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Last month a client reached out to me because he wanted a prescription for Naltrexone, an FDA-approved medication for addiction to alcohol and opiates, but his doctor wouldn’t give it to him. Was it because his alcoholism wasn’t severe enough for medication, that he had health problems that made him a bad fit for it, or because he was taking another prescription that could dangerously interact with it?

No. None of the above was relevant. Instead, the doctor said that the client needed to show proof of at least 6 months of Alcoholics Anonymous (AA) attendance before she’d even consider Naltrexone as an option. Essentially the client needed to admit he was powerless over alcohol, turn himself over to God, and then pray that God remove his character defects before he could get a prescription for a potentially life-threatening health condition. Not only could this be considered medical malpractice, but it is also symbolic of a troublesome theme in the addiction treatment world.

How Does Naltrexone Work?

Naltrexone is an opioid antagonist medication that works by inhibiting the “euphoria” that alcohol, opiates and potentially other rewards create. It blocks opioid receptors in the brain, thereby inhibiting the release of endorphins that cause the pleasure one associates with these substances. Over time, one no longer experiences the desirable effects of them and cravings gradually cease. While an alcoholic drink may, much like a can of your favorite soda, continue to taste good, it does not create any pleasure or euphoria beyond that.

Naltrexone itself is not addictive and it does not adversely interact with alcohol. Furthermore, the safety and efficacy of Naltrexone for alcoholism have been upheld by a large body of research since the time of its acceptance by the FDA in 1984. Unfortunately, Naltrexone still faces some barriers in becoming a more commonplace choice of treatment.

Strong Evidence, Weak Implementation

A recent national study of addiction treatment centers found that, depending on the type of Naltrexone, only 9 to 17 percent of centers offered it (U.S. Department of Health and Human Services, 2016). Furthermore, while an estimated 16.3 million adults in the U.S. have an alcohol use disorder, in 2010 only 658,000 people received prescriptions for medications like Naltrexone—that’s only 5 percent!

Why has the rollout of Naltrexone been so limited? Abraham et al (2015) found that counselors at addiction treatment centers with a 12-Step ideology, meaning they require clients to follow the 12 Steps of AA (much like the doctor above), were significantly less likely to consider Naltrexone effective. Also, Roman et al (2011) found that addiction programs that place a greater emphasis on the 12 Steps were less likely to adopt any form of medication-assisted therapy (MAT). When you consider that 80% of addiction treatment centers in this country incorporate the 12 Steps, the low uptake of Naltrexone makes a whole lot of sense.

Addiction counselors with a Master’s degree or higher were more likely to view Naltrexone as a viable treatment compared to counselors with less education. Altogether, these results suggest that the misconception that Naltrexone is just another “narcotic” that can be addictive, a commonly-held view in the 12 Step community, and a widespread lack of knowledge regarding its effectiveness are major barriers to its adoption.

So what’s to be done? Abraham et al (2015) have suggested integrating medication-specific training and practice guidelines into coursework for students seeking certification in addiction counseling. Such strategies may contribute to a faster, more efficient adoption of the medication by treatment programs. However, given AA’s stronghold on the treatment community, it may take a while before Naltrexone is widely available enough to meet the need for it. Luckily, there are options out there.

My thoughts on naltrexone

I make it my goal to be one of the most forward-thinking recovery resources available, and that includes embracing Naltrexone. I offer support services for the “Sinclair Method,” a controlled drinking program that incorporates Naltrexone to individuals with prescriptions for it. Double-blind clinical trials conducted by creator Dr. JD Sinclair (Sinclair, 2001) have demonstrated the benefits of Naltrexone are most evident when individuals continued consuming alcohol during treatment while taking it (the “Sinclair Method”), whereas individuals who practiced abstinence while taking it did not receive such benefits, suggesting the medication may be better suited for people who wish to control their drinking.

The Sinclair Method takes advantage of “extinction”, a learning mechanism that gradually reduces the positive reinforcement of alcohol use. Individuals with AUDs have been “conditioned” to positively associate benefits with drinking alcohol. Pairing Naltrexone with alcohol consumption helps to break this association. However, this extinction mechanism is not put into action when the original problem stimuli (alcohol) is not presented, supporting the efficacy of the Sinclair Method in the goal of treating AUDs.

