DBT: An Effective Addiction Treatment?

The debate over what causes addiction never seems to end. Is it nature or nurture? Is it a disease, or is it a choice? What makes it worse: drug availability or social isolation? While determining the cause of an addiction can be helpful, in truth it is an incredibly complex syndrome that arises from a web of factors, and addressing a single cause often does little. If we learn someone has a genetic predisposition for alcohol addiction and prescribe them Antabuse, a medication that induces nausea after a single sip, their cravings for alcohol might go away but they may still struggle with the lived experience of the disorder. That’s where good treatment comes in. Interestingly, a relatively new form of therapy—originally not even created for addiction—may be particularly helpful in treating it.

Dialectical Behavior Therapy (DBT) was created in the 1980s for the treatment of Borderline Personality Disorder (BPD). BPD is characterized by extreme mood swings that lead to unstable emotions, relationships, and sense of self. DBT views the disorder through a biosocial lens: it holds that BPD clients are not only biologically predisposed to emotional volatility, but also that their environment may exacerbate this emotional experience by trivializing or stigmatizing it. For example, if someone with BPD is seen as “bonkers” by their family members, this label will in turn make the individual even more volatile and prone to outbursts. This can take a tragic turn, as BPD patients are at an increased risk for hospitalization and suicide. Accordingly, the main goal of DBT is to improve emotional regulation so that the individual can better weather the storm of volatile emotions.

There are four components and four skills essential to DBT as a treatment.

First, to the four components:

 

  • Psychotherapy: weekly one-hour individual sessions
  • Phone Calls: clients have to option to hold brief phone calls with the clinician in between individual sessions
  • Skills Training:  weekly two-hour small group sessions led by two facilitators that focus on building particular skills
  • Consultations: weekly two-hour meetings between therapists and skills training facilitators to discuss progress of clients

 

Next, the four skills that serve as the basis of the Skills Training:

    1. Mindfulness: The sense of nonjudgmental awareness in which one’s present moment experience is dispassionately observed

 

  • Distress Tolerance: Techniques to endure an unpleasant emotional experience without reacting in a negative way
  • Emotional Regulation: The capacity to recognize detrimental emotions as they arise and take actions to offset them
  • Interpersonal Effectiveness: Strategies for better navigating social situations to reduce the compounding effect that environment has on emotional experience

 

These are the four components and four skills that constitute DBT, which, over time, has amassed a strong evidence base as a treatment for BPD. The question remains: could it be an effective addiction treatment as well? The four skills at the heart of DBT, particularly those regarding Mindfulness and Distress Tolerance suggest it may be especially helpful when working with addiction.

Mindfulness

Inspired by Buddhism’s 2,500 year-old tradition of meditation, mindfulness is the practice of bringing awareness to one’s present moment experience, such as thoughts, emotions, and sensations, without judgment. While there are many iterations of mindfulness practice, DBT’s focuses on a few key strategies. For example, clients are taught to cultivate a “wise mind,” that develops both emotional and rational thought patterns. Consequently, clients gain a sense of non-attachment from emotions and thoughts: an “angry person” is reframed as a “person briefly experiencing anger.” This would be especially helpful for someone with addiction, who may have long thought of themselves as an “addict,” but can now step back and see themselves as a “person experiencing addiction.” Another helpful strategy is “urge surfing,” in which clients are taught to bring awareness to their urges—acknowledging that like any other sensation, they will pass—without acting on them. This may also be helpful in working with addiction since cravings are often quickly acted on without any investigation.

Distress Tolerance

DBT holds that distressing situations can elicit harmful responses. For example, a bout of anger could lead someone to hurt themselves. With this skillset, clients are taught strategies to help them better deal with negative emotions. Two may be particularly helpful for addiction. Firstly, with the strategy of “adaptive denial,” clients are taught to reframe cravings for their drug of choice as a craving for something else. For example, a craving for the “high” of marijuana could be reattributed to craving for a natural “high,” achieved by taking a hike or going for a long run. Secondly, the skill of “burning bridges” asks that clients cut themselves off from any associations with drug use, such as friends that encourage use or establishments that foster it. This may be easier said than done and the client might need support from the therapist to fully break away.

