Introduction
Each year, medical problems caused by addiction, along with lost earnings, accidents and crime, cost Americans more than $500 billion. State and federal governments spend more than $15 billion per year, and insurers another $5 billion more annually on substance abuse treatment services for about four million people. Researchers estimate that some 20 million Americans who could benefit from treatment are not getting it. Additionally, for those patients who are receiving treatment, the majority of the industry still treats alcohol and drug addiction with only behavioral and psychosocial approaches.
Fortunately, we now have scientific evidence that concludes addiction is a chronic, progressive disease of the brain with many similarities to other chronic medical diseases such as diabetes, hypertension and asthma and needs to be treated with a combination of behavioral therapy and a medical based approach. The American Medical Association (AMA), National Institute on Drug Abuse (NIDA), National Institutes of Health (NIH), World Health Organization (WHO), American Psychiatric Association (APA), as well as many other organizations in the scientific and medical fields, now recognize alcohol/drug addiction as a chronic and progressive physical disease that attacks the brain, damaging key parts of the limbic system and cerebral cortex causing lasting changes in the brain. These changes don’t go away, sometimes for months or years, even after recovering patients stop using.
Although an individual’s initial choice to drink alcohol or use a substance is a voluntary one, over time the substance physically changes the brain to where the individual truly cannot stop his or her addictive behavior, even though the desire to do so might be high.
As with other chronic conditions such as cardiovascular disease, the standard of care involves front-line physiological interventions through surgery or medication, followed by environmental and behavior modifications. Hypertension and high cholesterol are often controlled by medication, but modifying dietary habits and exercise are necessary steps as well. Addiction treatment is no different and with the proper treatment approach, it too can be managed and give individuals hope that they can be healed and live a clean or sober life.
These scans clearly demonstrate that alcohol severely injures the brain. Scientists believe that it is this damage that causes the brain disease of addiction. This realization has led us to be smarter about how to treat addiction, and in recent years has resulted in the development of several FDA-approved, anti-addiction medications that when combined with the appropriate behavioral approaches can dramatically improve the treatment outcomes of substance-dependent patients.
Anti-addiction medications can be used to counter the brain injury caused by past alcohol or drug use and relieve withdrawal symptoms, or to help overcome alcohol or drug induced cravings. These medications intervene on the neurological pathways in the brain that cause the cravings and the euphoric “high” an individual experiences when they use. Once this process is interrupted, and the substances are removed from the body, the brain can start to “rewire” those damaged pathways and heal itself (the healing process usually takes between 4 – 12 months of complete sobriety). Medications are a remarkable tool in treating addiction, but they are not a magic bullet. For some, these treatments can “jump start” their recovery and provide relief from cravings – allowing them to better concentrate on the behavioral and psychosocial aspects of their recovery.
What Is Dual Diagnosis?
For many individuals, addiction treatment is only half the battle. It is estimated that 50 percent of alcohol abusers and 53 percent of drug abusers also have at least one co-occurring mental illness. These patients have what is called a dual diagnosis, a term used to describe co-existing conditions of a person suffering from a psychiatric illness and a substance addiction problem. A wide variety of psychiatric illnesses can accompany addiction. The most common co-occurring psychiatric illnesses are bipolar disorder, anxiety disorders, depressive disorders, post-traumatic stress disorder (PTSD) and schizophrenia.
Dual diagnosis is not simply one disease added to another. It is one disease multiplied by another. The two illnesses can interact, each making the other worse, complicating treatment and increasing the risk of relapse. At times, the symptoms of one may overlap and even mask the symptoms of the other, making diagnosis and treatment much more difficult. The presence of co-occurring illnesses also can slow the recovery process, weakening an individual’s resolve to stay sober.
Even if the co-occurring illnesses are correctly identified, it is extremely difficult to get an individual suffering from addiction plus emotional distress to actively engage in and cooperate with the treatment process. The addiction and the psychiatric illness must be managed simultaneously to insure that one illness does not cause a relapse of the other. The combined treatment plan must be comprehensive, coordinated, integrated and flexible. It must include treatment for the psychiatric illness, treatment for the alcohol or drug addiction, participation in a 12-step based program, appropriate non-addicting medication for each illness, stress management programs as well as family education and participation in treatment for both component illnesses.
The Role of Family Therapy
Addiction is never just one person’s problem; it affects the entire family system. This is because substance abuse and addiction are no longer considered an individual issue, but instead are viewed as a broader disease that impacts the entire family, affecting the family’s health, happiness and well-being. In fact, it has been found that addiction treatment approaches that include and focus on the family significantly increase a patient’s engagement and retention in the treatment process, resulting in improved outcomes for the entire family.
When a loved one is in the throes of addiction, family members can feel abandoned, anxious, fearful, angry, embarrassed, guilty and a host of other emotions. The damage extends throughout the family as they struggle to cover up the problem, work around the issue, deal with their own negative emotions and cope with the responsibilities the addicted family member has left unattended and unfilled. Many times the family members can unwittingly become enablers by allowing the loved one to continue their damaging behavior and keeping the addiction in play. For this reason, it is important that family members be involved in the treatment process from the beginning, participating in family therapy sessions for the benefit of both the addicted person and all members of the family.
