Addiction and Alcoholism

Integrative Drug Addiction Treatment for the Twenty First Century
Victor Sierpina, MD
Lodie Massey, BS, MA, PA

“Never give up.” In the darkest days of World War II, Winston Churchill advised the British, “Never, never, never, never, never give up!” The challenges of addiction and substance abuse require perseverance of similar dimensions. Recovery and sobriety are lifelong tasks for those who suffer from addictions and it is essential that those of us providing care for patients with addiction understand its chronicity and high recurrence rates.

I once admitted a patient for rehabilitation from poly-substance abuse. While pleased that he came to me stating he was ready to change his long-term problem by a commitment to detoxification and rehabilitation, I was taken aback when during his history I found that he had previously been in 13 or 14 treatment programs, only to slip back into his old behaviors. With limited expectation that this admission would be anything more than another transient attempt to solve his problem, I admitted him to our hospital’s drug and alcohol treatment program.

To my pleasure and astonishment, this 15th trip to rehab seemed to be the one that “worked.” More than three years later, he continued to be sober, drug-free, and vigilant against relapse with regular attendance at Alcoholics Anonymous and Narcotics Anonymous groups. His wife and children became the center of his life and support system rather than substances. He taught me a BIG lesson…. Never give up. While work with the addictive person can often be discouraging, the rewards of sustained effort, perseverance, and patience are enormous. Having a deep trust that at some level, those with such problems have the capacity to heal and be well is necessary to the task of being a helping professional.

In the year 2007, most health care professionals have learned that drug addiction (of course, alcohol is included as a drug) is a complex, chronic, progressive disease. Hopefully, they have also learned that it can be treated, just as other complex, chronic, progressive diseases, such as hypertension and diabetes, are treatable.

The goal of drug addiction treatment is not just abstinence, but also improving the patient’s ability to function in the family, workplace and society, and minimizing medical and social complications of drug abuse and addiction. Untreated substance abuse and addiction hurts families and communities, resulting in increased violence and property crimes, prison expenses, court and criminal costs, emergency room visits, healthcare utilization, child/spousal abuse and neglect, foster care and welfare costs, reduced productivity and unemployment.

In 2004, approximately 22.5 million Americans age 12 and older needed treatment for substance (alcohol or illicit drug) abuse and addiction. Despite extensive data that documents drug addiction treatment is as effective as are treatments for most other similar chronic medical conditions, only 3.8 million of the affected individuals received it. Why don’t more people receive treatment?

Addiction has so many dimensions and disruptions to multiple aspects of a person’s life that treatment is never simple. This fact, coupled with the opinion of many (including some medical professionals) that treatment does not work, despite extensive data to document otherwise, results in many people not receiving treatment that might lead to recovery. Many people equate addiction with simply using
drugs, and expect that addiction should be cured quickly, and if it is not, treatment is a failure. In reality, recovery usually requires sustained and repeated treatment episodes.

There is not a “one size fits all” treatment for addiction, just as not all people with diabetes should be given the same dosage of insulin. Over 30 years of scientific research and clinical practice have yielded a variety of approaches to effective drug addiction treatment.

Treatment may, or may not, begin with detoxification. However, medically assisted withdrawal is not in itself “treatment” only a first step in the treatment process. Research shows that patients who undergo only medically assisted withdrawal, without receiving further treatment show drug abuse patterns similar to those who received no treatment at all.

Long term drug use results in significant changes in brain function that persists long after cessation of use. Therefore, a period of intensive treatment is required, and may take the form of inpatient/residential or outpatient treatment. Studies show that participation for less that 90 days in this level of treatment has limited or no effectiveness, therefore three months is the minimum length recommended. During this time, a treatment plan is developed for the patient, that will include education, behavioral therapy, and participation in a support group (usually a 12 step group).
Behavioral treatment may include: cognitive behavioral therapy, multidimensional family therapy, and motivational interviewing. During this time it is important for the patient to maintain good nutrition, establish a support system of drug free people, and receive necessary treatment for medical problems. High dose B vitamins, zinc, and magnesium supplementation are particularly helpful. Just a few of the medical consequences associated with drug use are cardiovascular disease, stroke, HIV/AIDS, and hepatitis.