Lots of Potential, Little Research

While the philosophy of DBT’s Skills Training would suggest that the modality could be helpful with addiction, at this point in time no studies have been conducted on its efficacy in treating addiction alone. Most studies involve patients with co-occurring BPD and addictive disorders. A 1999 study of this population found that, in addition to producing better treatment completion rates, DBT helped patients achieve a higher proportion of days abstinent from drugs and alcohol compared to treatment-as-usual. However, there were inconsistencies across the treatment structures. A 2002 study compared the use of DBT to Comprehensive Validation Therapy (CVT) with clients with co-occurring BPD and opioid addiction. While DBT fared better in reducing drug use, CVT had better treatment completion rates, so it was not clear that one was better than the other. Dr. Marsha Linehan, the creator of DBT and leader of the two previously mentioned studies, and Dr. Linda Dimeff have suggested that while DBT may be effective in treating addiction, it may also be too extensive for some people. With so much focus on teaching emotional regulation, DBT may be best for clients whose addictions are mostly a result of dysregulation. Furthermore, DBT normally only gives clients the option of abstinence as a treatment goal. While this may be wise for someone with co-occurring BPD, it may be too restrictive for someone with an addiction but who is more interested in moderation-based treatment.

Despite DBT’s potential in treating addiction, issues regarding insurance coverage may be an obstacle. Since the Skills Training component requires two facilitators and is limited to ten clients, it is not well-reimbursed for by insurance. Also, in some cases, the Phone Calls and Consultations are not covered at all. On the bright side, if DBT gradually gathers an evidence base as an effective treatment for addiction it will likely be covered better by insurance. When that happens, more people will get the help that works for them.

My own Approach

When I work with clients, I always incorporate the best of cutting-edge treatment. While I don’t offer a full-fledged DBT program my work does contain the two elements with the most potential for treating addiction issues. Incorporating Mindfulness, CBT, and Neurofeedback helps my clients learn to attend to their state of being, reframe distressing situations, and reduce anxiety while improving emotional regulation. All combined this leaves clients with less distress and a better ability to regulate their behavior.

It’s a beautiful thing.

 

Citations:

  1. Chapman, A. L. (2006). Dialectical Behavior Therapy: Current Indications and Unique Elements. Psychiatry (Edgmont), 3(9), 62–68.
  2. Linehan, M.M., et al., 1999. Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal on Addictions 8(4):279-292.
  3. Linehan, M.M., et al., 2002. Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence 67(1):13-26.
  4. Dimeff, L. (2008). Dialectical Behavior Therapy for Substance Abusers. Addiction Science & Clinical Practice, 4(2), 39-47.
  5. Koons, C. R., O’Rourke, B., Carter, B., & Erhardt, E. B. (2013). Negotiating for Improved Reimbursement for Dialectical Behavior Therapy: A Successful Project. Cognitive and Behavioral Practice, 20(3), 314-324.

Death in rehab- What is wrong with California’s addiction treatment?

We at A3 have long been saying that there is something seriously wrong with the way addiction treatment is being regulated and with the addiction treatment system that has sprouted up as a result. Now, a government report created for the California Senate Rules Committee called “Rogue Rehabs: State failed to police drug and alcohol homes, with deadly results” (see here) supports our notion and extends them in alarming ways. Among the major findings:

  1. Over the past decade, the California department in charge of regulating residential drug and alcohol programs consistently failed to catch life threatening problems [with addiction treatment facilities].
  2. Many addiction treatment facilities in California are providing medical care in clear violation of their licenses and often by under-trained staff.
  3. Addiction treatment providers are accepting patients that are far too impaired (as in sick) for them to handle because they would rather take the money than turn away a patient.
  4. These problems have led to several deaths within the California addiction treatment system in the last decade.

Obviously these findings are extremely disturbing and cases like the one studies in the report of Brandon Jacques, a patient who died while under the care of MorningSide Recovery’s care,  could have been prevented with more attention and transparency in our system. The idea that addiction treatment facilities that are not equipped to handle severe cases are taking them just for the money is sickening and antithetical to the reason for their existence. As far as I’m concerned, such unethical flouting of patient care should lead to an immediate revocation of their license and a ban for the management from the field.