Finally, it is important to note that Naltrexone is part of medication-assisted therapy, meaning it is a supplement to a comprehensive program that must include a behavioral component. It is not a magic bullet. That’s why I offer a complete behavioral education and coaching program to support clients through The Sinclair Method experience

References

Abraham, A. J., Rieckmann, T., McNulty, T., Kovas, A. E., & Roman, P. M. (2011). Counselor attitudes toward the use of naltrexone in substance abuse treatment: A multi-level modeling approach. Addictive behaviors, 36(6), 576-583.

Anderson, K., M.A. (2013, July 20). Drink Your Way Sober with Naltrexone.

Litten, R. Z. (2016), Nociceptin Receptor as a Target to Treat Alcohol Use Disorder: Challenges in Advancing Medications Development. Alcohol Clin Exp Res, 40: 2299–2304. doi:10.1111/acer.13222

Roman, P. M., Abraham, A. J., & Knudsen, H. K. (2011). Using medication-assisted treatment for substance use disorders: Evidence of barriers and facilitators of implementation. Addictive behaviors, 36(6), 584-589.

Sinclair, J. D. (2001). Evidence about the use of naltrexone and for different ways of using it in the treatment of alcoholism. Alcohol and Alcoholism, 36(1), 2-10.

Thomas, C., Wallack, S., Swift, R., Bishop, C., McCarty, D., & Simoni-Wastila, L. (2001, January). Adoption of naltrexone in alcoholism treatment. In Journal of Addictive Diseases (Vol. 20, No. 2, pp. 180-180).

Thomas, S. E., Miller, P. M., Randall, P. K., & Book, S. W. (2008). Improving acceptance of naltrexone in community addiction treatment centers: A pilot study. Journal of substance abuse treatment, 35(3), 260-268.

U.S. Department of Health and Human Services (2016). The Surgeon General’s Report on Alcohol, Drugs, and Health. Office of the Surgeon General, 6-29.

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I recently gave a talk at the TEDxUCLA conference. The point of the talk was to point out just how impactful, often negatively so, mental health labels can be. In case you are not aware, mental health labels typically come with expectations. As I point out in my talk, these expectations can actually alter individual performance and bias those who are labelled towards meeting their reduced expected success. This effect has different names in different contexts including the expectancy effect, stereotype threat, and experimenter bias. Look them up, listen to the talk (and I’ve included the text to make things easier) and start making a difference in your life!

I think you’ll find that there’s a pretty convincing case for reducing our reliance on mental health labels as predictors of success in life.

Rebranding our shame

I’m going to start with an experiment, but I’m going to need your help. What words would you use to describe me?  What labels?

In August of 2001, I woke up in a hospital bed. Now anytime you wake up in a bed you can’t remember going to sleep in, it’s going to cause at least mild concern, but when that bed is in the hospital, you know something has gone wrong. I remember lying there, looking around, trying to figure out what might have happened and who these people around my bed were. And then I realized that my leg was throbbing in agony. Slowly, I stared to remember a little more. I had been riding my motorcycle through Beverly Hills. I remembered a car cutting right in front of me without signaling- I know, in Beverly Hills, it’s hard to believe- and I remembered trying to carefully go around it so I wouldn’t go flying into oncoming traffic. I also remembered not quite making it. I remembered, even while writhing in pain on the street, being pretty worried. One of the things I was dreading was the eventual conversation with my overprotective Jewish mother (who is sitting 20 feet form me right now, btw):

“I would’ve never let this family leave Israel if I knew you were going to be out here risking your life on these stupid crazy motorcycles!” She’d say.

As they were loading me onto the gurney, I remember thinking that I need to call my assistant and cancel the DJ gig I’d booked that night. At least I thought it was that night… I’ve always been terrible at schedules.

Now keep in mind, I’m completely out of it on pain meds, so these pieces are coming together slowly, but there’s definitely something weird going on. And that’s when it hits me: the person sitting next to me was a cop, and I’m handcuffed to the bed. And now I know exactly how I got here and the memories start coming…

Because I didn’t just crash my motorcycle in Beverly Hills. I crashed my motorcycle in Beverly Hills with a half-pound of cocaine in my jacket. During my final 3 years at UCLA I had been using, and selling, what I am pretty sure everyone here would consider a large variety and quantity of drugs. I had been on a delivery run. This was one of the other reasons I’d been worried while lying on the ground…

And then I went to court and rehab, then jail. I got into graduate school and eventually got my Ph.D. In Psychology from UCLA, started a national addiction related website and treatment center and ended up on a Ted X stage giving a speech.

