conduct is freely willed?

Of course, this assumption underlies much of our day-to-day lives.  We show up at work late and we are responsible for the choices we made that caused our lateness.  Our legal system relies on the same assumption as well.  It assumes people freely do what they do and must take responsibility for their actions.

This came up again recently when Sally Satel published a book questioning neuroscience and addiction:

“Brainwashed” is nervously libertarian; Satel is a scholar at the American Enterprise Institute, and she and Lilienfeld are worried that neuroscience will shift wrongdoing from the responsible individual to his irresponsible brain, allowing crooks to cite neuroscience in order to get away with crimes.

Once it’s defined as a choice, and the rational choice theory isn’t satisfactory, we’ve got economists coming up with their own answers to the age old question of, why do they do it? [emphasis mine]

First-hand accounts of poverty generally recognize that heavy users of drugs and alcohol pay a high material cost.  Yet they rarely reach my verdict: that other factors – like low IQ, low conscientiousness, low patience, or plain irrationality – must be driving both poverty and substance abuse.  Instead, observers usually say that the poor consume drugs and alcohol to “dull the pain.”  Some even argue that the poor are being entirely rational: If your life is a living hell, narcoticizing yourself is the simplest solution.

There’s just one problem with this explanation: By almost all accounts, substance abuse eventually makes your life worse.  The long-term addict’s life is utterly wretched – even if you average in his periodic drug-induced euphorias.  Someone who has yet to start using drugs and alcohol doesn’t face a choice between “full pain” and “dulled pain.”  Instead, he chooses between two paths of pain:

Path #1: Full pain in the short-run, followed by gradual life progress.

Path #2: Dulled pain in the short-run, followed by a gradual downward spiral into abject misery.

Suppose you’re poor.  Your life is unusually painful, so the immediate effect of drugs and alcohol is especially attractive.  The long-run prognosis for a poor substance abuser, however, is especially repellent.  You hit “rock bottom” sooner because you don’t have far to fall.  And your version of “rock bottom” is extra bleak because you lack the financial resources and social connections to cushion the blow and get back on your feet.

The lesson: On net, poverty isn’t a believable root cause of substance abuse, because being poor doesn’t make substance abuse a better overall deal.  Why then would poor people be more inclined to narcoticize themselves?  Once again, we should look for root causes of poverty and pathology.  Low patience is the most obvious suspect.  If you loathe to defer gratification, you’ll tend to have low income, and eagerly use drugs and alcohol today despite their awful cost down the line.

While I detest the blogger’s character-based explanation. He closes with a very salient question and observation:

Closing questions: If you were poor, would you turn to drugs and alcohol?  If you were a social worker, would you advise the poor to turn to drugs and alcohol?  I doubt it.  The reason, of course, is that on some level you already know what I’m telling you: Poverty is no excuse for substance abuse because substance abuse is an absurd response to poverty.

UPDATE: I’ve had several posts over the years about free will and addiction. One important thing to keep in mind is that when we say it’s a brain disease, it doesn’t mean the person always has zero control over their behavior.

Here are some excerpts that offer different ways to think about it.

On co-existing deterministic factors and free will:

A helpful metaphor is offered: If a machine has two controllers (one controller representing deterministic factors and the other representing free will), does that mean that only one controller works? Or, is it possible that they both are capable of controlling the machine?

On deterministic factors as a continuum:

There is certainly room to incorporate biological and genetic vulnerabilities in such a model. People may vary as to the reward power of drugs and alcohol: Some people get more pleasure than others from them. Social factors and personal experiences may also contribute to individual differences in such propensities. Thus, some people end up with stronger cravings than others.

Still, some freedom remains. The wine does not pour itself into a glass and thence down the alcoholic’s throat. The person thus makes a choice between competing impulses: indulging pleasure now versus abstaining for the sake of nonspecific but substantial delayed gains. Choosing the path of virtuous abstention depends on willpower, however. When willpower has been depleted (such as by other acts of self-control, or even by decision making in any context; see Vohs et al. 2008), their likelihood of choosing the immediate pleasure increases.

If a disease model for addiction is to be retained, we suggest abandoning the virus or germ models in favor of something more like Type II diabetes. One does not become infected with diabetes. Rather, a natural bodily vulnerability becomes exacerbated by experiences, many of which are based on personal choices. Many people will not become diabetics regardless of what they eat, but others will suffer diabetes to varying degrees as a function of diet and exercise. Moreover (and again unlike a virus), there is no definite boundary that separates the sick from the healthy. Diabetes, and by analogy addiction, is a continuum. Those who are constitutionally vulnerable move themselves along this continuum by virtue of the choices they make.

On will power as psychological energy:

…within the context of their metaphor of psychological energy, there might be times when a person has none and times when a person has no internal or external resources to replenish this energy.

…Acknowledging these considerations does disavow the role of choice. Even on the end of the continuum where a person’s biology and environment doom them to developing addiction, choices could influence the onset, course and severity. And, within the psychological energy metaphor, during periods of replenished energy a person may have the power to make choices that will protect or expend this energy in ways that preserve it (and initiate/maintain recovery) or diminish it (and lead to relapse).

On ditching the all or nothing mentality:

One way to partially reconcile the dilemma between the traditional and emerging views of choice is to first acknowledge that free will in addiction and recovery is not an all or none phenomena. The capacity for volitional control over AOD use and related decisions is variable across individuals (as a function of the interaction between problem severity/complexity and recovery capital) and is dynamic (shifts incrementally on a continual basis within the same individual through both addiction and recovery processes).