The most distrubing factor to my mind is the fact that many of these providers know that what they are doing is wrong. But they also know that more than 50% of people who are looking for addiction treatment are doing so for the first time and have no idea what to ask, what addiction services they need, or how to assess whether a facility is appropriate. That means they can take advantage of them with fancy websites and the use of terms like “holistic treatment” that mean little and promise much. It’s disgusting and flies in the face of everything our field is supposed to stand for. It’s also the main reason I worked so hard to develop our Rehab-Finder, which while far from perfect and in need of serious work that I can’t afford to put into it, tries to fix these problems by recommending treatment that is appropriate given the specific issues a client is dealing with. We are currently conducting a study with UCLA on the effectiveness of tools like this and I am committed to figuring out a safer way to help those in need find the right addiction treatment for them.

Importantly, the report also makes a number of recommendations:

  1. Allow for medical service provision at addiction treatment facilities but legislate strict oversight and accountability paid for by agency fees.
  2. Medical detox facilities should be required to have medical directors.
  3. Establishing requirements and procedures for death investigations at addiction facilities.
  4. Strict oversight of programs found to admit clients it is not fit to treat including immediate license suspension.
  5. Information sharing between addiction treatment licensing boards and medical boards.

We think it’s time that addiction treatment providers be held to the same standard that other medical facilities are held to. It might help finally close the gap in terms of recovery outcomes. Running as a relatively unregulated industry does not help patients, it does not help move the field forward, and although they can’t see it it does not even help the treatment providers who are behaving unethically since many of them are eventually forced to close and face lawsuits. It’s time to move forward on this.

More addiction cures: Early promise for Risperidone in crystal meth addiction

A recent open label study found some support for the effectiveness of a Risperidone injection, given once every 2 weeks, in reducing crystal meth (speed) use.

The 22 patients who participated reduced their weekly crystal meth use from an average of 4 times per week to only 1 time per week. The difference between those who were able to stay completely clean and the others seemed to have to do with the levels of Risperidone in the blood.

The nice thing about using an injection as addiction treatment is that it removes the possibility of patients choosing not to take their medication on any given day. Such non-adherence to treatment is very often found to be the reason for relapse.

This study will need to be followed up by placebo-controlled double-blind studies, but given Risperidone’s action as a Dopamine antagonist, I suspect that those trials will also show a strong treatment effect. The promise of medicines as addiction treatment cures always seems great, but I believe that at best, they can be an additional tool to be used in conjunction with other therapies.

The question will be whether the side-effects common with antipsychotic medication will be well-tolerated by enough people to make the drug useful for addiction treatment.

Criminal drug possession – Felony versus misdemeanor

In all but 13 States in the U.S., drug possession for personal use is still considered a felony punishable by years in prison and hefty fines. This despite the fact that a significant portion of those arrested meet criteria for dependence (addiction) on the drugs they are caught with, and the fact that our own federal drug abuse agencies (The National Institute on Drug Abuse – NIDA) considers addiction to be a medical condition that involves reduced control over the drug use itself. I guess that’s why the federal government also considers possession for personal use as a misdemeanor.

Drug users don't belong in prisonIn essence these state laws are putting drug users, and especially drug addicts, at risk of being locked up for years, placed on parole, and subject to the endless other barriers to employment and housing, which make it more difficult for these convicted felons to reintegrate into the community. As if fighting drug addiction wasn’t hard enough.

The question is, would reducing the penalty for drug possession for personal use to a misdemeanor in more states result in increased drug use and crime or would it actually help free up resources being used for incarceration towards more effective strategies for combating the problem?

California State senator Mark Leno is bringing up a bill for consideration in the state senate (SB1506) that is seeking to do just that – reducing the penalty for possession for personal use of any drug to a misdemeanor. Mind you, this law is not to affect any other drug-related offenses such as drug possession for sale, drug manufacturing, or transportation. What it would do is cap the maximum incarceration length of possession at one year in jail (not more years in prison) as well as cap the maximum community supervision length at 5 years (3 years are commonly assigned for such offenses).