OK. I’m sure as that story went along, you started filling in some details about me. I’ve put the most obvious ones on the screen behind me. Over the course of that story, you learned about more than a few specific labels you could have applied to me: I’m a Bruin; Jew; Immigrant; Musician. But let’s be honest, here-  because I have a strong feeling that those were not the labels that stood out and made an impression. Not compared to Drug Dealer. Or Addict. Or Criminal. Or, soon after that, Inmate.

But I know what part of my story stands out. Sometimes, people even bring it up as a compliment- “you should be so proud, you’ve overcome so much,” stuff like that. What I’m usually too polite to tell those people- but what I’m here to tell you now- is that one of the largest obstacle to my success has been statements just like that.

You see, Branding is an intensely powerful thing. This is why people who don’t know the difference between a first down and a touchdown (like my mother in law)still watch the Super Bowl. It’s why, when I ask you if you’d rather have a BMW or a Saturn, you immediately know the answer even if you’ve never sat inside either kind of car. And for branding to be effective, there has to be a core of truth- the BMW is, generally, going be better engineered, more carefully constructed and more luxurious. But is it truly “The Ultimate Driving Machine?” And while an exaggerated piece of branding material about a car isn’t going to ruin anyone’s life, it’s exactly that type of overstatement and blanket labelling when it comes to those who struggle with mental health issues that often keeps them from getting the help they need and overcoming.  I know that because…

Over the past 12 years, I’ve made the study of addiction my calling, and really, my obsession. In 2010, I conducted a study meant to examine why over 85% of people who struggled with addiction often do not even seek help. I was unsurprised, but terribly disheartened, to see the results: 75% of our participants identified shame, stigma, and the inability to share their problems with others as a main barrier.

Now, let me ask you this: what was the worst situation or lowest point that you’ve ever been in your life, that you ultimately got away from? Maybe you experienced bouts of severe depression in college but made it through without a lifetime of antidepressants. Maybe you woke up behind the wheel of your car after a night of heavy drinking and you’d made it home in one piece. Maybe you did a little cocaine here and there before going to the club with your friends without thinking much of it. Now let me ask you this: would your life be better or worse, right now, if before finding your way out you’d been officially caught and labelled “clinically depressed,” or an “alcoholic”, or an “addict?”

We need labels to help us understand the world and one another. Labels help us figure out which groceries to buy, what car to drive and what school to go to (UCLA logo on screen).

We’re pretty good at understanding physical labels, but when mental health is at issue we struggle. Typically we believe that each “label” comes with a specific amount of dysfunction in a simple, straight-forward way. If you’re depressed, you’re shut in your room all day, if you have ADHD, you do poorly in school, if you’re a drug addict, you’ve let every other responsibility in your life fall by the wayside because getting high is the most important thing in your world. These conclusions are simple, they make sense.

But there’s a cost to that, a human cost. You see, mental health labels in the early 21st century remain one of our clearest bastions of shame. I mean come on, every single person in this room, suffers from some neuroses, insecurities, and weaknesses, right? But the moment your issues cross the threshold into a certifiable Disorder, you become a walking condition. Suddenly you’re a label with a treatment that has less to do with who you are as an individual and more to do with how you’ve been categorized.

The problem is that, in serving as shortcuts to the truth, labels eliminate any sense of nuance.

This is a QEEG scan of my brain. I’ve already said that I struggle with Attention DeficitHyperactivity Disorder, and I obviously have some addictive tendencies as well. But let’s look at my brain and compare it to that of another person with the same ADHD label. They don’t look the same, do they? And you wouldn’t expect our ADHD to manifest in the same way knowing this. In the simplest of terms, what this means is that nearly every manifestation of a disorder is unique, with its own symptoms, its own strengths and weaknesses. We can diagnose and categorize and take our best shot at nailing down conditions, causes, and treatments, but the reality is that mental health as a profession is in an ongoing state of reevaluation and refinement, and labels are approximations. When we act as if we know more than we do, when we treat other human beings- no matter how compassionately- as if we fully understand them because of a mental health label that has been applied to them, we run a serious risk of addressing a concept, rather than the actual person.

Now here’s the question at least some of you are asking yourselves: so what? Who cares if we overgeneralize? Doesn’t an ADHD diagnosis get a student extra help in school?

To answer that question, I’d like to tell you about a group of kids in a California elementary school. At the beginning of the school year these children took the standard battery ofintelligence and performance measures. Afterwards, researchers informed some of the teachers that a specific test called the Harvard Test of Inflected Acquisition had identified a subset of kids who were expected to outperform their peers. They were told to expect great things this year from these children in particular. When these so-called “growth spurters” end-of-year IQ tests were compared to those from the beginning of the year, they were indeed found to have outperformed the student body as a whole by as many as 15 IQ points! The test was right!