When a person’s family is involved in the recovery process, the family members gain a better understanding of the disease of addiction and the underlying issues. This understanding gives the patient a stronger network of support during and after treatment. He/she is more likely to remain engaged in the recovery process, utilize healthier and broader methods of coping when faced with stressors, and successfully return to employment, school or parenting. Research also has found that family involvement has long-term benefits for the patient and family, such as sustained recovery, increased marital satisfaction and even family and job stability.
One of the most common problems seen in families with addicted loved ones is codependency, a complex relationship between the individual and a family member, or in some cases a friend, that appears to be loving, but is actually dangerous and damaging to all involved. Codependency is a habitual pattern of self-defeating coping mechanisms. Typically, the codependent offers help to the loved one, but it is too much help and is often inappropriate. The addicted person learns to depend on the codependent to help “fix” his or her problems and what begins as a kind gesture, becomes an enabling mechanism for the addiction. Because the codependent protects the addicted person from the negative consequences of the addiction, the loved one can continue drinking or using. While the codependency is a dysfunctional behavior that family members adopt in order to survive the emotional pain and stress caused by the addiction, in the long run it can be counterproductive and detrimental to an addicted loved ones recovery process. Both parties involved, the loved one and the codependent family member, should be involved in therapy to understand how to form a healthier relationship. Helping a family member engage in a comprehensive addiction treatment program is never a codependent action, however.
At times, families separate from their loved ones as the physical, emotional and financial stress of the addiction becomes overwhelming. But, it is important to remember that individuals who have encountered such family dynamics are not without support resources. There are a variety of sober support systems that addicts can utilize, including but not limited to community groups (e.g., 12-step programs, Recovery Inc., Families Anonymous, etc.), religious and spiritual programs, and even online e-lessons (www.enterhealth.com) and recovery blogs. An individual’s family support system does not have to be blood-related relatives, or even the individuals he or she live with. Whether it is a parent, significant other, children, close friend, coworker or a sober support group, the ability to build a solid system of recovery resources is essential to an individual’s ability to sustain his or her life without alcohol or drugs.
Comprehensive Approach
There are many types of alcoholism and addiction, and various stages to each type so it’s no wonder that the traditional treatment methods do not work for everyone. Addiction is definitely not a “one treatment fits all” disease. Research shows that the 70 percent of the people who are in a constant cycle of treatment-recovery-relapse-treatment-recovery-relapse need a 90-day residential stay, followed by months of comprehensive outpatient programs, behavioral therapies and social support in order to have the optimal chance for lasting recovery. Depending on how severe a person’s brain has been injured by addiction, it can take 45 to 90 days or more for the brain’s chemistry to start to “reboot.” After that, it takes 4 to 12 months for an alcoholic brain to heal and get back to normal and often longer for someone with an addiction to stimulants or other drug classes. People sometimes want to avoid residential treatment because it’s disruptive to their family, their job and their life. But someone suffering from addiction needs some amount of disruption in order to break the harmful patterns that they have created.
A comprehensive approach to alcohol and drug addiction treatment (defined by the National Institute of Health) incorporates treatments for many different components of a patient’s life including: psychiatric care, anti-addiction medication, wellness/nutrition programs, family therapy, stress management, skill building, individual and group psychoeducational components and therapy, spirituality and 12-step fellowships. It takes all of these components individualized to a specific patient’s life experience, to be able to approach that 90 percent long term sobriety success rate.
When an individual completes one phase of treatment, they do not walk out completely sober and free of the challenges that they once had. Their brain is still injured by addiction. The triggers, people and places that led to their addictions are still there, the same as before they entered treatment. The only difference is that the individual now has the tools and information to defeat or manage those influences. Historically, the leading cause of relapse is failure to follow a prescribed, on-going addiction treatment plan. To reduce the risk of relapse, it is important that individuals have a lifelong care plan (Life Care) that provides consistent touch points to support positive future recovery. Individuals in recovery should participate in Life Care counseling and focus on sober friends, using people for support when experiencing negative feelings and avoiding people, places and activities that were strongly associated with their addiction. They should also continue and adjust any medications and therapies started in their initial treatment phase.
By using proven, evidence-based treatment methods and medications to address the psychological, relational and spiritual aspects of addiction, individuals and family members will give their loved one hope and a high chance of success. As an industry, it is time that we move beyond traditional approaches that have struggled for the past 70 years and show that we now have the tools and techniques to improve outcomes and achieve what we all set out to do – which is to help others successfully manage the disease of addiction throughout their life.
Dr. Urschel, a board-certified addiction psychiatrist, is chief medical strategist of Enterhealth, LLC, which is an addiction disease management company based in Dallas TX. He is the author of the New York Times best seller, Healing the Addicted Brain. For more information, please visit www.enterhealth.com.
In figure 1, you can clearly see the overall decreased activity in the brain of a 38-year-old male with 17 years of heavy weekend alcohol use when compared to a
normal brain. (SPECT images courtesy of D.G. Amen, MD)