I know what some of you are saying – drug users know they’re breaking the law and they should be punished for it. Indeed, punishing them for it will make them less likely to use, which will leave them facing no jail time instead of continuously facing single years in jail for reduced drug possession offenses. Besides, if we cut the penalties for drug possession aren’t we being soft on crime? Aren’t we saying that using drugs is okay?

The problem with that argument is that it assumes that states that have higher penalties for drug possession for personal use have lower rates of crime, drug use, or drug possession arrests. The don’t. Indeed, the 13 states (and D.C.) that already consider drug possession for personal use a misdemeanor have incarceration rates that are no higher, illicit drug use rates that are slightly lower, and addiction treatment admission rates that are on par and even a bit higher than the rates of felony states. Again, that means the states that reduced the penalty for drug possession see less arrests, more people in addiction treatment, and a smaller percentage of their population using such drugs. Interestingly, those results are somewhat similar to the effect complete decriminalization had on drug use, crime, and addiction treatment in Portugal.

In previous articles we’ve spoken about the stigma of addiction and the barriers people report to entering addiction treatment in the U.S. Aside from cost and lack of information, people usually report that they either don’t want help, think they can handle the problem on their own or are too ashamed to ask for help. We’ve also reported on the ridiculous prison overcrowding problem in California due to the high incarceration rates of drug users. The question of decriminalization has come up many times (see here, here, and here) and the evidence I’ve seen keeps pointing towards the conclusion that reduced penalties get more people into addiction treatment while reducing incarceration rates with no real collateral increased in illicit drug use or crime. When you think about it, since the Harrison Narcotics act of 1914 essentially created the black drug market in the U.S. when it restricted, for the first time, the sale of narcotics, it makes sense that loosening up those restriction would reduce the size of that same black market and with it drug-associated crime.

I have spent the last 10 years researching the best ways to fight addiction problems and almost everything I’ve seen suggests that treatment and prevention efforts, not long jail or prison sentences, are the best ways to combat the problem. I have seen evidence that very shirt-term incarceration can help certain resistant offenders, but those efforts can easily be applied for misdemeanor and require nothing close to multiple-year sentences. For that reason, I support not only Senator Leno’s SB1506 bill in California, but other efforts around the country to reduce the criminal penalties associated with simple drug possession to get more of the people who need help into addiction treatment and away from jails. It saves us money, it is more humane, and it just makes sense.

If you want to help Senator Leno pass this bill, contact his office through this link: http://sd03.senate.ca.gov/

 

Citations/Reading:

U.S. Census Bureau, 2012 Statistical Abstract, Table 308. Crime Rates by State, 2008 and 2009, and by Type, 2009 (2012).

Collins et al., (2010). The Cost of Substance Abuse: The Use of Administrative Data to Investigate Treatment Benefits in a Rural Mountain State. Western Criminology Review 11(3), 13-28.

Gardiner, Urada, and Anglin (2011). Band-Aids and Bullhorns: Why California’s Drug Policy Is Failing and What We Can Do to Fix It. Criminal Justice Policy Review, 23, 108-135.

Barriers to Addiction Treatment Entry

By Dr. Adi Jaffe and Tariq Shaheed

How annoying is it to be running late for work unable to find your keys, wallet, or coveted smart phone? You check under the bed, between the sofa cushions, and in your useful phone valet, before giving up and calling in late to work (if it’s not your phone you’re missing). You ask your wife, who says she hasn’t seen it, and your child, who thinks it’s under the bed (you’ve looked, it’s not). Finally, giving up, you go to your car, where your phone sits smugly right on the passenger seat. As troubling and frequent as this story might be, it’s nothing compared to the difficult experience of over 20 million Americans who annually look for addiction treatment but don’t find it [2]. So what’s keeping so many Americans out of treatment?