Obviously there’s a twist. There was no such thing as the Harvard Test of Inflected Acquisition. In reality the “growth spurters” had been randomly selected, and yet, their IQ improvement results matched the misleading information the teachers were given. The students, btw, were never made aware of these groupings, so we can eliminate their own internalization as the cause for this effect. The only conclusion left to draw is that the teachers, unconsciously acting on a false belief, actually affected these students towards extra success- an actual increase in their measured intelligence – and also condemned others to fall relatively behind.

Or we can also consider the studies that show that African-American students perform more poorly on standardized tests when they are specifically told that those tests will be used to measure their intelligence. and this differences disappears if the tests are labelled as simple experimental exercises but shows back up with the simple act of making students check a box indicating their race group before taking the test. This isn’t a problem of ability. We’re dealing with expectations and the self-recognition by these students that they’re expected to perform more poorly in some contexts.

And if you’re not yet entirely convinced, I’d like to introduce you to the albino rat. Animals like these are used regularly in neuroscience and genetics research to do things like run mazes, press levers and perform other simply tasks. But what if I told you that simply by labelling some rats as “bright” and others as “dull,” experimenters managed to produce a difference of about 50% in the time it took these animals to run a maze? The only issue, of course, is that all of the rats were essentially identical, with the “bright” ones chosen completely at random. The only true difference were the expectations the research assistants had for them based on instructions.

Take a moment to consider just how incredible the implications of that experiment are. It suggests that even when the subjects in question are unable to understand the meaning of the labels applied to them or what might be expected of them, the preconceptions of those observing them still undeniably alter the results.

What these examples show us is that labels and expectations pinch those being labelled on both ends. They’re being set up for a failure that, even if they somehow have the strength to overcome, is still almost surely going manifest itself in the eyes of those evaluating them.

So how sure are you now that children with ADHD underperform in school slowly because of their own dysfunction? And in how many other setting are we creating failure?

My ADHD can definitely be a burden to me – I can’t plan ahead to save my life – if we were all friends in this room I would have disappointed many of you by missing some scheduled get together or forgetting an important event. I also get easily frustrated and bored and I hate sitting still. But in other ways my ADHD is a real asset. I think outside the box, even in the face of pressure to conform. I thrive in the face of pressure and multitasking that makes many others crumble. And I’m driven, unable to rest on the laurels of small accomplishments when a bigger prize is out there. My various assistants, in contrast, have some pretty noticeable Obsessive-Compulsive-like tendencies- they needs to fill in details, double and triple-check schedules, make sure they can see the path from A to B to C before starting. And you know what? Together, we’re perfect. The same complementary aspect is there in my relationship with my wife, the most balanced, calm, centered person I know, and the only one who can take my crazy anxiety and balance me out. I’m still not exactly sure how I make her life better…

So what’s the takeaway here? Should we throw all the diagnoses out the window and say that everyone’s normal in their own way? Not quite. We don’t need to eliminate labels- categories are helpful. What we need to do, however, is to get comfortable with a much more expanded and nuanced approach to our labels, and avoid moralistic value judgments. Every disorder has levels, and sub-components of those disorders can be just as beneficial as they are debilitating. Sometimes all it depends on is a simple point of view or context. In this way we can start thinking about these less as disorders and more as simply labels that explain differences in our functioning.

It’s up to us to change the conversation to open our society to the attributes and potential of those who have been labeled. The notion that all psychological differences need treatment with the goal of getting the person in question back to “normal” is only sometimes true- but it’s always stigmatizing and shame-inducing. And that shame leads nearly 9 out of 10 to not even ask for help.

If you’re one of the labeled, like me, I’m asking you here and now to take back ownership of what others have put on you. Forget the meaning of label that’s been applied to you and start building your own brand – Identifying the parts that fit and rejecting the ones that don’t.  Learn more about yourself and find a life that fits your brain, your body, your world. Your disorder might just prove to be your biggest gift.

If you know someone who is labeled, and we all do, I urge you to reconsider your responsibility to that person. Reconsider what it might mean for your daughter to have ADHD and what elements of that disorder might actually apply to her; what your husband might be capable of despite being labeled an addict; or what your friends’ depression, or anxiety, or bipolar disorder might mean for your relationship. That simple act of careful thought can pull you out of that automatic brand-messaging-mode and might allow you to recognize strengths they have that you’ve ignored because of their “disorder”. More importantly, your effort at truly understanding them might be just the glimmer of light through the clouds that the people who are important to you need.