Initially, treatment programs discouraged patients from using drugs of any form. However, most now recognize that some patient may benefit from prescribed medications. If the patient has a co-occurring mental illness, medications such as antidepressants, mood stabilizers, or neuroleptics may be critical for treatment success.

Methadone and buprenorphine are effective medications for the treatment of opiate addiction. Acting on the same targets in the brain as heroin and morphine, these medications act to block the abused drug’s effects, suppress withdrawal symptoms, and relieve cravings for the drug of choice. This enables the patient to be more receptive to behavioral treatments. Buproprion is often useful in tobacco withdrawal and a new produce varenicline is targeted to affect nicotine receptors in the CNS . Tricyclics, SSRI’s, MAOI’s, and amantadine have all been used in cocaine treatment for cravings and relapse prevention.

After the intensive phase of treatment, it is important for the recovering patient to receive continuing care, which may take the form of individual or group therapy, support group participation, and or/ prescribed medications. Indeed, just as the addictive process is polyfactorial, an integrative treatment approach is fundamental and must recognize the multiple levels of mind, body, spirit, social, emotional, vocational, legal issues involved in both the addiction and the recovery process.

In addition to medical detoxification, social and group treatments, and medications, a number of alternative therapies can be considered for the treatment of addiction. Acupuncture has been widely employed to reduce both the cravings and withdrawal syndrome from opiates, cocaine, and tobacco. Though clinical studies show mixed results, long-term benefits by groups such as Dr. Michael Smith’s Lincoln Hospital in the Bronx treatment program and the National Acupuncture Detoxification Association (NADA—http://acudetox.com) have shown sufficient benefits that judges in a number of jurisdictions have remanded repeat offenders to auricular acupuncture treatment as a step toward rehabilitation. In fact, the role of endorphins in the mechanism of acupuncture was first suspected when post-operative opium addicts in Hong Kong who had received electroacupuncture for post-surgical analgesia did not experience typical narcotic withdrawal that those who did not receive acupuncture.

A traditional Chinese herb, kudzu, has been known for centuries as an “anti-inebriation” treatment though its mechanism of action is not know. Some botanicals such as valerian and kava kava might be useful in reducing the anxiety and insomnia associated with withdrawal. They affect levels and action of GABA so may have a role in reducing alcohol cravings and in relapse prevention. Milk thistle is widely used for its hepatoprotective effect and is most useful in toxic hepatitis such as that induced by alcohol.

Relaxation and reduced physiological responses to stress are highly useful to the recovery process. Such changes can be induced by a variety of mind-body therapies such as meditation, guided imagery, yoga or tai chi, biofeedback, and hypnosis. By providing patients with experience using such techniques, daily stressors that might make them reach for a cigarette, drink, or a drug can be approached differently with higher autonomy and range of options. Spirituality is also highly useful in the treatment of addictions and is the basis for twelve-step programs such as Alcoholics Anonymous. Strong involvement in spiritually based treatment programs provided social support and a reformed view of the world that can be very useful to recovery. When I practiced in Colorado, I was medical consultant to Teen Challenge, a residential recovery program for addicts and their families. Based on a model in which participants were involved in intense Biblical and Christian training, this voluntary 9-12 month treatment program had an incredibly high rate of 70% of its graduates maintaining a drug-free lifestyle 2 years following completion. Various ethnic groups have other culturally imbedded therapies for substance abuse such as the Native American sweat lodge and talking circle.

So, remember Churchill’s’ admonition to “never give up.” By equipping yourself with a wide variety of approaches to addiction along with the persistence and faith to maintain the relationship with the patient despite the inevitable recurrences, you will be in the best role to be a healing and change agent in their lives.

Victor S. Sierpina, MD is the W.D. and Laura Nell Nicholson Family Professor of Integrative Medicine and Professor, Family Medicine at the University of Texas Medical Branch, Galveston, Texas.

Lodie Massey founded the Gulf Coast Center Recovery Programs in 1990 and was director 1990-1995. She has a BS from UTMB-Galveston and an MA from the University of Houston. She also has many years of clinical experience as a Physician’s Assistant.