Internal and external barriers to addiction treatment entry

Barriers to addiction treatment entry are plentyIn a study done in 2008, researchers surveyed a sample of 518 subjects varying in race and age, to find out about the barriers keeping them out of addiction treatment. [1] The study was conducted in Montgomery County Ohio, was a part of nationally funded “Drug Barrier Reduction” effort lead by the National Institute on Drug Abuse (NIDA). Most participants were using crack (38.4%), heroin (25.1%), marijuana (14.9%), and alcohol (11.2%). The researchers found a number of internal and external barriers that keep drug abusers from getting the help they need. Internal barriers included stigma, depression, personal beliefs, and attitudes about treatment, while external barriers (systematic or environmental circumstances that are out of a person’s control) include time conflicts, addiction treatment accessibility, entry difficulty, and cost of addiction treatment. [1]

The researchers concluded that both internal and external barriers can be addressed and improved, but that eliminating the external barriers to addiction treatment is most feasible and could substantially decrease the number of untreated addicts in the United States. Since addressing an internal barrier like “believing one can quit at anytime” (accounts for 29.3% untreated Americans) still requires the ability of the substance user to get treatment, it seems that addressing external triggers will be more immediately effective. Just as motivation to find an item such as keys, phone, or wallet is not the only factor in obtaining that item, a substance user with no internal barriers to treatment is still constrained by all those external barriers, and still not in substance abuse treatment.

The most commonly cited external barriers in the study were:

  1. Time conflicts – being unable to get off work for treatment, household obligations, busy schedules and simply not having time for substance abuse treatment.
  2. Treatment accessibility –  living too far away for treatment, not knowing where to go for treatment, having difficulty getting to and from treatment, and not understanding the addiction treatment options. Subjects reported that being wait-listed for a facility, and having to go through to many steps contributed to deterring them from seeking treatment.
  3. Financial barriers included inability to pay for treatment and being uninsured.

Some common internal barriers include:

  1. Stigma associated with the label of being call an alcoholic or an addict, or stigma regarding addiction treatment. Thus being unwilling to share problems and ask for help.
  2. Psychological distress such as depression and neuroticism which produces a lack of motivation among substance abuse treatment seekers.
  3. Personal beliefs
    1. Religion- God will remove the addiction at the right time
    2. Denial – User doesn’t believe they are an addict
    3. Doesn’t need treatment – For example 30% of heroin abuser believed they would recover without treatment.

Although getting substance abusers help is difficult, it starts by understanding the nature of the problem. While one person may not believe they are addicted, another may not understand how sliding scale payment for treatment works. Different individuals may need different helpful resources when it comes to understanding their options.

Thoughts and limitations regarding the research

As we pointed out in a recent article, it’s important to know who is participating in addiction research. In this case, the individuals recruited were reporting for substance abuse treatment assessment at a county intake center. This means the clients are likely from relatively low Socioeconomic Status (SES) groups, but also that they are for some reason motivated to find treatment. Those reasons themselves could be internal (decided to make a change) or external (got arrested), but it’s important to know that these findings do not necessarily apply to more affluent, insurance carrying, or addiction treatment uninterested, individuals. We are currently in the process of conducting a more general study to assess needs in that group.

Also, the time and costs constraints identified by participants can often be overcome by increasing flexibility in searches and by better tailoring the treatment referrals (see our Rehab Finder articles). Costs can be reduced while saving time by looking into outpatient, rather than residential, treatment options. Unfortunately, Americans have been exposed only to the residential treatment model (a la the Dr. Drew and Intervention television shows), but outpatient addiction treatment is effective, costs less, and truly a better fit for many clients (especially those still working, attending school, etc.).

Finally, not all of the internal beliefs can be written off as unreasonable barriers – indeed, it is likely that most individuals who do not seek official substance abuse treatment, and certainly most of those who never enter official substance abuse treatment, will still recover from their addiction without it. As we pointed out in previous articles (see here, and here), most people who use drugs do recover and many do it with no treatment per se, especially when looking at our biggest substance abuse problem – alcohol. That means that some people termed “in denial” and “not needing treatment” were actually either correct, lucky, or both. Recovery doesn’t have to look like we expect it to, it just has to result in a person who is no longer suffering with addiction.

A3 Plug (you knew it was coming)

At A3 we believe information is the key; by dispelling myths about addiction, removing stigma and anonymity, reviewing the latest research in treatment, and finding 21st century solutions to barriers, we hope to reduce the number of untreated. Join us in the fight to educate and treat addiction.