Imagine what we can do if we take shame out of the equation? I am making it my own mission to flip this problem on its head. I want 90% of individuals who struggle in this way to reach out – and I want you to help me!

Because I am definitely not unique in overcoming my difficulties. I am maybe unique in being so public about it – in not succumbing to the shame that I too feel. And I can tell you from personal experience that sure, beating expectations is nice, but it’s a lot nicer not to be chained down by low expectations in the first place.

My name is Adi and I am not an addict. I am not an ADHD sufferer. I am so much more. And I don’t expect failure for myself, I expect success. Fuck Shame. Sure, I work hard every day to overcome the parts of myself that frustrate and complicate me- but who among us, diagnosed or not, can truly say otherwise?

And while I’m pretty sure that your impression of me now is somewhat different from that you had of me 15 minutes ago, I hope you don’t hold that against me…

by Emma Haylett

As Breaking Bad ends a wildly successful season—don’t worry, you won’t find spoilers here—

the show is on many of our minds for many different reasons. While the idea certainly wasn’t

groundbreaking (there are so many that deal with drug and alcohol addictions and various forms

of recovery, to varying degrees of accuracy and success), it managed to capture the hearts

and minds of people across the United States. Likely it is because of the variety of emotions a

show like this evokes, often in the span of one episode. As humans, we crave a deep emotional

connection to the media we consume, and in an age of reality television, this may be lacking.

We want good guys and bad guys and carefully constructed (and filmed) plot.

Breaking Bad though doesn’t adhere to our ideas of good and evil, instead subverting them

over and over again. But we stay tuned because we’re interested in how far our own thinking

can go and transform, how like or unlike an addict we might feel in our journey with the show.

Strangely, or perhaps not, is the scenario put in place by writers and producers that even allows

for a man like Walter White to find himself in such predicaments.

For Walter White to make and deal methamphetamines, he had to get cancer, be unable to

treat it, be unwilling to accept money from friends, know a shady high school student, and be

later consumed by a world darker than he could have imagined. It’s an excellent premise e for a

show, certainly—but imagine the setup for a black man. Other shows have proven that we don’t

need to suspend our disbelief by establishing a crazy cancer scenario to believe that a minority

might make, sell, or do drugs.

And Breaking Bad has other issues with race—while Albuquerque, New Mexico is nearly half

Latino, Gus Fring is the only Latino character to reoccur enough to get a billing as regular cast.

In a Salon article titled “Breaking Bad’s Racial Politics Walter White, Angry White Man”, Todd

Van Derwerff suggests that it is the idea of the antihero that speaks most effectively to white

privilege. “His is the voice of white male privilege, the angry, unfiltered sense that one is owed

something and has had it taken away. Never mind that Walter built an empire worth $80 million.

He always wanted more—respect or fear or worship—and he never got it. He could never quite

get over the fact that other people weren’t placed on Earth to play supporting characters in his

own story, and even in the series’ pilot, he’s bogged down by an overbearing boss and a wife

who seems interested in anything but him,” writes Van Derwerff.

But Breaking Bad is good television, and, while ignoring some aspects of racial diversity, it

perhaps addresses the reality of methamphetamine in rural areas—states like Idaho and

Wyoming have documented problems with the use of meth. If we look at Idaho, 70% of drug

related offenses are meth related, which costs the state between $60 million and $102 million

for incarceration and arrest. 89% of women in Idaho jails are meth users, and 80% of children

placed by Health and Welfare are removed from their homes because of drug abuse—mostly

meth.

Meth is affecting areas that are not dirty or dangerous—teachers and factory workers, high

school students and high school dropouts are part of the growing meth problem and, if nothing

else, Breaking Bad has drawn attention to it. To the show’s credit, it doesn’t glamorize the

addiction or recovery from addiction in the way that some shows have—the characters who use

are decaying, they’re mean, they’re painfully addicted and involved in an extremely dangerous

world.

Ultimately, Breaking Bad presents a scenario in which the viewer is asked to examine the good

and evil within themselves. It is also (though perhaps not intentionally) raising a discussion

about race—who deals and uses, who produces, develops, and distributes meth. And that’s a

conversation worth having.

Emma Haylett is really good at thinking up nicknames, though she has few of her own. When she’s not

packing around a too-heavy backpack at graduate school or working as a Certified Prevention Specialist

Intern, you can find her advocating for healthy drug rehabilitation programs around the US.