Citations:

1. Jiangmin Xua; Richard C. Rappa; Jichuan Wanga; Robert G. Carlsona. (2008) The Multidimensional Structure of External Barriers to Substance Abuse Treatment and Its Invariance Across Gender, Ethnicity, and Age.
2. An investigation of stigma in individuals receiving treatment for substance abuse

Treating alcohol withdrawal with benzodiazepines – Safe if mindful

Alcohol withdrawal can lead to some pretty horrible side effects

Contributing co-author: Andrew Chen

Alcohol withdrawal can be extremely unpleasant (see here for an overview). Symptoms vary from person to person, but most people will experience some negative symptoms of alcohol withdrawal if they try to stop drinking after long term use.

Mild to moderate symptoms include headache, nausea, vomiting, insomnia, rapid heart rate, abnormal movements, anxiety, depression, and fatigue. Severe symptoms of alcohol withdrawal include hallucinations, fever, and convulsions (known as DT’s or delirium tremens). Most people undergoing alcohol detox do not require hospitalization, but in severe cases, hospitalization may be necessary (1). Since their introduction in the 1960s, benzodiazepines have been the drug of choice for treating severe cases of alcohol withdrawal.

Benzodiazepines, or benzos for short, are a class of psychoactive drugs that work to slow down the central nervous system by activating GABA receptors. This provides a variety of useful tranquilizing effects. Aside from relieving symptoms of alcohol withdrawal, benzodiazepines are also commonly prescribed to treat insomnia, muscle spasms, involuntary movement disorders, anxiety disorders, and convulsive disorders.

The most common regimen for treating alcohol withdrawal includes 3 days of long-acting benzodiazepines on a fixed schedule with additional medication available “as needed.” (2)

The two most commonly prescribed benzos are chlordiazepoxide and diazepam. Chlordiazepoxide (Librium) is preferred for its superior anticonvulsant capabilities while diazepam (Valium) is preferred for its safety against overdose with alcohol. Short-acting benzos like oxazepam and lorazepam are less frequently used for treating alcohol withdrawal (1).

Compared to other drugs, benzos are the safest and most effective method for treating difficult alcohol withdrawal. However, benzodiazepines do come with their own potential for dependence and abuse. Ironically, symptoms of benzodiazepine withdrawal are quite similar to those of alcohol withdrawal. Tapering off dosage is the best way to prevent serious withdrawal symptoms. To avoid such complications, benzodiazepines are only recommended for short-term treatment of alcohol withdrawal.

In short

Benzos can be very useful for helping long terms alcoholics deal with the difficult withdrawal symptoms that can accompany the detox period. Just be mindful so as not to find yourself right back where you started.

Citations:

1. Williams, D., McBride, A. (1998) The drug treatment of alcohol withdrawal symptoms: A systematic review. Alcohol & Alcoholism. 33(2), 103-115

2. Saitz, R., Friedmn, L. S., Mayo-Smith, M.F. (1996) Alcohol withdrawal: a nationwide survey of inpatient treatment practices. 10(9), 479-87

Naltrexone the addiction cure?

CNN released a news article a little while back titled “With anti-addiction pill, ‘no urge, no craving‘” that seems to suggest that a cure for addiction has been found. As usual, news reporting on these sort of topics revolves around a kernel of truth, with nice window dressing an a serving of embellishment.

While naltrexone, and topiramate, have been shown to improve outcomes in addiction treatment, they have by no means revealed anything that would warrant giving them the title “anti-addiction pills.”

Indeed, there are now a few different preparations of Naltrexone, including a long acting version called Vivitrol that while relatively expensive, has been shown to be relatively effective at cutting relapse rates for both alcoholics AND heroin (or opiate addicts). Note the difference though here between my language and that used by CNN; Naltrexone has been shown to reduce relapse rates, not eliminate them, and current research seems to show that it is most effective only for specific groups of alcoholics who have a specific type of Mu opioid receptor.

As the article points out, a combination of therapies, including behavioral therapies, medications, and social-support, are still the best option when it comes to addiction treatment.

We’re a long way off from finding anything that can be considered a cure for addiction, no matter what some treatment centers like to claim, but these pills should help us stem the tide while we keep looking…